nicotine dependence andnicotine dependence and evidence ... · smoking cessation medication...

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Nicotine Dependence AndNicotine Dependence And Evidence-Based Treatment

Richard S Lang, MD, MPH, FACPChairman, Preventive Medicine

DOS CME Course 2011DOS CME Course 20111 Oxtober 20101Confidential

Vice-Chair, Wellness Institute

Raul J Seballos, MD, FACPVice-Chair, Preventive MedicineWellness Institute

February 24, 2011April 7, 2011

© Cleveland Clinic 2011

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Deaths Attributed to Cigarette Smoking

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SOURCE: MMWR 2005; 54 (25): 625-8

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Tobacco use is a risk factor for 6 of 8 leading cause of death in the world

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Source: WHO Report 2008

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Deaths and Disease in the USA from Tobacco Use

Kids under 18 alive today who will ultimately Kids under 18 alive today who will ultimately die from smoking (unless smoking rates die from smoking (unless smoking rates decline)decline)

6,000,000+6,000,000+

People in the USA who currently suffer from People in the USA who currently suffer from smokingsmoking--caused illnesscaused illness

8.6 million8.6 million

Smoking kills more people than alcohol, AIDS, car accidents, Smoking kills more people than alcohol, AIDS, car accidents, illegal drugs murders and suicides combinedillegal drugs murders and suicides combined

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illegal drugs, murders, and suicides combinedillegal drugs, murders, and suicides combined

Source: “Cigarette Smoking-Attributable Morbidity – United States, 2000” MMWR 52(35): 842-844, September 5, 2003.

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Risks of Tobacco Use

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Health Benefits of QuittingImmediate: Air around is not dangerous to peopleImmediate: Air around is not dangerous to people

20 Minutes20 Minutes: Blood : Blood Pressure DropsPressure Drops 24 Hours:24 Hours: Chance for Chance for

heart attack decreasesheart attack decreases

2 to 12 Weeks:2 to 12 Weeks:Circulation improvesCirculation improves 1 year:1 year: Excess risk of Excess risk of

heart disease drops to heart disease drops to ½ of a smoker½ of a smoker

5 to 15 Years:5 to 15 Years:Stroke risk isStroke risk is

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Stroke risk is Stroke risk is reduced to that of reduced to that of a non smoker a non smoker

10 Years:10 Years: Risk of Risk of cancer of lung, mouth, cancer of lung, mouth, throat, esophagus, throat, esophagus, bladder, kidneys, and bladder, kidneys, and pancreas decreasespancreas decreases

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Math of Smoking

1 Week 1 Month 1 Year 5 Years 10 Years

$3.50 $24.50 $105.00 $1,277.50 $6,387.50 $12,775.00

$4.50 $31.50 $135.00 $1,642.50 $8,212.50 $16,425.00

$5.50 $38.50 $165.00 $2,007.50 $10,037.50 $20,075.00

$6.50 $45.50 $195.00 $2,372.50 $11,862.50 $23,725.00

Pack a day for 30 yearsPack a day for 30 years

ff

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Lifetime cigarette count: 219,000Lifetime cigarette count: 219,000

Lifetime puff count: 2.2 millionLifetime puff count: 2.2 million

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Forms of Tobacco

Cigarette Flavored (small) cigarsBidis

Cigars

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PipesSmokeless TobaccoKreteks

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Newer Trends

Snus E-cigarette

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HoukaDissolvable

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Nicotine Dependence

• Nicotine is a highly addictive substance that occurs naturallyNicotine is a highly addictive substance that occurs naturally in tobacco.

• It is a poisonous and oily substance that turns brown upon exposure to air.

• In concentrated form, nicotine is used as a potent insecticide.

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• One drop of pure nicotine can cause respiratory failure, paralysis and death.

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Pharmacology

Pharmacokinetics Ph d iPharmacokinetics• At physiologic pH, nicotine is

readily absorbed

• Absorption in lungs, bowels, and skin

• Rapid distribution, in the brain in 7-11 seconds

• Hepatic metabolism: 70% cotinine in urine

PharmacodynamicsCNS

PleasureArousal↑task performanceAnxiety relief

CV Heart rate Cardiac output Blood pressure

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• Half life: Nicotine =2 hr and cotinine = 16 hr

• Excretion through kidneys and breast milk

Blood pressureCoronary vasoconstrictionCutaneous vasoconstriction

OTHERAppetite suppressionIncreased metabolic rateSkeletal muscle relaxation

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Dependence and Withdrawal Cycle

Body becomes accustomed to having nicotine regularly.

Tolerance develops from repeated exposure.

Behavioral aspects are associated with addiction

B i ithi h t ft

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Begin within an hour or two after they stop, peak for several days, and may last several weeks

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What Are Nicotine Withdrawal Symptoms?

