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Practical Skills for Working with your Patients who Smoke

Daryl Sharp, PhD, APRN, BC, FNAP University of Rochester

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Epidemiology: Smoking and Mental Illness

People with serious mental illness die, on average, 25 years younger than the general population

Poorer health careA 10 year study of elevated coronary heart disease risk in schizophrenia: tobacco use identified as the major causal factor after controlling for BMI/weight

59% of public mental health facilities permit smoking

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Epidemiology: Smoking and Mental Illness

Overall smoking in the United States has decreased but the proportion of smokers with psychiatric disorders has increased

75% of those with either addictions or mental illness smoke compared to 21% in the general population

Nearly ½ the cigarettes smoked in the U.S. are smoked by those with psychiatric disorders

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Epidemiology: Smoking and Mental Illness

Smoking Prevalence among People with Mental Illnesses

Major Depression 50-60%Anxiety Disorder 45-60%Bipolar Disorder 55-70%Schizophrenia* 65-85%ADHD 40%

*20% of those with schizophrenia started smoking at college age and many began smoking in mental health settings, receiving cigarettes for “good behavior”

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Social factors to consider

Limited educationPoverty

Steinberg, Williams, & Ziedonis (2004) found that smokers with schizophrenia spent at least 1/4 of their monthly disability on cigarettes

UnemploymentAbundance of smoking peersUnderground market for cigarettes

LoosiesIndian Reservations

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Clinician factors to consider

Psychiatric clinicians have responded slower than other health professionalsCigarettes as behavioral reinforcementBelief that smoking reduction/cessation is not a realistic goalPatients “only pleasure” & “least of their worries”Contributes to “normalizing”

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Common Patient Perspectives

“Smoking helps me calm down.”“Smoking helps me concentrate.”“I smoke because I’m bored.”“Smoking is one of the few things I do that I enjoy.”“Sticking to a cessation plan is too hard.”

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Yet many smokers with psychiatric illnesses do want to quit

People with mental illnesses want to stop smoking and often seek information about how to stop smoking

They (and we) often lack confidence, however, in their ability to be successful

They often lack social support, which predicts better cessation rates

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The same interventions that help the general population are likely to help

our clients if provided at greater intensity and for longer periods of

time

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The nature of nicotine addiction

Of all the substances of abuse, nicotine has the highest probability of causing dependency when one has tried it at least once; nicotine may be the most addicting substance known.

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Nicotine Pharmacodynamics (Taylor, 2006)

Nicotine binds to receptors in the brain and other

sites in the body

Other:Neuromuscular junctionSensory receptorsOther organs

Central nervous system

Exocrine glands

Adrenal medulla

Peripheral nervous system

Gastrointestinal system

Cardiovascular system

Nicotine has predominantly stimulant effects.

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Nicotine Pharmacodynamics

Central nervous systemPleasureArousal, enhanced vigilanceImproved task performanceAnxiety relief

OtherAppetite suppressionIncreased metabolic rateSkeletal muscle relaxation

Cardiovascular system↑ Heart rate↑ Cardiac output↑ Blood pressureCoronary vasoconstrictionCutaneous vasoconstriction

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Nicotine entersNicotine enters brainbrain

Stimulation of Stimulation of nicotine receptorsnicotine receptors

Dopamine releaseDopamine release

Dopamine Reward Pathway (Schwartz-Bloom: www.nida.nih.gov)

Prefrontal cortex

Nucleus accumbens

Ventral tegmental

area

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Chronic Administration of Nicotine: Effects on the Brain

Nonsmoker Smoker

Human smokers have increased nicotine receptors in the prefrontal cortex.

Hig h

Low

Image courtesy of George Washington University / Dr. David C. Perry

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Neurochemical and Related Effects of Nicotine

Dopamine Norepinephrine

AcetylcholineGlutamateSerotoninβ-EndorphinGABA

Pleasure, appetite suppressionArousal, appetite suppression

Arousal, cognitive enhancementLearning, memory enhancement

Mood modulation, appetite suppression

Reduction of anxiety and tension

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Nicotine Addiction Cycle

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Depressed mood

Insomnia

Irritability

Anxiety

Difficulty concentrating

Restlessness

Increased appetite & eating

Craving for tobacco

Hedonic dysregulation

Nicotine Pharmacodynamics: Withdrawal Effects

Although symptoms may peak 24–48 hr after quitting and subside within 2–4

weeks, there is considerable individual

variation in withdrawal symptoms so it is very important

to listen to what your patients tell

you!

