Continuing Medical Education COPD Case Presentation LEARNING OBJECTIVES Those completing this activity will receive information that should allow them to Assist a patient in developing a quit plan; Advise appropriate smoking cessation strategies; Supply or refer patients to cessation materials and social support; and Arrange for follow-up contact. 1 CME Credit Physicians Physician Assistants Nurse Practitioners Valid 2/1/2009-2/1/2010 Woman, Concerned About Weight Gain Jennifer is a 27-year old, married, Caucasian woman, who comes to clinic seeking advice about and assistance with smoking cessation in preparation for getting pregnant. 6/12 Wanting to Get Pregnant Jennifer has smoked two packs of cigarettes a day since the age of 15. She has tried to stop smoking three times on her own, without success. She did not use pharmacotherapy and resumed smoking each time because of weight gain. Her longest abstinent period was three weeks. Other than smoking cigarettes, her relevant past medical, surgical, social, family history and review of symptoms is notable for a history of being raised in a home where both parents smoked. Her mother was recently diagnosed with lung cancer and her father has severe emphysema and is oxygen dependent. Her husband also smokes two packs of cigarettes daily. She usually smokes when she drinks. Her physical examination is unremarkable. Jennifer indicates that she is willing to quit smoking cigarettes in the next 30 days, but is concerned about weight gain.
QUESTION 1 At this time, all of the following interventions can be recommended EXCEPT: A. Encourage the patient to decrease her cigarette intake by 25% every 1 to 2 weeks. B. Initiate pharmacotherapy. C. Evaluate her concerns related to family history. D. Schedule joint appointment with husband to evaluate his readiness to stop smoking to support Jennifer and create healthy home environment. E. Arrange weekly follow-up phone calls for 6 weeks after her she stops smoking QUESTION 2 All of the following interventions have been shown to increase the success rate of smoking cessation EXCEPT: A. Counseling. B. Varenicline. C. Nicotine lozenge. D. Alprazolam. E. Clonidine. QUESTION 3 ADDITIONAL INFORMATION JENNIFER IS VERY CONCERNED ABOUT WEIGHT GAIN, WHICH WAS ONE IF NOT THE MAJOR REASON HER PRIOR QUIT ATTEMPTS FAILED. Of the following statements regarding weight gain after smoking cessation, which is correct? A. Certain pharmacologic interventions prevent the weight gain associated with smoking cessation. B. The average weight gain associated with smoking cessation is approximately 15 pounds. C. The adverse health effects of weight gain are equivalent to those of continued smoking. D. Limiting caloric intake does prevents the weight gain associated with smoking cessation. E. Women, African-Americans and smokers less than 55-years-old are at greatest risk of weight gain. QUESTION 4 QUESTION 5 All of the following are recommended strategies to combat the weight gain associated with smoking cessation EXCEPT: A. Nicotine gum. B. Buproprion SR. C. Varenicline. D. Strict dieting. E. Moderate exercise. Jennifer and her husband would like to get pregnant in the near future. If she is still smoking at that time, which of the following treatments would you recommend? A. Prescribe a nicotine patch. B. Prescribe bupropion SR. C. Prescribe varenicline. D. Provide self-help materials, referral to a smoking cessation program. E. Provide self-help materials, 5 minute session with a health educator.
QUESTION 1 ANSWER A Once a patient is ready to stop smoking, it is recommended that the individual set a quit date, ideally within two weeks. In addition, a successful quit attempt requires total abstinence. Continued, though decreased, cigarette intake decreases the likelihood of success. For patients like Jennifer who are willing to quit, the five major steps for intervention are the 5As (Ask the patient about smoking, Advise the patient to quit, Assess willingness to make a quit attempt, Assist the patient in making a quit attempt, and Arrange for follow-up to prevent relapse). In Jennifer s case, she expressed a willingness to quit. This should be reinforced. Thus, the clinician s major responsibilities in this circumstance involve assisting the quit attempt and arranging a p p r o p r i a t e f o l l o w - u p. U n l e s s contraindicated or a special circumstance exists, pharmacotherapy is indicated for all persons motivated to make a quit attempt. Such special circumstances include smoking fewer than ten cigarettes/day, pregnant/breastfeeding women, and adolescent smokers. Part of assisting involves identifying and anticipating challenges and developing solutions. In Jennifer s case, barriers to a successful outcome that need to be adequately addressed include concern about weight gain, her alcohol intake and her husband's smoking. An individual who has quit smoking is most likely to relapse in the first three months, and particularly during the first two weeks. Follow-up contact should occur soon after the quit date, preferably during the first week. A second follow-up contact is recommended within the first month. Further follow-up is individualized, based on assessment of need. QUESTION 2 CASE DISCUSSION ANSWER D In the 2000 practice guideline, pharmacotherapy was divided into first and secondline treatments. First-line treatments include bupropion SR and nicotine replacement therapies. New treatments developed since that initial guideline, which are now also considered first-line therapies include varenicline and nicotine lozenges. Nortriptyline and clonidine were considered second-line therapies. There is no evidence to support the use of alprazolam for smoking cessation. Even minimal counseling, lasting fewer than three minutes, increases overall tobacco abstinence rates. Every cigarette smoker should be offered at least minimal intervention, whether or not they are referred to a more intensive intervention. There is a strong dose-response relation between the session length of person-to-person contact and successful treatment outcomes. While individually, both pharmacotherapy and counseling increase abstinence rates, analysis by Hughes, confirmed in the 2008 practice guideline, has shown that the most effective approach to treating nicotine addiction is combined behavioral and pharmacologic interventions. QUESTION 3 ANSWER E While the patient is on buproprion SR, nicotine replacement therapy, especially nicotine gum, these agents are useful in reducing post-cessation weight gain. However, once these agents are stopped, the quitting smoker, on average, gains an amount of weight that is about the same as if he had not used these treatments. Limiting caloric intake does not prevent the weight gain associated with smoking cessation. The average weight gain associated with smoking cessation is approximately 10 pounds. Woman, African-Americans, smokers less than 55-years old and those smoking more than 25 cigarettes a day are at greatest risk of weight gain. The adverse health effects of weight gain are minor compared to those of continued smoking. QUESTION 4 ANSWER D It is recommend that intensive weight control strategies such as strict dieting be avoided until the patient is no longer experiencing withdrawal symptoms and is confident that the patient will not return to smoking. In fact, some evidence suggests that attempts to prevent weight gain (e.g., strict dieting) at the same time as quitting smoking may undermine the attempt to quit smoking. Nonetheless, the patient should be encouraged to maintain or adopt a healthy lifestyle, including engaging in moderate exercise, eating plenty of fruits and vegetables, and limiting alcohol consumption. Nicotine replacement therapy, in particular, nicotine gum, bupropion SR and varenicline are also useful adjuncts. These therapies may delay, but do not prevent, the weight gain associated smoking cessation.
