What’s New in Tobacco Use Cessation

1. What’s New in Tobacco Use Cessation KY Cardiac Rehab Association Conference 3/15/2012 Audrey Darville, APRN, CTTS University of Kentucky

2. According to the Centers for Disease Control and Prevention and the World Health Organization: Tobacco’s Effects on Health Are the Single Greatest Cause of Preventable Death in Our Nation and Worldwide.

3. The Tobacco Industry wants us to believe tobacco use is a personal choice

4. The Problem • Tobacco dependence is not “just a habit”; it’s a chronic disease with devastating health effects Fiore, et al (2008) Clinical Practice Guidelines • Controlling for confounders, over half a million people die annually in the US from tobacco related causes that could have been preventedRostron(2011), Epidemiology • Even exposure to small amounts of direct or indirect tobacco smoke increase risk of CV mortality, the relationship is not linear Pope, et al (2009), Circulation

5. Tobacco Smoke is Deadly Tobacco Smoke is a toxic mix of over 7000 chemicals and compounds There is NO SAFE LEVEL of exposure to tobacco smoke. Damage from tobacco smoke exposure is IMMEDIATE. Surgeon General, 2010

6. How Does Tobacco Smoke Cause Vascular Disease? Surgeon General Report, 2010 • Oxidizing Chemicals cause inflammation, endothelial dysfunction, oxidation of LDL, and platelet activation • Carbon Monoxide reduces oxygen carrying capacity • Nicotine has a sympathomimetic effect and may also contribute to endothelial dysfunction, insulin resistance, and lipid abnormalities

7. For full discussion, see Benowitz (2003) Progress in Cardiovascular Diseases 46 (1), 91-111.

8. New Data on Smoking & Lung Disease Asthma, Smoking & Nicotine Dependence: “Nearly two-thirds of individuals with both asthma and nicotine dependence reported asthma onset at the same age as, or prior to, smoking initiation” McLeish, A.C., Cougle, J.R., & Zvolensky, M.J. (in press). Asthma and cigarette smoking in a representative sample of adults.  Journal of Health Psychology.

9. Gender & COPD Controlling for lung function reduction and COPD severity, women were: • younger • started smoking at a later age • had smoked fewer pack-years Differences were most pronounced in the early-onset and low exposure COPD subgroups Sorheim, I., Johannesen, A., Gulsvik, A., Bakke, P.S., Silverman, E.K., & DeMeo, D.L. (2010). Gender differences in COPD: are women more susceptible to smoking effects than men? Thorax,65, 480-485

10. What We Know About Tobacco Use • Nicotine is a highly addictive substance • Reward, Attention, Cognitive Control, Anxiety, Arousal are all affected by the action of nicotine on the brain • Genetic studies focus is on Gene-Environment interactions and find specific susceptibilities, particularly related to age of initial exposure, including in-utero exposure

11. Benefits of Quitting for Persons with CVD • 36% reduced mortality and 32% lower risk of re-infarction for patients with CHD who quit compared with those who continued smoking • As few as 3 cigarettes/day doubles a woman’s risk of having another MI • Multiple benefits have been identified (effects on lipids, endothelial dysfunction, inflammatory markers, drug efficacy, glucose metabolism) • BOTTOM LINE: Smoking cessation is a highly effective TREATMENT for CVD that SAVES patients lives and money!

12. We know: • 70% of smokers want to quit • Evidence based practice exists to help people quit but is underutilized • If a tobacco user is currently unwilling to make a quit attempt, motivational treatment should be provided.

13. Counseling Helps Motivate and Quit • All patients regardless of their readiness to quitbenefit from cessation treatment (Fiore & Baker, 2011) • Patients expect their healthcare providers to ask about tobacco use • Brief advice during a “window of opportunity” can increase quit attempts by 40% • Several models exist: Simplest is Ask, Advise, and Refer or Ask and Act

14. Treating Tobacco Use • There is a dose response curve with counseling: The more the better • Counseling and medication are effective and combining counseling and medication is more effective than either alone Treating Tobacco Use & Dependence clinical Practice Guideline, 2008

15. Components of Effective Addiction Counseling • Promoting Motivation to Quit: Develop discrepancies between current behavior and desired behavior • Promoting Confidence to quit: Develop a plan and useful tools to assist in changing behavior “Building Self-Efficacy”

16. Getting Started • Determine readiness to quit • Provide motivational counseling based on readiness • Develop a practical plan that is tailored to the individual and recognizes potential barriers to quit & triggers for smoking • Anticipate relapse and develop a plan to prevent it

17. Expectancies Matter and Are Dynamic and Changeable • Withdrawal/Aversion experiences • Expense • Improved health and physical functioning • Weight • Image and appearance • Social relationship changes • Self-esteem • Effectiveness of treatment • Cue sensitivity (Hendricks, Wood & Hall, 2009)

18. Quit Date Anxiety • Nearly half of smokers quit spontaneously; many of them stay quit (West & Sohal, BMJ, 2006) • Setting a quit date is recommended within 2 weeks for those willing to quit (TTUD CPG, 2008) • Quit dates are not an essential part of the quitting process for some • Tailored approaches based on prior Practice Quits can be helpful Quitting is a process, NOT a Pass/Fail Test!