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Potential neurobiological benefits of nicotine for those with psychiatric disorders

Effects on neurotransmitters postulated to: Reduce negative (deficit) symptoms of the schizophrenic syndromeImprove working memory, attention, & motor speedNormalize impaired sensory gating functionReduce antipsychotic drug side effects, e.g. akathisia

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Nicotine Pharmacology & Addiction

Nicotine dependence is a form of chronic brain disease.

Tobacco use is a complex disorder involving the interplay of the following:

Pharmacology of nicotine (pharmacokinetics and pharmacodynamics)

Environmental/social factors

Physiologic factors

Treatment of tobacco use and dependence requires a multifaceted treatment approach

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Tobacco Dependence Treatment

Tobacco DependenceTobacco Dependence

Treatment should address the physiological and the behavioral aspects of dependence.

PhysiologicalPhysiological BehavioralBehavioral

Treatment Treatment

The addiction to

nicotine

Medications for

cessation

The habit of using tobacco

Behavior change program

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PHS Guideline for Treating Tobacco Use & Dependence

Highly significant health threat

Disinclination among clinicians to intervene consistently

Presence of effective interventions

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Types of Interventions

Lower intensity3-10 minutesTargets smokers who are willing, unwilling, and those who recently quit

Higher intensitySession length > 10 minutes4 or more sessionsTend to be coordinated by tobacco dependence specialistsMultiple clinician types

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Recommended Clinical Approaches4

The “5 A’s”

for patients willing to make a quit attempt

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The “5 R’s”

for patients unwilling to make a quit attempt at this time

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Relapse prevention for patients who have recently quit

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Intensive interventions should be provided when possible (there is a strong dose-response; more intensity = better quit rates)

4

Health care administrators, insurers, and purchasers should institutionalize guideline findings

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Lower Intensity Interventions: The “5A’s” for Patients Willing to Quit

ASK about tobacco use4ADVISE to quit4ASSESS willingness to make a quit

attempt4ASSIST in quit attempt4ARRANGE for follow-up4VARIATIONS include (per SCLC):4Ask-Advise-Refer* (*our first targeted goal)

4Ask & Act

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Lower Intensity Interventions: The “5R’s” for Patients Unwilling to Quit

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RELEVANCE: Tailor advice and discussion to each patient

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RISKS: Discuss risks of continued smoking4

REWARDS: Discuss benefits of quitting4

ROADBLOCKS: Identify barriers to quitting4

REPETITION: Reinforce the motivational message at every visit

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PHS Guideline: Format & Process of Higher Intensity Treatment

Format:Multiple types of cliniciansSession length: Longer than 10 minutesNumber of sessions: 4 or moreIndividual or group; can supplement with telephone counseling

Clinician approach (process):*Support autonomyEmpathic

*Recommended for both lower and higher intensity interventions

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PHS Guideline: Components of Higher Intensity* Treatment (*our second targeted goal)

PharmacotherapyRisks/benefitsEducate regarding withdrawal/toxicity

Practical counselingProblem solvingSkills training (coaching re: coping)Supplement with 1-800-QUITNOW

Intratreatment social supportPositive, encouraging, & compassionate

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Pharmacotherapeutic Interventions

All patients attempting to quit smoking should be encouraged to use effective pharmacotherapy except under special

circumstances

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2008 Meta-Analysis Effectiveness & Abstinence Rates 6 months post-quit (N = 86 studies)

Medication Estimated Odds Ratio Estimated abstinence rates

Placebo 1.0 13.8%

Varenicline (2 mg/day)

3.1 33.2%

Nicotine nasal spray 2.3 26.7%

High dose nicotine patch (>25mg)

2.3 26.5%

LT nicotine (>14 wks) 2.2 26.1%

Varenicline (1 mg/day)

2.1 25.4%

Nicotine inhaler 2.1 24.8%

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2008 Meta-Analysis Effectiveness & Abstinence Rates 6 months post-quit (N = 86 studies)

Medication Estimated Odds Ratio Estimated abstinence rates

Placebo 1.0 13.8%

Clonidine 2.1 25.0%

Bupropion SR 2.0 24.2%

Nicotine patch (6-14 wks)

