“How to Stop Blowing Smoke”

1. “How to Stop Blowing Smoke” Jennifer D. Gholson, M.D. Chief Medical Officer Information & Quality Healthcare

2. Treating the Tobacco Dependent PatientTobacco Cessation 101 Tobacco Basics Tobacco & Health Nicotine Dependence

3. The Basics “Cigarettes, some say, when used as directed by the manufacturer, are the most lethal product available for peacetime use in the United States.” Gold, MS (1995). The neurobiological effects of tobacco. In Drugs of abuse: A comprehensive series for clinicians. Volume 4, (p. 27). New York: Plenum Press.

4. Nicotine Dependence

5. Nicotine • Cardiovascular effects • Vasoconstrictor • Blood pressure • Heart rate • Weight suppression • Attention and memory • Endogenous opiods

6. Carbon Monoxide ( CO ) • Colorless, odorless gas • Replaces oxygen • Arterial wall damage • Cardiovascular disease risk

7. Carbon Monoxide Levels Normal Air 1-5 ppm EPA Warning 9 ppm Smokers’ Levels 25-50 ppm

8. Total Particulate Matter ( Tar ) • Solid matter in smoke; spit tobacco “juice” • 100’s of compounds • Carcinogenic properties

9. Tobacco & Health

10. Annual Deaths from Smoking Relative to Other Causes: 1990* McGinnis JM, et al., JAMA 1993 *Alcohol data from 1987

11. Deaths Attributable to Cigarette SmokingIn Excess of 430,000 Annually in the US CDC, MMWR, 8-27-93

12. Pulmonary Disease • Emphysema • Chronic Bronchitis • Asthma • Lung Cancer

13. Oral Diseases • Gingival inflammation and recession • Periodontal disease • Bone loss • Tobacco-induced lesions (Leukoplakia) • Squamous cell carcinoma

14. Snuff Dipper’s Lesion

15. US Cancer Death Rate by Site1930 - 1991 Women Men National Center for Health Statistics, 1994

16. Other Health Issues • Immune system • General illness • Hospital stay and recovery • Bone fracture • Facial wrinkles • Male sexual impotence (mixed data)

17. Role ofPsychological Factors • Environmental cues, negative mood (distress) and stressful events • Trigger urges • Adversely impact quitting / relapse • Social factors and coping style • Positive impact • Negative impact

18. FTND Item Content • Amount used per day • Greater use in morning • Duration from awakening to first use of the day • Difficulty refraining • Preference for first cigarette • Use tobacco even when ill

19. The 5A’s Approach • Ask • Advise • Assess • Assist • Arrange Designed for the busy office environment Flexible Easily implemented

20. General Considerations • Approach tobacco dependence as any other medical condition • Tobacco use is common, but expect the following: • Embarrassment re: usage, or failure to quit • Perceived need as a stress management tool • Concern over increased health insurance premiums • Confidentiality • HIPAA issues

21. ASK • Every patient/client, every time – consistency will make the person realize how important it is to quit • Document response in their record – tobacco use may be an important point in other reasons for their visit to you • Use motivational statements depending on their response: Never User “great , you are healthier for it” Former User “great job, keep up the good work” User “I would like to talk with you about quitting”

22. ADVISE Every User to Quit • Clear“I think that it is important for you to quit using tobacco now, and I will be happy to help you.” • Strong“In my opinion, quitting is the most important thing you can do for your health.” • Personalized“Your family history for cancer puts you at higher risk than others, and smoking increases that risk even more.”

