11GIM Primary Care Conference Presentation GIM Primary Care Conference Presentation

October 25, 2006October 25, 2006

University of Wisconsin School of Medicine and Public Health University of Wisconsin School of Medicine and Public Health

Center for Tobacco Research and InterventionCenter for Tobacco Research and Intervention

Stevens S. Smith, Ph.D.Stevens S. Smith, Ph.D.Assistant Professor / Licensed PsychologistAssistant Professor / Licensed Psychologist

Department of MedicineDepartment of Medicine

University of Wisconsin School of Medicine and Public HealthUniversity of Wisconsin School of Medicine and Public Health

Center for Tobacco Research and InterventionCenter for Tobacco Research and Intervention

Psychiatric Morbidity and Psychiatric Morbidity and Smoking Cessation Smoking Cessation

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Disclosure StatementDisclosure Statement

I have received research support (but no consulting or I have received research support (but no consulting or speaking fees) from the following companies that market speaking fees) from the following companies that market smoking cessation medications:smoking cessation medications:

• SmithKline BeechamSmithKline Beecham

• GlaxoSmithKlineGlaxoSmithKline

• Elan Corporation, plcElan Corporation, plc

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Learning ObjectivesLearning Objectives

• Psychiatric morbidity and cessation in Psychiatric morbidity and cessation in two case studiestwo case studies

• Influence of psychiatric morbidity on Influence of psychiatric morbidity on smoking cessationsmoking cessation

• Evidence-based cessation treatment Evidence-based cessation treatment for smokers with psychiatric disordersfor smokers with psychiatric disorders

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Case StudiesCase Studies

Patient APatient A Patient BPatient B

Psychiatric Psychiatric DiagnosisDiagnosis

Dysthymia,Dysthymia,

Tobacco Use DisorderTobacco Use Disorder

Adj Disorder w/Anxiety,Adj Disorder w/Anxiety,

Tobacco Use DisorderTobacco Use Disorder

Age, Race, SexAge, Race, Sex 60 y.o., White, Female60 y.o., White, Female 25 y.o., White, Female25 y.o., White, Female

OccupationOccupation Social WorkerSocial Worker Autism Therapist Autism Therapist

Marital StatusMarital Status Never married; not in Never married; not in relationship currentlyrelationship currently

Never married; in 7-yr Never married; in 7-yr relationshiprelationship

General General Medical Medical ConditionsConditions

DM Type II, Hypothyroidism,DM Type II, Hypothyroidism,

Hyperlipidemia,Hyperlipidemia,

Hypertension,Hypertension,

Atheroscler. Heart Dis.Atheroscler. Heart Dis.

NoneNone

MedicationsMedications Aspirin, Bupropion, XL, Aspirin, Bupropion, XL, Desloratadine, Enalapril, Desloratadine, Enalapril,

Vytorin, Glyburide, Metformin, Vytorin, Glyburide, Metformin, Levothyroxine,Levothyroxine,

RosigliatazoneRosigliatazone

KarivaKariva

55

Case StudiesCase Studies

Patient APatient A Patient BPatient B

Psychiatric Psychiatric DiagnosisDiagnosis

Dysthymia,Dysthymia,

Tobacco Use DisorderTobacco Use Disorder

Adj Disorder w/Anxiety,Adj Disorder w/Anxiety,

Tobacco Use DisorderTobacco Use Disorder

Age, Race, SexAge, Race, Sex 60 y.o., White, Female60 y.o., White, Female 25 y.o., White, Female25 y.o., White, Female

Weight, Ht., BMIWeight, Ht., BMI 151 lbs, 61”, BMI=28.5151 lbs, 61”, BMI=28.5

(no signif change in years)(no signif change in years)

159 lbs, 64”, BMI=27.3159 lbs, 64”, BMI=27.3

(181 lbs, 64”, BMI=31.1)(181 lbs, 64”, BMI=31.1)

