Download - SMOKING CESSATION
SMOKING CESSATION
• Leading Preventable Cause of Death
• 400,000 to 500,000 deaths per year in USA
• 3 Million deaths world wide
• 1 of every 6 deaths in USA Directly attributable to smoking
• Yet — 46 Million continue to smoke
SMOKING
“A cigarette is a finely tuned drug delivery system”
Katherine E. Hartman, MD
SMOKING
“Smoking is not a bad habit ---
It is a chronic medical condition”
Michael C. Fiore, MD
SMOKING CESSATION
• Why do we smoke?
• Why should we stop/benefits?
• How do we stop?
Nicotine Dependence slide
“As an addictive substance, nicotine, on a milligram for milligram basis, is 10 times more potent than heroin…”
Sachs DPL. Advances in Smoking Cessation Treatment In: Simmons, ed. Current Pulmonology, Chicago; Year Book Medical Publishers, 1991, 12:139-198
SMOKING CESSATION
Why Do We Smoke?
3-Pronged Dependency
• Physiological
• Psychological
• Behavioral
Why Do We Smoke? Physiological
• Nicotine to brain – 7 seconds
• Binds to nicotine receptors resulting in secretion of Dopamine
• Causes a pleasurable sensation and cognitive arousal
Physiological
Increased Levels of:NorepinephrineBeta-EndorphinAcetylcholineSerotoninGlutamateVasopressin
Physiological
• Enhance:– Concentration– Alertness– Memory
• Decrease:– Tension– Anxiety
Promotes feeling of well being
SMOKING CESSATION
Why should we stop smoking?
Benefits:GeneralCardio-cerebrovascularCancerPulmonary
SMOKING CESSATION
• Long term tobacco use raises the risk of premature death by 50% *
• Quitting at any age increases longevity
• Those who quit smoking by age 50 decrease their risk of dying over the next 15 years by 50% compared with those who do not stop **
* W.H.O. Tobacco Dependency Fact Sheet #222 1999
** U.S. Dept of Health & Human Services publication #90-8416
SMOKING CESSATION
Why should we stop smoking?
Benefits:GeneralCardio-cerebrovascularCancerPulmonary
Why should we stop smoking?
• 30% of all Cancer Deaths related to Smoking
• 4000 Chemicals in Tar– 43 Carcinogenic
Why should we stop smoking?
• Lung Cancer – Most Common in Cancer– Oral 9 fold increase– Throat 9 fold increase– Esophagus 75% in smokers– Bladder 7 fold increase– Kidney 5 fold increase– Pancreas 2 fold increase– Stomach 1.5 fold increase
Why should we stop smoking?
Lung Cancer
• Life Long risk in Non-Smoker – 1%
• 15-25% risk in heavy smokers
• Each Cigarette cuts 6 minutes off of life
SMOKING CESSATION
Why should we stop smoking?
Benefits:GeneralCardio-cerebrovascularCancerPulmonary
How Do We Stop Smoking?
Problems
• Patient Motivation
• Physician Interest
• Medications
• Support Systems
SMOKING CESSATION
Patient Motivation
• 70% want to quit
• 2 large studies
• Appropriate moment
SMOKING CESSATION
The Right Moment
Acute MI
Intervention Minimal 55% 34%
Dornelas, E.A. Prev Med 2000; 30, 216-228
The Negatives
• Physicians advising patients to stop
1975 – 38%
1983 – 42%
1991 – 48%
• 1672 Ex-Smokers– 3.6% Physician Helped
• 70% smokers see physician yearly
SMOKING
• 38 Family Practices• 2963 Smokers - Addressed in 21%• Increased to 58% if Doctor used standard
forms for recording smoking status• When smokers identified
– smoking cessation therapy started in only 38%
• 68% of the offices had smoking cessation material
J. Fam. Pract. 2001; 50: 688-9
Physicians Role in Smoking Cessation
The Positives
• Admit Nicotine is an Addiction• Provide information• Show an interest• Train office personnel• Select the opportunity
SMOKING CESSATION
The 5 A’s
AskAdviseAssessAssistArrange
Planning a Program
• Establish degree of nicotine dependency– Serum Cotinine Level– Fagerstrom Test
• Quit Date
• Support Group
• Behavioral Modification
• Discuss Relapses & Weight Gain
Pharmacologic
• Nicotine Replacement
• Bupropion
Planning A Program
• Low Dependency– Nicotine Replacement
• High Dependency– Bupropion +– Nicotine Replacement x 2
Nicotine Replacement
N=504
Patch 21%
Gum 20%
Spray 24%
Inhaler 24%
Arch. Int. Med. September 27, 1999
Nicotine Replacement
Gum – 1984
Advantages
•Neutral PH
•More Rapid
•Adjunct
Disadvantages
•Heartburn and Indigestion
•Throat and Mouth Irritation
•Sore Jaw
•Flatulence
Nicotine Replacement
Patch – 1991Advantages
•Convenient
•Best Compliance
•30-40% while on patch
•10% at 1 year
Disadvantages
•Skin Irritation
•Over the counter
Nicotine Replacement
Nasal Spray
Advantages
•Alone or Combination
•Fast Acting - Urge
Disadvantages
•Irritation
•Low Compliance
Nicotine Replacement
Inhaler
Advantages
•Hand-Mouth
Disadvantages
•Low Compliance
•Less Nicotine
•Delivery
Nicotine Replacement
Lozenge – 2002
Bupropion
• Placebo 23%
• Nicotine Replacement 36%
• Bupropion 300 MA 49%
• Bupropion + Nicotine 58%
• Long Term 25-35%
SMOKING CESSATION
N 12 MO KG
• Placebo 160 15.6% 2.1
• Nicotine Patch 244 16.4% 1.6
• Bupropion 244 30.3% 1.7
• Bupropion + patch 245 35.5% 1.1
JORENBY - N.E.J.M. 3/4/99
SMOKING CESSATION
BUPROPION450 Smokers
(Failed Treatment)
Again Placebo
27% 5%
Gonzales DH, Clin. Pharm Therapy 2001; 69
SMOKING CESSATION
BUPROPIONDuration
784 PATIENTS
7 WEEKS
TREATMENT PLACEBO12 MONTHS
55% 42%
Hays, JT. Ann Intern Med. 2001 135
SUMMARY
• Smoking KILLS
• Physicians can and should play a role in helping patients stop smoking
• Effective tools are available and they work
SUMMARY
• Include Smoking as a Vital Sign
• Use the 5 A’s
• Use multiple modalities
• Use them long enough
• Be Persistent