23. ASSESS Motivation to Quit • 0 – 3 Low Motivation Not Ready to Quit • 4 – 7 Moderate Motivation May Be Ready to Quit • 8 – 10 High Motivation Ready to Quit

24. ASSIST with Quit Attempt • Set a Quit Date within 30 days • Use meaningful upcoming dates • Encourage serious effort • Emphasize complete abstinence • Provide self-help materials x

25. Managing Stress • Engage in distracting activities • Physical activity • Schedule time for hobbies • Relax…explore preferences • Enjoyable social activities

26. Quit Day Preparations • Inform supportive family & friends • Inform supportive tobacco users (not to offer any tobacco) • Throw away any remaining tobacco • Put away ashtrays, lighters, etc. • Negotiate smoke-free areas of home • Plan distracting activities

27. Managing Weight Gain • Typical 10 – 12 lb gain with cessation • Associated health risks minimal • Anticipation of gain is a better predictor of poor outcome over actual gain • NRT and Bupropion delay, but do not prevent weight gain • Clinical considerations: • Cessation first; option to target later • Modest increase in physical activity level • Modest changes in diet

28. Factors Associated with Readiness Nicotine Dependence Social Factors Psychological Dependence

29. Stopping Tobacco Use is a Process Contemplation Precontemplation Preparation Relapse Action Maintenance

30. Primary Symptoms ofNicotine Withdrawal • Dysphoric / Depressed Mood • Can last > 1 month • Difficulty Concentrating • Evident within 1st day of quitting • Peaks within 1 – 3 days • Lasts 3 – 4 weeks • Generally mild • Restlessness • Lasts < 1 month • Perceived as highly aversive • Increased Appetite / Weight Gain • Appetite change lasts 10 weeks • Decreased Heart Rate • Average decrease is 10 bpm • Insomnia • Evident within 1st day of quitting • Primarily sleep fragmentation; can lead to dysphoria • Some report decrease in sleep latency • Peaks within 1 – 3 days • Lasts 3 – 4 weeks • Irritability / Frustration / Anger • Can last > 1 month • 80% of quitters endorse this item • Anxiety • Often evident prior to quit attempt • Peaks within days • Lasts 3 – 4 weeks

31. ARRANGE for Follow-Up • Important contact points • 1-2 days prior to quit date • 1-2 weeks after quit date • Monthly while on meds • 3-6 month follow-up • Additional, as necessary • Types of contact • In person • Phone • Post card

32. Generally initiate at 21 mg Consider 14 mg if: Smoking 10 or less a day Weight < 100 lbs Side effects noted from 21 mg patch Not a rate fading method, however: Health-related concerns are minimal Tobacco use while on patch (or any NRT) may indicate insufficient dose Usage First patch applied on morning of quit day Place on different, non-hairy area of upper torso on waking May remove at night if vivid dreams or sleep interference occurs 8 – 12 weeks duration Can wean; not required Transdermal Nicotine Patch FDA Approved 1st Line Medication

33. Advantages Few contraindications Once a day dosing Steady state in plasma Higher compliance Patch Advantages & Disadvantages • Disadvantages • Less “control” • Even 21mg dose may be insufficient for some • Longer time to peak levels • Skin-related side effects common • Excessive sweating (use a stretchable, breathable tape like Cover Roll) • Insomnia • Caution with recent CV disease

34. Nicotine Polacrilex “Gum” • Up to 24 pieces per day • 2mg: up to 24 cigs / day • 4mg: 25+ cigs / day • Usage • One piece every 1 – 2 hours • Slowly chew – only a few times – then ‘park’ • Staged reduction – over several weeks • 12 weeks recommended FDA Approved 1st Line Medication

35. Advantages Flexible dosing – use as needed in high-risk situations Perceived control Oral substitute ‘Irregular’ smokers Non-stick, sugarless Orange / Mint / Original Disadvantages Adherence: More complex to use Chew / Park Chewing too much Drinking & eating Insufficient use common Unpleasant taste (Original) Mouth soreness Dyspepsia Cost Some abuse potential Gum Advantages & Disadvantages