BPBP 130/70130/70 126/86126/86

LipidsLipids Tot Chol=155, Triglyc=122,Tot Chol=155, Triglyc=122,

HDL=57, LDL=74HDL=57, LDL=74

Tot Chol=232, Triglyc=96,Tot Chol=232, Triglyc=96,

HDL=67, LDL=146HDL=67, LDL=146

TSHTSH 3.71 (119 in Sept 2005)3.71 (119 in Sept 2005) 1.401.40

Exercise / DietExercise / Diet No exercise, no special diet No exercise, no special diet Exercise 30 min 3x/wk,Exercise 30 min 3x/wk,

Weight WatchersWeight Watchers

HbA1c %HbA1c % 7.8% (10.2% in Sept 2005)7.8% (10.2% in Sept 2005) N/AN/A

Other HxOther Hx Hx of Alcoholism; no alc for Hx of Alcoholism; no alc for 20+ years20+ years

NoneNone

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Case Studies: Smoking HistoryCase Studies: Smoking History

Patient APatient A Patient BPatient B

Psychiatric DiagnosisPsychiatric Diagnosis Dysthymia,Dysthymia,

Tobacco Use DisorderTobacco Use Disorder

Adj Disorder w/Anxiety,Adj Disorder w/Anxiety,

Tobacco Use DisorderTobacco Use Disorder

Age, Race, SexAge, Race, Sex 60 y.o., White, Female60 y.o., White, Female 25 y.o., White, Female25 y.o., White, Female

Age 1Age 1stst Cig Cig 18 years old18 years old 13 years old13 years old

Daily smokingDaily smoking 23 years old23 years old Started at age 15, 20 cpdStarted at age 15, 20 cpd

# years smoking# years smoking 42 years42 years 10 years10 years

Most recent cigs/dayMost recent cigs/day 1 pack/day1 pack/day 10-15 cigs/day10-15 cigs/day

# prior quit attempts# prior quit attempts ““Many” but no serious Many” but no serious quit attemptsquit attempts

6 (3 serious)6 (3 serious)

Longest quitLongest quit 1 day1 day 2 months (2005)2 months (2005)

Prior Cessation TxPrior Cessation Tx N/AN/A Bupropion SR, taperingBupropion SR, tapering

Other infoOther info Work stress, caretaker Work stress, caretaker for Mom w/Alzheimer’s, for Mom w/Alzheimer’s,

shaky social supportshaky social support

Partner smokesPartner smokes

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Progress: Dramatic Decrease in Adult Progress: Dramatic Decrease in Adult Smoking Prevalence Over 40 YearsSmoking Prevalence Over 40 Years

19651965 20052005

Number PercentNumber Percent Number PercentNumber Percent

Current 50 million Current 50 million 42.4%42.4% 47 million 47 million 20.9%20.9%

Former 16 million Former 16 million 13.6%13.6% 51 million 51 million 21.5%21.5%

Never 52 million Never 52 million 44.0%44.0% 135 million 135 million 57.6%57.6%

(Source: National Health Interview Surveys, 1965-2005)(Source: National Health Interview Surveys, 1965-2005)

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20.9%20.9% 42.4%42.4%

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• > 400,000 deaths per year nationally (8000 in WI)> 400,000 deaths per year nationally (8000 in WI)

• 2,000 children and adolescents become regular 2,000 children and adolescents become regular

smokers each daysmokers each day

• $75 billion in added healthcare costs$75 billion in added healthcare costs

• $80 billion in lost productivity$80 billion in lost productivity

• Low rates of clinical assistance with quittingLow rates of clinical assistance with quitting

Remaining ChallengesRemaining Challenges

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2003 Wisconsin Tobacco Survey2003 Wisconsin Tobacco SurveyLong-term success rate of “cold turkey” method is about 5%Long-term success rate of “cold turkey” method is about 5%

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Disproportionate Smoking RatesDisproportionate Smoking Rates