1.9 23.4%

LT nicotine patch 1.9 23.7%

Nortriptyline 1.8 22.5%

Nicotine gum (6-14 wks)

1.5 19.0%

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How Nicotine Replacement Therapies (NRT) Work

Smoking stimulates α4β2 receptorsReceptors become desensitized within minutes (~one cigarette)Receptors re-sensitize after 45 minutes

WITHDRAWAL symptomsNRT alleviates re-sensitization of nicotinic α4β2 receptors responsible for withdrawal20 cig/pack

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Polacrilex gumNicorette (OTC)Generic nicotine gum (OTC)

LozengeCommit (OTC)Generic nicotine lozenge (OTC)

Transdermal patchNicoderm CQ (OTC)Generic nicotine patches (OTC, Rx)

Nasal sprayNasal sprayNicotrol NS (Rx)Nicotrol NS (Rx)

InhalerInhalerNicotrol (Rx)Nicotrol (Rx)

NRT: Products

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A Patient-Centered Approach to NRT Dosing

Estimate amount of nicotine patient is getting from smokingGenerally 1-1.5 mg. of nicotine/cigarette

Cover with comparable NRT (often helpful to use a continuous + intermittent form of NRT) mindful that NRT is more slowly absorbed than nicotine from cigarettes; higher peak levels of nicotine result in higher subjective effects of nicotine; often need higher doses of NRT to achieve same effects

Review signs/symptoms of potential side effects including information that combination NRT is not FDA approved/discuss risks & benefits

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A Patient-Centered Approach to NRT Dosing

Teach patient signs/symptoms of nicotine withdrawal & nicotine toxicity

On a scale of 0-3 (0=none; 1=mild; 2= moderate; 3= severe)Signs of withdrawal:

AnxietyIrritabilityDifficulty concentratingCravings for cigarettes

Signs of toxicityNauseaSweatingPalpitations

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Nicotine Patch

Advantages:Easy to use, private, one per day, helps with early morning cravings

Disadvantages:Skin reactions, not orally gratifying, vivid dreams, insomnia

Dosage: 4 weeks - 21mg/24hrs. then 2 weeks -

14mg/24hrs.

then 2 weeks -

7mg/24 hrs. Costs:

$4.25/day

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Nicotine Gum

Advantages:Orally gratifying, useful to offset cravings

Disadvantages:Poor taste, mouth soreness, dyspepsia, hiccups

Dosage: Maximum dose: 24 pieces/daypatient smokes < 25 cigs/day: 2mg patient smokes > 25 cigs/day: 4mg

*must use correctly: chew & park Costs:

$6.25/day (about 10 pieces)

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Nicotine Inhaler

Advantages:Mimics smoking, keeps hands & mouth busy

Disadvantages:Mouth & throat irritation, coughing, rhinitis, Less effective below 40° F

Dosage: 6 – 16 cartridges/dayOne cartridge lasts 20 min. continuous puffingGood for 24 hours if not used completely

Costs: $6.00 -16.00/day

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Nicotine Nasal Spray

Advantages:Higher nicotine levels, fast relief for heavy smokers, rapid delivery of nicotine

Disadvantages:Nasal irritation, sneezing, coughing, runny nose

Dosage: 1 – 2 doses/hour (in each nostril)minimum dose: 8 doses/daymaximum dose: 40 doses/day

Costs: $5.00 -15.00/day

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Nicotine Lozenge

Advantages:Keeps mouth busy, easy to use in social situations

Disadvantages:Mouth/throat irritation, heartburn, indigestion, hiccups & nausea

Dosage: minimum dose: 9 lozenges/day2mg: smokes 1st cigarette after 30 min. of waking4mg: smokes 1st cigarette within 30min.of waking

Costs:$4.50/day

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Additional NRT Guidelines

Combining the nicotine patch & ad libitumNRT (nicotine gum/nicotine nasal spray) is more efficacious than a single form of NRT

FDA has not approved combination NRT strategy

Certain groups of smokers may benefit from extended use of NRT

Continued use of medication is clearly preferable to a return tosmoking with respect to health consequences

Risks/benefits analysis and patient preferences should inform pharmacotherapy choices