Office of Professional and Continuing Education 3500 Camp Bowie Boulevard Fort Worth, Texas 76107 1 CME Credit Physicians Physician Assistants Nurse Practitioners Valid 2/1/2009-2/1/2010 QUESTION 5 ANSWER D During pregnancy, because of potential fetal risk from pharmacotherapy, psychosocial intervention alone is recommended as a preferred treatment. Brief interventions have not been shown to be effective with pregnant women who smoke, so treatments more intensive than brief advice are indicated. Most effective programs involved multiple contacts, often with different healthcare professionals. SUMMARY Many patients hold the concern that they will gain weight if they stop smoking. While valid, that concern should not be the reason that prevents smoking cessation. Setting up a quit plan involving smoking cessation and other lifestyle changes can be successfully accomplished as long as realistic expectations are established and understood. Ensuring these patients have adequate resources and follow-up care is the key to their ongoing success.
BACKGROUND Chronic obstructive pulmonary disease (COPD) is responsible for one death every four minutes in the US. While 12 million Americans have been diagnosed with the disease, it is estimated that at least that many have COPD but are undiagnosed. Several COPD risk factors converge in East Texas, resulting in some of the highest rates of unnecessary hospitalizations in the state. Since primary care physicians, PAs and NPs in the region are the most likely to diagnose and manage COPD, they should be made aware of the most current information available on how to improve patient outcomes and overcome clinical barriers to diagnostic testing and treatment. WHY SMOKING CESSATION This case dealing with smoking cessation was chosen because 60% of clinicians polled by the University of North Texas Health Science Center listed it as their primary barrier in treating COPD patients. HOW TO RECEIVE CREDIT After reading the case presentation, you may use the response form attached or go online to www.registerwithunt.com to complete the information electronically. To use the provided form, record your responses to the question on the response form, complete the credit request and evaluation. Return the response form, evaluation and credit request to: PACE Office 3500 Camp Bowie Blvd Fort Worth TX 76107 Or Fax to 817-735-2598 Online at www.registerwithunt.com Verification Code: COPD6 Your certificate will be mailed within three weeks of receipt. Questions? Call 800-987-2263 RELEASE & REVIEW DATE This activity was last reviewed and released on February 1, 2009 and expires February 1, 2010. Credit cannot be awarded after this date. ACCREDITATION & CREDIT PHYSICIAN ACCREDITATION The University of North Texas Health Science Center at Fort Worth is accredited by the American Osteopathic Association to award continuing medical education to physicians. The University of North Texas Health Science Center is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians. REFERENCES PATIENT RESOURCE 1-800-QUIT-NOW A solid body of scientific evidence demonstrates that quit lines are an effective tool to help tobacco users quit. Fiore MC, Jaen, CR, Baker, TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008. Gonzales D, Rennard SI, Nides M, et al.: Varenicline, an alpha4beta2 nicotinic acetylcholine receptor partial agonist, vs sustained-release bupropion and placebo for smoking cessation: a randomized controlled trial. JAMA 296: 47-55, 2006. Hughes JR.. New treatments for smoking cessation. CA Cancer J Clin. 50:143-151, 2000. Jorenby DE, Hays JT, Rigotti NA, et al.: Efficacy of varenicline, an alpha4beta2 nicotinic acetylcholine receptor partial agonist, vs placebo or sustained-release bupropion for smoking cessation: a randomized controlled trial. JAMA 296: 56-63, 2006. CREDIT DESIGNATION The University of North Texas Health Science Center has requested that the AOA Council on Continuing Medical Education approve this program for 1.0 hour of AOA Category 2B CME credits. Approval is currently pending. The University of North Texas Health Science Center at Fort Worth designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit(s). Physicians should only claim credit commensurate with the extent of their participation in the activity. PHYSICIAN ASSISTANTS & NURSE PRACTITIONERS The University of North Texas Health Science Center at Fort Worth is accredited by ACCME to provide continuing medical education for physicians, and will provide physician assistants and nurse practitioners who successfully complete the activity with a Statement of Participation indicating that the activity was designated for 1 AMA PRA Category 1 Credit(s). COMMERCIAL SUPPORT This activity is commercially supported by Boehringer Ingelheim and Pfizer. Great care has been exercised to ensure the content is fair and balanced. This case was produced by the CS2Day consortium. For more information on the Cease Smoking Today Project please visit www.cs2day.com