The highest rates of smoking are seen in individuals :The highest rates of smoking are seen in individuals :

• living below the poverty levelliving below the poverty level

• with the least educationwith the least education

• working in blue-collar and service jobs working in blue-collar and service jobs

• with psychiatric and substance use disorderswith psychiatric and substance use disorders

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Tobacco Dependence and Mental IllnessTobacco Dependence and Mental Illness

• Individuals with mental disorders typically smoke more Individuals with mental disorders typically smoke more cigarettes per day and they have greater difficulty cigarettes per day and they have greater difficulty quitting smokingquitting smoking

• Individuals with a current psychiatric disorder currently Individuals with a current psychiatric disorder currently make up about 30% of the population but consume 46% make up about 30% of the population but consume 46% percent of all cigarettes smoked inpercent of all cigarettes smoked in the U.S.the U.S.

1313(Source: Lasser et al., JAMA. 2000;284:2606-2610)(Source: Lasser et al., JAMA. 2000;284:2606-2610)

Smoking Status and Mental Illness:Smoking Status and Mental Illness:The National Comorbidity SurveyThe National Comorbidity Survey

U.S. PopulationU.S. Population

CurrentCurrent

SmokersSmokers

Lifetime EverLifetime Ever

SmokersSmokers

No Mental IllnessNo Mental Illness 50.7%50.7% 22.5%22.5% 39.1%39.1%

Mental Illness Mental Illness During LifetimeDuring Lifetime

49.3%49.3% 34.8%34.8% 55.3%55.3%

Any Past Month Any Past Month Mental IllnessMental Illness

28.3%28.3% 41.0%41.0% 59.0%59.0%

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% Current% Current

Past 30 DaysPast 30 Days SmokingSmoking Quit Rate, %Quit Rate, %

• No Mental IllnessNo Mental Illness 2323 43 43• Major DepressionMajor Depression 4545 26 26• Nonaffective PsychosisNonaffective Psychosis 4545 0 0• Gen. Anxiety DisorderGen. Anxiety Disorder 5555 29 29• Alcohol Abuse or DependenceAlcohol Abuse or Dependence 5656 17 17• Bipolar DisorderBipolar Disorder 6161 26 26• Drug Abuse or DependenceDrug Abuse or Dependence 6868 22 22

(Source: Lasser et al., JAMA. 2000;284:2606-2610)(Source: Lasser et al., JAMA. 2000;284:2606-2610)

Smoking Status and Mental Illness:Smoking Status and Mental Illness:The National Comorbidity SurveyThe National Comorbidity Survey

1515

0

10

20

30

40

50

60

% Who Are Smokers

0 1 2 3 4 >4

No. of Lifetime Psychiatric Diagnoses

% Heavy Smokers

% Light-ModerateSmokers

(Adapted from Lasser et al., 2000)(Adapted from Lasser et al., 2000)

Smoking Rate and Number of Smoking Rate and Number of Lifetime Psychiatric DiagnosesLifetime Psychiatric Diagnoses

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Tobacco Dependence and Tobacco Dependence and Mental IllnessMental Illness

• Smokers with mental illnesses are aware of the Smokers with mental illnesses are aware of the health risks of smokinghealth risks of smoking

• However, nicotine may alleviate positive and However, nicotine may alleviate positive and negative psychiatric symptoms as well as side negative psychiatric symptoms as well as side effects of psychiatric medicationseffects of psychiatric medications

• Effective smoking cessation treatments are Effective smoking cessation treatments are available for smokers with mental illnessavailable for smokers with mental illness

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U.S. Public Health ServiceU.S. Public Health ServiceClinical Practice GuidelineClinical Practice Guideline

Michael C. Fiore, MD, MPHMichael C. Fiore, MD, MPHPanel ChairPanel Chair

Published June, 2000Published June, 2000

Evidence-basedEvidence-based

50 meta-analyses of 50 meta-analyses of 6000 articles (1975-1999)6000 articles (1975-1999)

