Smoking Cessation and Chronic

Mental Illness

CSAM

May 15, 2009

David Kan, M.D.

E-mail: David.Kan2@va.govSan Francisco VA Medical CenterAsst. Clinical Professor, UCSF

Overview

Epidemiology Nicotine & Tobacco

Aka: Dr. Jekyll & Mr. Hyde Smoking Cessation

Psychosocial Pharmacological

Epidemiology Total

47.2 million adults (24.1%) were current smokers

24.8 million men and 22.4 million women. 82.4% of all smokers were everyday smokers

Age The highest rate of smoking was in 18-24 year olds: 27.9% and 25-44 year olds: 27.5%.

Smoking rates drop with Age

Source: CDC 1998 Survey

Epidemiology Ethnicity

Native Americans/Alaska Natives: 40%,

25% of Caucasians and 24.7% of African Americans smoke.

Hispanics: 19.1% and Asians/Pacific Islanders:13.7%.

Education and income More Education = Less Smoking More Income = Less Smoking

Source: CDC Survey 1998

Smoking Rates

22.50%

34.80%41%39.10%

55.30%59%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

No Mental Illness Lifetime MentalIllness

Past-Month MentalIllness

Current Smoking

Lifetime Smoking

Smoking and Mental Illness, Lasser, et al. JAMA. 2000;284:2606-2610.

Smoking Rates & Mental Illness In general 2x Non-Mentally Ill

Diagnosis In Past Month

US Population, %

Current Smokers, %

Lifetime Smokers, %

Quit Rate, %

Major Depression 4.9 44.7 60.4 26

Non Affective Psychosis 0.2 45.3 45.3 0

Drug Abuse or Dependence 1 67.9 87.5 22.4

Bipolar Disorder 0.9 60.6 81.8 25.9

National Comorbidity Study – 1989 US NHIS

Nicotine vs. Tobacco

Nicotine

Ideal CNS DrugVery EffectiveVery Safe

Neurochemical Effects

Slide Courtesy: David Sachs, M.D.

Why Cigarettes?Ideal Drug Delivery SystemVery Rapid DeliveryHigh DoseHighly Concentrated

What is the Problem with Cigarettes?

Toxic Delivery System

SMOKE is the PROBLEMNOT NICOTINE!!!

Smoking Related Illness

1/3rd of Smokers will die prematurely of tobacco-related illness

Tobacco – Drug Interactions Pharmacokinetic

Polycyclic aromatic hydrocarbons (PAHs) are some of the major lung carcinogens found in tobacco smoke

PAHs - potent inducers of the hepatic cytochrome P-450 (CYP) isoenzymes 1A1, 1A2, and, possibly, 2E1

CYP 1A2 – largest effect

Kroon, L “Drug interactions with smoking.” Am J Health Syst Pharm. 2007 Sep 15;64(18):1917-21

Tobacco – Drug Interactions

Drugs Affected Clozapine Fluvoxamine Olanzapine Caffeine Tacrine

UP TO 50% REDUCTION IN BLOOD LEVELS

Kroon, L “Drug interactions with smoking.” Am J Health Syst Pharm. 2007 Sep 15;64(18):1917-21

Tobacco – Drug Interactions

Hormone Contraceptives Increased risk of Stroke and Heart Attack

Inhaled Corticosteroids Decreased Efficacy

Kroon, L “Drug interactions with smoking.” Am J Health Syst Pharm. 2007 Sep 15;64(18):1917-21

What About Quitting?

Tobacco Dependence In Perspective Approximately 35% try to quit each year 70% to 80% try to quit “cold turkey”

Most Relapse — 95%

Cold turkey quit rates at 1 year are 5%

Physician-assisted quit rates (short-term counseling + medications) at 1 year are 10% to 30%

Fiore MC, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: US Dept of Health & Human Services. Public Health Service. June 2000. (www.surgeongeneral.gov/tobacco/default.htm)

Disease Model of Tobacco Dependence

Acute Disease Short-Term Disorder Severe Sudden in Onset Single, Time-limited intervention

Examples: Common Cold Broken Bone

Chronic Disease Long-Term Disorder Periods of relapse and remission

Requires ongoing rather than acute care

Examples: Diabetes Hypertension Addiction

Smoking!