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NRT: Precautions

Patients with underlying cardiovascular disease; package insertsrecommend caution:

Recent myocardial infarction (within past 2 weeks)Serious arrhythmiasSerious or worsening anginaThere is no evidence of increased cardiovascular risk with NRT

Other precautionsActive temporomandibular joint disease (gum only)

Pregnancy/Lactation

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Bupropion SR

Advantages:Antidepressant, less weight gain, FDA approved for maintenance therapy (6mos)

Disadvantages:May disrupt sleep, possible headaches, &dry mouth, seizure risk

Dosage: Begin 1-2 weeks prior to quit date150mg q am for 3 daysIncrease to 150mg b.i.d. (at least 8 hours apart)

Costs: $3.25/day

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Varenicline

Partial agonist selective for the nicotine acetylcholine receptorAdvantages:

Dual mechanism of action: agonist and antagonist effectsDisadvantages:

Nausea, insomnia, vivid dreams, headaches; use with caution in patients with renal dysfunction

Dosage: Begin 1 week prior to quit date to minimize nausea/insomniaDays 1 –

3: 0.5 mg qdDays 4 –

7: 0.5 mg bidDays 8 –

28: 1 mg bid

An additional 12 wks recommended for those who quitAdjust dose for real insufficiency 0.5 mg/d for GFR < 30

*Should be taken after eating and with full glass of waterCosts: $3.30/day

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Varenicline: Public Health Advisory

FDA WARNINGS and PRECAUTIONS (February 2008)Serious neuropsychiatric symptoms

Changes in behaviorAgitationDepressed moodSuicidal ideationAttempted and completed suicide

Developed during Chantix therapy and during withdrawal of Chantix therapyMay cause recurrence or exacerbation of psychiatric illness

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Combination Pharmacotherapy

Bupropion SR + NRT can be safely combined; considered a first line medication combination

NRT should NOT be combined with Varenicline

The safety of combining Bupropion & Vareniclinehas NOT been established

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Second-Line: Clonidine* *NOT FDA APPROVED FOR SMOKING CESSATION

Alpha-2 agonist used primarily as an antihypertensive; decreases nicotine withdrawal symptoms Advantages

Available as transdermal patchDisadvantages

SE: sedation, dry mouth, hypotension, dizzinessAbrupt discontinuation: HA, agitation, tremor, rapid rise in BP

Dosage0.1-0.75 mg/day (dosing regimen in smoking cessation not established)

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Second-Line: Nortriptyline* *NOT FDA APPROVED FOR SMOKING CESSATION

Tricyclic antidepressant; decreased urges to smoke Advantages

Efficacy: doubles chances of long-term abstinence; inexpensive

DisadvantagesCV effects: orthostatic hypotension; arrhythmias; dry mouth; sedation; weight gain; blurred vision; urinary retention

Dosage75-100 mg/day

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When patients stop smoking

May be at risk for medication toxicityThe tar in smoke enhances P450 enzyme system

Increased 1A2 isoenzyme activitySmoking can increase metabolism of meds (decreased serum levels)Those who smoke tend to be on higher medication doses

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Drugs potentially affected by smoking

Watch for signs of toxicityCaffeineTheophyllineFluvoxamineOlanzapineClozapine

Not a problem with NRT!

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On the HorizonRimonibant (a cannabinoid or CB-1 receptor antagonist)

Nicotine Vaccines

Monoamine oxidase inhibitors (MAO-A & MAO-B)

Dopamine D3 partial agonists or antagonists

Inhibitors of CYP2A6 activity

Selective nicotinic cholinergic receptor agonists and antagonists in addition to Varenicline

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Tobacco Dependence Coverage

MedicareCounseling: document time spent with patient3 – 10 min, 10 min. or more per sessionTwo cessation attempts/yr.Each attempt = 4 sessions

Medicaid (NYS)Medications: NRT, bupropion SR, & vareniclineTwo courses/yr.Course = 90 day supply

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Medications are not magic!