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Putting the 5 A’s into PRACTICE: Putting the 5 A’s into PRACTICE: ASK – ADVISE – ASSESS – ASK – ADVISE – ASSESS – ASSISTASSIST- ARRANGE- ARRANGE

• Help develop a quit planHelp develop a quit plan

• Provide practical counselingProvide practical counseling

• Provide intra-treatment social supportProvide intra-treatment social support

• Encourage the smoker to seek social supportEncourage the smoker to seek social support

• Recommend pharmacotherapy except in special Recommend pharmacotherapy except in special circumstancescircumstances

• Provide supplementary materialsProvide supplementary materials

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•The Guideline recommends the use of FDA-approved The Guideline recommends the use of FDA-approved

pharmacotherapy, except when contraindicatedpharmacotherapy, except when contraindicated

First-line medicationsFirst-line medications: : Bupropion SR, nicotine patch, Bupropion SR, nicotine patch, nicotine gum, nicotine inhaler,nicotine gum, nicotine inhaler,nicotine nasal spraynicotine nasal spray

• Second-line medicationsSecond-line medications: Clonidine, nortriptyline: Clonidine, nortriptyline

(Although not available when the 2000 Guideline was (Although not available when the 2000 Guideline was developed, consider OTC nicotine lozenge, varenicline)developed, consider OTC nicotine lozenge, varenicline)

ASK – ADVISE – ASSESS – ASK – ADVISE – ASSESS – ASSISTASSIST- ARRANGE- ARRANGEPharmacotherapyPharmacotherapy

2020

• The Guideline recommends that The Guideline recommends that ALLALL smokers smokers trying to quit should be offered cessation trying to quit should be offered cessation medication except for special circumstances:medication except for special circumstances:

- medical contraindications- medical contraindications

- smoke < 10 cigarettes/day- smoke < 10 cigarettes/day

- pregnant/breastfeeding- pregnant/breastfeeding

- adolescent smokers- adolescent smokers

Who Should Receive Pharmacotherapy?Who Should Receive Pharmacotherapy?

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Guideline Recommendations for Smokers Guideline Recommendations for Smokers With Psychiatric ComorbiditiesWith Psychiatric Comorbidities

• The antidepressants bupropion SR and nortriptyline The antidepressants bupropion SR and nortriptyline should be considered for smokers with current or past should be considered for smokers with current or past history of depressionhistory of depression

• Stopping smoking may affect the pharmacokinetics of Stopping smoking may affect the pharmacokinetics of certain psychiatric medications: need to monitorcertain psychiatric medications: need to monitor

• No specific recommendations in the Guideline for No specific recommendations in the Guideline for treating smokers with anxiety disorderstreating smokers with anxiety disorders

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General Recommendations for General Recommendations for Depressed Smokers Depressed Smokers

• Smoking cessation treatment can be initiated in Smoking cessation treatment can be initiated in depressed smokers who are motivated to quit and depressed smokers who are motivated to quit and clinically stableclinically stable

• Consider prescribing bupropion SR or nortriptyline (as Consider prescribing bupropion SR or nortriptyline (as appropriate given other possible psychotropic meds)appropriate given other possible psychotropic meds)

• Consider nicotine replacement therapy (NRT) either as Consider nicotine replacement therapy (NRT) either as a first-line pharmacotherapy or to augment bupropion a first-line pharmacotherapy or to augment bupropion SR or nortriptylineSR or nortriptyline

2323

General Recommendations for General Recommendations for Depressed Smokers Depressed Smokers

• Consider varenicline as another first-line Consider varenicline as another first-line pharmacotherapy but do not combine with NRTspharmacotherapy but do not combine with NRTs

• There are no clinical studies of varenicline in There are no clinical studies of varenicline in combination with bupropion SR or nortriptyline (no combination with bupropion SR or nortriptyline (no concern about drug interactions according to Michael concern about drug interactions according to Michael Fiore, M.D.)Fiore, M.D.)