Psychiatric Conditions Psychiatric Conditions

2x as likely to smoke

Depressed Smokers More Depression less likely to quit

Psychiatric Conditions Data mixed or lacking as to long-term outcomes

Many studies show interventions work as well as with those not mentally ill

Ranny, et al: Systematic review: smoking cessation intervention strategies for adults and adults in special populations. Ann Intern Med. 2006 Dec 5;145(11):845-56. Epub 2006 Sep 5. Review.

Substance Abuse

Alcohol & Tobacco Alcohol Use Triggers / exacerbates tobacco use

Quitting both led to higher quit rates for both

Joseph, AM et al A randomized trial of concurrent versus delayed smoking intervention for patients in alcohol dependence treatment. Stud Alcohol. 2004 Nov;65(6):681-91

Indications for Longer/More Intensive Treatment High Nicotine Dependence

FTQ >5

High Serum Cotinine >250ng/ml

Depression Beck Depression Inventory > 9

Smoker in Household Decreases chances by 50%

Sachs DPL. “Tobacco Dependence: Pathophysiology & Treatment” Pulmonary Rehabilitation Guidelines to Success, 3rd Edition 2000:261-301

Indications for Longer/More Intensive Treatment Smoking Initiation at Younger Age

<17 years old

Heavy Smoker >1 Pack Per Day

# of Prior quit attempts

Alcohol or Drug Abuse

Psychotic Spectrum Illness

Sachs DPL. “Tobacco Dependence: Pathophysiology & Treatment” Pulmonary Rehabilitation Guidelines to Success, 3rd Edition 2000:261-301

Treatment Recommendations

Psychosocial Interventions Counseling

Behavioral Therapy

Quit Line (1-800-NO-BUTTS)

Motivational Enhancement

FDA Approved Medications CONTROLLER MEDICATIONS

Bupropion SR (Zyban, Wellbutrin SR, Wellbutrin XL)

Nicotine Patch Varenicline (Chantix)

RESCUE MEDICATIONS Nicotine Inhaler Nicotine Nasal Spray - Fastest Nicotine Polacrilex Gum (Nicorette) – pH dependent

Nicotine Polacrilex Lozenge (Commit) – pH dependent

Slide Courtesy: David Sachs, MD

Success Strategies

Combined Strategies Behavioral + Medication

Always at least 1 controller

Almost always need Rescue

Nicotine Replacement“Clean vs. Dirty”1

Start with Patch

Add lozenge, gum, nasal spray, inhaler

Target 30-60 days smoke free prior to tapering Taper short acting first

Weeks to YEARS!1. Peter Banys, MD – Personal Communication

Nicotine Replacement Dosing?

80% of 1-PPD smokers not adequately replaced with 21mg nicotine patch

Clear Dose-Response Curve1

Serum Cotinine 24-Hour half-life of nicotine metabolism Dose to level

No absolute maximum

10-15% smoke free at one year

1. Sachs DPL. J Smoking-Related Dis 1994;5: 183-193

Bupropion(Wellbutrin/Zyban) Mechanism

Affects dopaminergic projections

Dosing Start 1 week before quit date 150mg SR x 3-6 days then 150mg BID Psychosocial treatment recommended

Contraindications Seizure Disorder Eating Disorder

Bupropion(Wellbutrin/Zyban) Common SE

Insomnia – 28-35% vs. 22%* Headache – 30% vs. 28% Dry Mouth – 15% vs. 5%* Dizziness – 8-9% vs. 8% Nausea – 5-7% vs. 5%

Uncommon SE Seizures (1/1000 patients) Psychosis Hypertension Suicidal Ideation

* Statistically significant

Varenicline(Chantix) Mechanism

Α4β2 - Nicotinic Receptor Partial Agonist

Dosing 0.5mg PO qd x 3 days 0.5mg PO BID x 4 days 1mg BID thereafter Quit date is day #8

Varenicline(Chantix)

Duration3 months initial6 months total (if pt. can get 10 days smoke-free in first 3 months

Varenicline Warnings Common SE:

Nausea Abnormal Sleep / Dreams Dizziness Fatigue

Uncommon AE but reported: Aggressive and erratic behavior Suicidal thoughts Possible suicide attempts

Varenicline vs. BupropionWeeks 9-52 Abstinence

Varenicline Maintenance

Conclusions & Recommendations

1. Tobacco Use is the #1 preventable cause of death

2. Psychiatric Patients carry a large disease burden both medical and physical

3. Tobacco is the problem - NOT Nicotine

4. Tobacco Use Disorder is a Chronic Illness needing repeated intervention

5. Smoking Cessation Works6. Combine your treatments