19. Medication increases success in both quitting and staying quit • Nicotine Replacement: tailored, combination therapy is now becoming standard of care • Safe, effective, and low cost • OTC forms (patches, gum, lozenges) not generally covered by insurance; Medicaid in KY now covers with prescription) • A few insurers cover inhaler and nasal spray (prescription)

20. Tailoring NRT to the tobacco user • Studies show efficacy in smokers and smokeless tobacco users (Ebbert, et al, 2010) • Combining patch with shorter acting form of NRT has been shown to be safe and effective (Stead, et al, Cochrane Review, 2008; Kozlowski, et al, 2007) • Extended use of NRT or other medications is being shown to reduce relapse rates (Schnoll, et al, 2010) • High dose NRT is safe and effective for heavy smokers (Fredrickson, et al, 1995)

21. Nicotine and Cardiovascular Disease • Multiple studies have demonstrated no increased CVD risk with use of nicotine replacement products; CPG’s recommend caution when using in immediate post MI period • The harmful CV effects of smoking are well known and related to several factors, not just nicotine • Not treating tobacco use results in the greatest harm!

22. The Nicotine Replacement Debate • Recent study1 found that NRT was not effective in helping people stay quit • Numerous methodological issues with study • Released to popular media • This study is contrary to many others and the current treatment guidelines that recommend the use of NRT to help tobacco users quit 1 Alpert, et al, Tobacco Control 2012

23. Zyban (bupropion SR): • Contraindicated with history of seizures • Most effective when used with NRT • Carries black box warning regarding neuropsychiatric symptoms/suicide risk • Metabolism: CYP2B6 and CYP2D6; potential for interaction with class 1C antiarrhythmics/some beta blockers, warfarin, theophylline • Available generic; coverage/cost varies • Adjustable dosing: Usually 150 mg in AM first 3-5 days, then 150 bid, last dose with supper helps minimize insomnia

24. Chantix (varenicline): • Titrated dosing: begin with starter pack then continuation pack (1 mg. bid) for 14 weeks…or more • Nausea (up to 30%) and vivid dreams most common side effects; can be helped with slower titration of dose • Carries Black Box warning about serious neuropsychiatric symptoms • Most expensive option; available on some KY Medicaid, State health plan, Pfizer PAP

25. New Chantix CV Concerns: • Recent meta-analysis1 led FDA to issue statement regarding use in patients with CVD • Recommendations based on randomized clinical trial of 700 smokers with cardiovascular disease • Chantix may be associated with a small, increased risk of certain cardiovascular adverse events (not mortality) in patients with CVD • The absolute risk of cardiovascular adverse events with Chantix, in relation to its efficacy, is small 1 Singh, et al (2011) DOI:10.1503/cmaj.110218

26. Chronicity and Relapse • Relapse is common and expected • 2009 Cochrane Review concluded we know very little about effective relapse prevention strategies • Prolonged use of medication can be effective but barriers exist

27. Harm Reduction? • The Tobacco Industry wants us to believe Less Harm = Harmless • Light, Ultra Light terminology is bogus and now banned by the FDA • A lot of Harm Reduction science is funded by the Tobacco Industry

28. Smokeless Tobacco Can Kill • Less Harm ≠ No Harm • ST use has been associated with an increased risk of fatal MI and Stroke Piano, et al (2010), Yatsuya & Folsom (2010) • US Smokeless contains high concentrations of carcinogens: TSNA, NNN, NNK AND high concentrations of nicotine • Focus on tobacco use: most smokeless users don’t consider themselves “smokers” • “Dual use” is increasingly common • Tobacco industry is aggressively marketing smokeless products

29. Switch to Quit • Based on Swedish Model, where there is a high rate of snus use, and low rate of smoking • Funded by $3 million in unrestricted gifts by U.S. Smokeless Tobacco Company and Swedish Match North America, Inc. to the University of Louisville • Using Owensboro as a “lab” (Human Subjects Protection???) • Potential to provide valuable marketing information to the tobacco industry

30. A recent study found a significant reduction in exhaled nitrous oxide in electronic cigarette users Vardavas, et al. Chest 2011

31. What’s in that “vapor”? • Nicotine • Acetaldehyde • Formaldehyde • Acetone • Styrene • Propylene glycol • Xylene and more….

32. Years of Unbiased Research Informs us of What Works

33. And What Kills When Used as Directed

34. Association for the Treatment of Tobacco Use and Dependence An organization of providers dedicated to the promotion of and increased access to evidence-based tobacco treatment for the tobacco user. www.attud.org

35. Questions or Comments? Feel Free to Contact Me: audrey.darville@uky.edu 859-323-4222