• Consider referral to a mental health specialist Consider referral to a mental health specialist especially if the smoker’s depression is not responding especially if the smoker’s depression is not responding to antidepressant pharmacotherapy aloneto antidepressant pharmacotherapy alone

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General Recommendations for General Recommendations for Smokers With an Anxiety DisorderSmokers With an Anxiety Disorder

• Smoking cessation treatment can be initiated in anxious Smoking cessation treatment can be initiated in anxious smokers who are motivated to quit and clinically stablesmokers who are motivated to quit and clinically stable

• Neither bupropion SR nor nortriptyline are Neither bupropion SR nor nortriptyline are recommended for patients with anxiety disordersrecommended for patients with anxiety disorders

• SSRIs and benzodiazepines are commonly prescribed SSRIs and benzodiazepines are commonly prescribed for anxious patients; neither of these has shown for anxious patients; neither of these has shown efficacy for smoking cessationefficacy for smoking cessation

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General Recommendations for General Recommendations for Smokers With an Anxiety DisorderSmokers With an Anxiety Disorder

• Consider nicotine replacement medication as the first-Consider nicotine replacement medication as the first-line pharmacotherapyline pharmacotherapy

• Consider varenicline as another first-line Consider varenicline as another first-line pharmacotherapy but do not combine with NRTspharmacotherapy but do not combine with NRTs

• Consider referral to a mental health specialist Consider referral to a mental health specialist especially if the smoker’s anxiety is not responding to especially if the smoker’s anxiety is not responding to pharmacotherapy alonepharmacotherapy alone

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Real-World Use of Real-World Use of Combination PharmacotherapyCombination Pharmacotherapy

Source: University of Medicine & Dentistry of New Jersey – Tobacco Dependence Clinic – Annual Report 2004Source: University of Medicine & Dentistry of New Jersey – Tobacco Dependence Clinic – Annual Report 2004

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Case StudiesCase Studies

Patient APatient A Patient BPatient B

Psychiatric Psychiatric DiagnosisDiagnosis

Dysthymia,Dysthymia,

Tobacco Use DisorderTobacco Use Disorder

Adj Disorder w/Anxiety,Adj Disorder w/Anxiety,

Tobacco Use DisorderTobacco Use Disorder

Age, Race, SexAge, Race, Sex 60 y.o., White, Female60 y.o., White, Female 25 y.o., White, Female25 y.o., White, Female

Date Tx Initiated Date Tx Initiated for Psychiatric for Psychiatric ConditionCondition

June 2002June 2002

(33 Tx sessions to date)(33 Tx sessions to date)

August 2006August 2006

(7 Tx sessions to date)(7 Tx sessions to date)

Status of Quit Status of Quit Attempts During Attempts During Current Treatment Current Treatment With Dr. SmithWith Dr. Smith

Patient has been unable to Patient has been unable to quit quit at allat all despite setting quit despite setting quit dates (QDs) for:dates (QDs) for:

January 1, 2004January 1, 2004

February 2004February 2004

June 2006June 2006

(Next: January 1, 2007;(Next: January 1, 2007;

wants to use varenicline)wants to use varenicline)

Patient quit on Sept 10Patient quit on Sept 10thth

She elected to use the She elected to use the 14 mg nicotine patch 2 14 mg nicotine patch 2 weeks, then 7 mg patch weeks, then 7 mg patch for 2 weeksfor 2 weeks

Has been successfully Has been successfully quit for 6 weeksquit for 6 weeks

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Stevens S. Smith, Ph.D.Stevens S. Smith, Ph.D.Phone: 608-262-7563Phone: 608-262-7563

sss@ctri.medicine.wisc.edu

www.ctri.medicine.wisc.eduwww.ctri.medicine.wisc.edu

Contact InformationContact Information