Ni ti ithd l d i h t i d b f f thNicotine withdrawal syndrome is characterized by four or more of the following signs:

– Dysphoric or depressed mood– Insomnia– Irritability, frustration, or anger– Anxiety– Difficulty concentrating

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– Restlessness or impatience– Decreased heart rate– Increased appetite or weight gain–– Cravings for cigarettes or chew is not a DSMCravings for cigarettes or chew is not a DSM--IV symptom IV symptom

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Comparing Nicotine to Other Drugs

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Source: Henningfield; JE; New York Times, Aug. 2, 1994 "Is Nicotine Addictive? It Depends on Whose Criteria You Use." .

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Comparing Nicotine to Other Drugs

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1. Hunt et al. J Clin Psychol. 1971;27(4):455-456.

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What Do We Know About Smokers?


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Belief in Success

• Almost 50% of smokers regard quitting as difficult calling itAlmost 50% of smokers regard quitting as difficult, calling it “very hard” or “almost impossible”

• Smokers remain confident of success, with up to 78% expecting to quit in the next year despite as many as 9 failed quit attempts in the past

• Confidence in quitting is essential to successfully quitting

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• As many as 85% of smokers who fail to quit will regroup to make future quit attempts

1. Weinstein et al. Nicotine Tob Res. 2004;6(suppl 3):S375-S380. 2. Miller et al. Motivational Interviewing: Preparing People for Change. 2002:111-125. 3. Prochaska et al. Am Psychol. 1992;47(9):1102-1114.

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Physician Support In Relation To Smoking

• 82% of respondents said that they would feel comfortable asking their physician about quitting smoking

• A physician’s advice to stop smoking can increase the rate of smoking cessation among

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patients by approximately 30%

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When Talking To Their Physicians About Smoking

• 54% of respondents felt the negative emotions54% of respondents felt the negative emotions while 28% reported the positive feelings of motivation, pleasure, or confidence

• 20% were provided with self-help cessation materials

• Less than half (44%) were recommended a

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smoking cessation medication

*Responses to a national online survey of 2037 adult smokers, conducted from November 13 through December 12, 2008.1†Responses to the question, “How comfortable would you feel asking [your/a] health care provider (doctor, nurse, nurse practitioner, or physician assistant) about quitting if you wanted to quit smoking?” Response options: “very comfortable,” “somewhat comfortable,” “somewhat uncomfortable,” “very uncomfortable.”1

‡Responses to the question, “[During your last visit/The last time you discussed the issue of smoking] with your health care provider (doctor, nurse, nurse practitioner, or physician assistant) did he or she provide you with self-help cessation materials or information about classes and counseling programs, show you a video about quitting, or make a referral to a cessation specialist?”1

§Responses to the question, “[During your last visit/The last time you discussed the issue of smoking] with your health care provider (doctor, nurse, nurse practitioner, or physician assistant) did he or she make recommendations about prescription or over-the-counter medications that may help you quit smoking? Please select all that apply.” Response options: “Yes, he/she recommended prescription medications,” “Yes, he/she recommended over-the-counter medications,” “No, he/she did not recommend or prescribe any medications to help me quit smoking.”1

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How to start


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The 5A’s or 3 A’s/R

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REFER the patient to a resource to help with quit effort

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The Basic Dialogical Model Of Health Behavior Change1

Establish rapport

Exc

hang

e nf

orm

atio

n Reduce

resistance

Assess importance and confidence

Single behavior

Set agenda

Multiple behaviors

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Explore importance1. Rollnick et al. Health Behavior Change: A Guide for Practitioners. 1999:3-15.

E in

Build confidence

Assess importance and confidence(and readiness)

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Strategies For Implementing Health Behavior Change: Assessing Readiness To Change

5 t f h 1Precontemplation

Contemplation

A ti

Preparation

• 5 stages of change1

– Useful for selecting appropriate interventions

• By identifying a patient’s position in the change process, health care providers can tailor their intervention1

• The focus is not to convince

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Action

Maintenance

• The focus is not to convince the patient to change behavior, but to assess current readiness to change and then help the patient move along the stages of change1

1. Prochaska et al. Am Psychol. 1992;47(9):1102-1114.

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Approaches To Therapy Of Tobacco DependenceSmoking cessation presents difficult physical and behavioralchallengeschallenges

According to the US Public Health Service clinical practice guideline: The combination of counseling and medication is more effective for smoking cessation than either alone 4

Physical challengesWhen they smoke: Smokers experience reward/satisfaction due to increased dopamine release; this encourages them to keep smoking.1,2

When they stop smoking: Smokers experience craving and withdrawal symptoms that drive them to smoke again.1,2

Behavioral challenges

+

Pharmacotherapy

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smoking cessation than either alone.4

1. DiFranza et al. Nicotine Tob Res. 2005;7(1):9-26. 2. Dani et al. Pharmacol Biochem Behav. 2001;70:439-446.3. Rigotti. N Engl J Med. 2002;346(7):506-512. 4. Fiore et al. Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update. 2008.