36. Nicotine Inhaler FDA Approved 1st Line Medication • Produces a nicotine vapor that is absorbed in mouth and throat • Use 6 – 16 / day • Usage • 12 weeks of primary treatment, can taper over 6-12 additional weeks • 1 cartridge: 20 minutes continuous use • Cartridge good for 24 hours once opened • Stop if not quit in 4 weeks

37. Advantages Supports ad lib dosing Most similar to smoking – oral substitute Disadvantages Must actively manage treatment Mouth / throat irritation Expensive Lower dosing Caution with COPD Inhaler Advantages & Disadvantages

38. Nicotine Nasal Spray • Newer – limited data and clinical experience • Maximum of 40 doses per day (1 dose = 1 spray in each nostril) • 1 – 2 doses per hour; max 5 • Usage • 12 weeks, up to 6 months • Do not inhale while spraying • Stop if not quit in 4 weeks FDA Approved 1st Line Medication

39. Advantages Supports ad lib dosing High dose delivery: good option for highly addicted users Disadvantages Must actively manage treatment Nasal irritation Costly Caution with COPD NNS Advantages & Disadvantages

40. Nicotine Lozenge • Newer – less data and clinical experience • Up to 20 per day; 5 per 6 hour period • 4mg: smoke within 30 minutes of awakening • 2mg: smoke after 30 minutes • Absorbed via oral mucosa • Usage • Stop all tobacco • No eating or drinking 15 minutes before use • 12 weeks • It’s not the Ariva Cigalette FDA Approved 1st Line Medication

41. Advantages Ad lib dosing Oral substitute ‘Irregular’ smokers Perceived control Disadvantages Adherence Issues No drinking or eating Lozenge Advantages & Disadvantages

42. Bupropion SR • Therapeutic effect NOT based on antidepressant qualities • Set quit date 7 (PDR) to 14 (Guideline) days after initiating bupropion treatment • Usage • First 3 – 7 days: 150mg qd • Afterwards: 150mg bid • Active treatment: 7 – 12 weeks • D/C if no progress within 7 weeks • Tapering not necessary FDA Approved 1st Line Medication

43. Disadvantages Delay for therapeutic effect Contraindications / Warnings Seizure history Eating disorder Pregnancy Uncontrolled HTN Low BMI Heavy ETOH users Side Effects Agitation Insomnia Dry mouth Shakiness Sedation Advantages Can use while smoking Weight May be best choice for patients with a history of depression, or current depressive symptoms Bupropion SR Advantages & Disadvantages • Medication Interactions • MAOIs / TCAs • Ethanol / sedative withdrawal • NRT • Protease Inhibitors • Some SSRIs

44. Chantix (Varenicline) • Approved in May 2006 • Used as part of a cessation program • Oral medication – intended ONLY for tobacco cessation • 1 mg twice per day, 12 week treatment • Additional weeks improve quit compliance • Recommended only for adult use • Dose adjustment for severe renal impairment • Most common adverse side effects: - Nausea - Insomnia - Headache - Abnormal dreams

45. Other Points… • Expected course of treatment • First 24 to 48 hours often most difficult • Withdrawal symptoms peak within 1-3 weeks, then begin to fall • First 2 weeks: Highest relapse risk • First 3 months: Most relapses have occurred • Long-term relapses highlight need for: Chronic Management

46. AAFP Ask and Act Program • Coding guides/reimbursements • Integration into EHR • Group Visits • Patient Powerpoints • CME • Prescribing Guidelines

47. ACT Center • 15 locations throughout the state • Treatment if free (1 initial visit, 6 treatment visits and follow up as necessary) • Provides medications as appropriate • Follow 2008 PHS Clinical PracticeGuidelines

48. Mississippi Tobacco Quitline1-800-QUITNOW (1-800-784-8669) • No charge, professional cessation counseling over the phone • Eight weeks of the NRT patch or gum at no charge to qualified callers • Intake screening to ensure the most appropriate level of treatment • Follow up for 3, 6 and 12 months after quit • Consent/fax form in use with healthcare providers