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Rx for CHANGE

Rx for CHANGE. Clinician-Assisted Tobacco Cessation for Surgical Patients. Developed through a collaboration of the American Society for Anesthesiologists and the Rx for Change: Clinician-Assisted Tobacco Cessation program.

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Rx for CHANGE

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  1. Rx for CHANGE Clinician-Assisted Tobacco Cessationfor Surgical Patients Developed through a collaboration of the American Society for Anesthesiologists and the Rx for Change: Clinician-Assisted Tobacco Cessation program. Funded by the National Cancer Institute and the Robert Wood Johnson Foundation.

  2. TRAINING OVERVIEW • Epidemiology of Tobacco Use • Benefits of Quitting for Surgical Patients • Tobacco Dependence and Medications for Quitting • Changing Behavior – How You Can Help

  3. EPIDEMIOLOGY of TOBACCO USE

  4. is the chief, single, avoidable cause of death in our society and the most important public health issue of our time.” “CIGARETTE SMOKING… C. Everett Koop, M.D., former U.S. Surgeon General

  5. ADULT PER-CAPITA CONSUMPTION of TOBACCO, 1880–2005 All forms of tobacco are harmful. Year Adapted from NCI Smoking and Tobacco Control Monograph 8, 1997, p. 13. Data from U.S. Department of Agriculture. Reprinted with permission. Thun et al. 2002. Oncogene 21:7307–7325.

  6. TRENDS in ADULT SMOKING, by SEX—U.S., 1955–2006 Trends in cigarette current smoking among persons aged 18 or older 20.8% of adults are current smokers Male Percent 23.9% Female 18.0% Year 70% want to quit Graph provided by the Centers for Disease Control and Prevention. 1955 Current Population Survey; 1965–2005 NHIS. Estimates since 1992 include some-day smoking.

  7. TRENDS in TEEN SMOKING, by ETHNICITY—U.S., 1977–2007 Trends in cigarette smoking among 12th graders: 30-day prevalence of use White Percent Hispanic Black Institute for Social Research, University of Michigan, Monitoring the Future Project www.monitoringthefuture.org

  8. PUBLIC HEALTH versus “BIG TOBACCO” The biggest opponent to tobacco control efforts is the tobacco industry itself. Nationally, the tobacco industry is outspending our state tobacco control funding. For every $1 spent by the states, the tobacco industry spends $18 to market its products.

  9. TOBACCO INDUSTRY ADVERTISING $13.11 billion spent in the U.S. in 2005 $35.9 million a day 95% increase over 1998 figures New marketing restrictions Billions of dollars spent Year Federal Trade Commission. (2007). Cigarette Report for 2004 and 2005.

  10. The TOBACCO INDUSTRY For decades, the tobacco industry publicly denied the addictive nature of nicotine and the negative health effects of tobacco. April 14, 1994: Seven top executives of major tobacco companies state, under oath, that they believe nicotine is not addictive: http://www.jeffreywigand.com/7ceos.php (video) Tobacco industry documents indicate otherwise Documents available at http://legacy.library.ucsf.edu The cigarette is a heavily engineered product. Designed and marketed to maximize bioavailability of nicotine and addictive potential Profits over people

  11. ANNUAL U.S. DEATHS ATTRIBUTABLE to SMOKING, 1997–2001 Percentage of all smoking-attributable deaths* 32% 28% 23% 9% 8% <1% TOTAL: 437,902 deaths annually * In 2005, it was estimated that nearly 50,000 persons died due to second-hand smoke exposure. Centers for Disease Control and Prevention. (2005). MMWR 54:625–628.

  12. COMPOUNDS in TOBACCO SMOKE An estimated 4,800 compounds in tobacco smoke, including 11 proven human carcinogens Gases Particles • Carbon monoxide • Hydrogen cyanide • Ammonia • Benzene • Formaldehyde • Nicotine • Nitrosamines • Lead • Cadmium • Polonium-210 Nicotine is the addictive component of tobacco products, but it does NOT cause the ill health effects of tobacco use.