Behavioral challengesDaily activities—such as having a morning cup of coffee or taking a break at work—may trigger the desire to smoke.3

Counseling

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Ensure Follow-up Contact

• Follow-up contact should begin soon after the quit dateFollow up contact should begin soon after the quit date, preferably during the first week

• Identify problems already encountered and anticipate challenges in the immediate future

• Assess medication use and problems

• For patients who relapse, identify reasons why they did not

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p p y y ysuccessfully quit and recommend that they try again

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Variables Associated With High Or Lower Quit Rates

Higher Abstinence Rates Lower Abstinence Rates

High motivation High nicotine dependence

Ready for change Psychiatric co morbidity or substance abuse

Moderate to high self-efficacy High stress level

Supportive social network Exposure to other smokers

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pp p

Source: Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline Rockville, MD: USDHHS, PHS.

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Does it work?


Screening System for Tobacco Users

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Specific Populations of Successful Cessation Efforts

HIV-positive

Hospitalized Patients

Lesbian/Gay/Bisexual/Transgender

Low-SES

Medical Co-Morbidities

Older Smokers

Psychiatric disorders including substance abuse

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Racial/Ethnic Minorities

Women

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Effectiveness of Intervention Formats

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Intensity of Intervention

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Number of Sessions for Effectiveness

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Typical Long Term Quit Rates

SupportBriefNo SupportGroup

Brief Advice

NoTherapy

30%20%10%Medication

15%10%5%No medication or placebo

H i l l

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Having a support group or support plan to supplement medications may increase your chances of quitting.

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Medications for Cessation

1984

Nicotine gum

Nicotine patch

1991

1997

2002

Nicotine nasal inhalerBupropion SR

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Nicotine patch

1996 2006Nicotine nasal spray

OTC gum & patch

Nicotine lozenges

Varenicline

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FDA Approved Smoking Cessation Products

Type of Product Over-the-Counter Prescriptionyp p

Nicotine patch Nicotrol®

Nicoderm CQ®

Nicotine gum Nicorette®

Nicotine inhaler Nicotrol Inhaler®

Nicotine nasal spray Nicotrol NS®

Ni ti l C it®

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Nicotine lozenge Commit®

Non-nicotine Buproprion (Zyban)®

Varenicline (Chantix)®

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Medication Effectiveness


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Medication Effectiveness



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Varenicline

A 12-Week Prescription:• CHANTIX should be taken after eating and with a full glass (8 ounces) of water. • A 12-week CHANTIX prescription includes 1 Starting Month PAK and 2 Continuing Month PAKS

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A 12 week CHANTIX prescription includes 1 Starting Month PAK and 2 Continuing Month PAKS. • Within each one-month PAK are 4 Weekly doses of CHANTIX.

The first week:• In the first week of CHANTIX, white pills are taken. • During days 1-3, take 1 white pill (0.5 mg) daily. • During days 4-7, take 1 white pill twice daily.

The remaining weeks:• During weeks 2-12, take 1 blue pill (1 mg each) twice daily.

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Agent Advantages Disadvantages

Nicotine gum Less expensive than other forms of nicotine.

Chewing replaces smoking habit.

No prescription.

Some find taste unpleasant

Nicotine patch Less expensive.

No prescription.

Some skin irritation

Nicotine spray Some prefer this delivery method. More expensive.

Prescription required.

Safety not established for > 6 mth use

Nicotine lozenge Some prefer this delivery method. More expensive.


Not recommended for > 6 mth use

Bupropion Some antidepressant activity. May be good option for pts with history of


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good option for pts with history of depression Other drug interactions.

Safety during pregnancy unclear

Varenicline No hepatic clearance.

No sig drug interactions


Avoid in kidney disease.

Sleep disturbance, fatigue, drowsiness, constipation, flatulence, nausea

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Integrative Therapies

Acupuncture Lobeline

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LaserHypnosis

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Defining Success

• Clinicians must adjust their definition of success whenClinicians must adjust their definition of success when treating the tobacco-dependent patient

• Clinicians are accustomed to near 100% success with some other conditions – e.g., vaccinating a patient against rubella

– e.g., treating a bacterial infection with antibiotics

• For the dependent tobacco user must learn to

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• For the dependent tobacco user - must learn to consider a 10%–20% quit rate as success

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Conclusions

Single greatest cause of preventable death in the United States g g p(and the world) today.

Any cessation effort will produce a better outcome

Tobacco use needs to be treated as a chronic disease

Counseling and medication combinations yield higher success rates, “cold turkey not the best”

S d i t ll ti t

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Screen and intervene all patients

Most tobacco users don’t plan to fail, they fail to plan

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Acknowledgements

Iyaad Hasan DNP©, MSN, CNP, CTTSy , , ,

Director of Cleveland Clinic’s Tobacco Treatment Center


Thank you!


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