Clients do best with properly dosed pharmacotherapy AND intensive tobacco dependence counseling

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Practical Counseling: Skills building/problem solving and mobilizing social support

Developing Quit Plans

Problem-solving

Skills building

Identifying sources of social supportIntratreatment (treatment team)Extratreatment (family/friends; not included in 2008 PHS Guidelines)

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Process of counseling

Studies have shown that the way in which you counsel your clients makes a difference in how successful they are in changing health behaviors

The PROCESS of counseling is as important as the CONTENT of the intervention

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Mobilizing Motivation: Autonomy Support/Motivational Interviewing

Stay mindful of importance of psychological need satisfaction:

AutonomyCompetenceRelatedness

Counselor-client relationship is a partnership (not expert/recipient)

Elicit and acknowledge the client’s perspectiveListen well and reflect

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Mobilizing Motivation: Autonomy Support/Motivational Interviewing

Advise client about the importance of stopping smoking to health in a clear but non-controlling manner

Do not use information as a weapon/threatening manner

Provide health risks/benefits information; pharmacotherapy & quit plan options when invited/client signals readiness

Ask permissionCheck in with clients about how they are hearing the informationProvide rationale for suggestions you offer

Avoid willfulness and maintain neutrality

Support client initiatives for change

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Preventing Relapse

4

Relapse prevention interventions should be provided with every smoker who has recently quit

4

Crucial to address relapse the first 3 months after quitting (6 months in SMI population)

4

Strategies to use with recent quitters:0

Encourage continued abstinence0

Invite discussion of benefits, success milestones, problems encountered or anticipated

0

Use or refer to an intensive intervention as appropriate

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Case Study #1: Tobacco free X 3 weeks

History: 44 y/o male with schizoaffective disorder; generalized anxiety disorder20-30 CPD X 31 yearsMeds:

RisperidoneAbilifyDepakoteAtivanLipitor

Successfully quit for 3 months using: 21mg. patch + 7 mg. patch + 6-7 doses of nasal sprayRelapsedUnsuccessful trial of VareniclineCurrent NRT:

21 mg. Patch7 mg. Patch4 mg. gum (5-6 pieces)Nasal spray (6-7 doses)

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Case Study #2: Smokes 2-4 cigarettes over the weekend only

Hx: 48 y/o female with paranoid schizophrenia; 2 PPD X 34 yearsReceived tobacco dependence counseling in group homeVarenicline: 1 mg. BID(prescribed by PCP)Is tobacco free during week; smokes 2-4 cigarettes on weekends with mother; has had a few 2-4 week periods of abstinence

Used 2 mg. gum over the weekends after feeling “deprived”Discontinued gum and continues on VareniclineX 9 monthsNo adverse effects reported although client eager to discontinue ASAP: PCP advised her that she needed to be abstinent 3 months prior to d/cing Varenicline

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Case Study #3: Tobacco free X 10 weeks

Hx: 24 y/o male with schizoaffective disorder; seizure disorder and learning disability; alcohol dependence; 1 PPD X 4 yearsMeds:

DepakoteLamictalGeodonEffexor

Stopped smoking 6.5 weeks: January ‘08 using Nicotrol inhaler (5-6 cartridges a day) + 21 mg patch

Called AA sponsor when tempted to use ETOH; advised to take a cigarette insteadBought chewing tobacco as did not want to smoke but then relapsed8 weeks tobacco free using Nicotrol inhaler (3-4 cartridges) + Commit lozenge (4 mg.): up to 10 dailyPsychiatrist then prescribed Varenicline/client used lozenges while building level in Week INot currently smoking

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Summary

Tobacco dependence is an addictive disorderLong term & chronic

Characterized by periods of relapse & remission

Requires ongoing vs. acute care

Calls for ongoing support, counseling, education& pharmacotherapy

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Summary

Few mental health professionals effectively address tobacco dependence currently

Interventions delivered in primary care or other public health settings usually lack intensity needed for SMI population

Effective treatment:Promoting a tobacco free culture in treatment settings

No smoking policiesStaff consistently addressing tobacco use and supporting clients’ efforts to quit

Providing a specialized tobacco dependence serviceEasy access to medications Unlimited treatment sessions

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Nursing’s responsibility & challengeIt is unethical to provide health care and

at the same time remain silent (or inactive) about a major health risk

The time to act is NOW!

Failure to act = HARM

Action = HOPE

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References

References available via separate document in conference booklet

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Acknowledgementshttp://rxforchange.ucsf.edu/

Smoking Cessation Leadership Center: http://smokingcessationleadership.ucsf.edu/

Misty Gonzalez, PharmDBuffalo Psychiatric Center