  13. 2004 REPORT of the SURGEON GENERAL:HEALTH CONSEQUENCES OF SMOKING Smoking harms nearly every organ of the body, causing many diseases and reducing the health of smokers in general. Quitting smoking has immediate as well as long-term benefits, reducing risks for diseases caused by smoking and improving health in general. Smoking cigarettes with lower machine-measured yields of tar and nicotine provides no clear benefit to health. The list of diseases caused by smoking has been expanded. FOUR MAJOR CONCLUSIONS: U.S. Department of Health and Human Services. (2004). The Health Consequences of Smoking: A Report of the Surgeon General.

  14. HEALTH CONSEQUENCES of SMOKING Cancers Acute myeloid leukemia Bladder and kidney Cervical Esophageal Gastric Laryngeal Lung Oral cavity and pharyngeal Pancreatic Pulmonary diseases Acute (e.g., pneumonia) Chronic (e.g., COPD) Cardiovascular diseases Abdominal aortic aneurysm Coronary heart disease Cerebrovascular disease Peripheral arterial disease Reproductive effects Reduced fertility in women Poor pregnancy outcomes (e.g., low birth weight, preterm delivery) Infant mortality Other effects: cataract, osteoporosis, periodontitis, poor surgical outcomes U.S. Department of Health and Human Services. (2004). The Health Consequences of Smoking: A Report of the Surgeon General.

  15. ANNUAL SMOKING-ATTRIBUTABLE ECONOMIC COSTS—U.S., 1995–1999 Prescription drugs, $6.4 billion Other care, $5.4 billion Medical expenditures (1998) Ambulatory care, $27.2 billion Hospital care, $17.1 billion Nursing home, $19.4 billion Societal costs: $7.18 per pack Annual lost productivity costs (1995–1999) Men, $55.4 billion Women, $26.5 billion Billions of dollars Centers for Disease Control and Prevention. (2002). MMWR 51:300–303.

  16. 2006 REPORT of the SURGEON GENERAL: INVOLUNTARY EXPOSURE to TOBACCO SMOKE • Second-hand smoke causes premature death and disease in nonsmokers (children and adults) • Children: • Increased risk for sudden infant death syndrome (SIDS), acute respiratory infections, ear problems, and more severe asthma There is no safe level of second-hand smoke. • Respiratory symptoms and slowed lung growth if parents smoke • Adults: • Immediate adverse effects on cardiovascular system • Increased risk for coronary heart disease and lung cancer • Millions of Americans are exposed to smoke in their homes/workplaces • Indoor spaces: eliminating smoking fully protects nonsmokers • Separating smoking areas, cleaning the air, and ventilation are ineffective USDHHS. (2006).The Health Consequences of Involuntary Exposure to Tobacco Smoke: Report of the Surgeon General.

  17. FINANCIAL IMPACT of SMOKING Buying cigarettes every day for 50 years @ $4.32 per pack Money banked monthly, earning 4% interest $755,177 $755,177 $503,451 $503,451 Packs per day $251,725 $251,725 Dollars lost, in thousands

  18. SMOKING CESSATION: REDUCED RISK of DEATH • Prospective study of 34,439 male British doctors • Mortality was monitored for 50 years (1951–2001) On average, cigarette smokers die approximately 10 years younger than do nonsmokers. Years of life gained Among those who continue smoking, at least half will die due to a tobacco-related disease. Age at cessation (years) Doll et al. (2004). BMJ 328(7455):1519–1527.

  19. QUITTING: HEALTH BENEFITS Time Since Quit Date Circulation improves, walking becomes easier Lung function increases up to 30% Lung cilia regain normal function Ability to clear lungs of mucus increases Coughing, fatigue, shortness of breath decrease 2 weeks to 3 months 1 to 9 months Excess risk of CHD decreases to half that of a continuing smoker 1 year Risk of stroke is reduced to that of people who have never smoked 5 years Lung cancer death rate drops to half that of a continuing smoker Risk of cancer of mouth, throat, esophagus, bladder, kidney, pancreas decrease 10 years Risk of CHD is similar to that of people who have never smoked after 15 years

  20. BENEFITS of QUITTING for SURGICAL PATIENTS

  21. Quitting Smoking Improves Surgical Outcomes Surgery May Promote Quitting Smoking WHY SHOULD SURGICAL PROVIDERS ADDRESS TOBACCO USE?

  22. TOBACCO CESSATION IMPROVES SURGICAL OUTCOMES Quitting reduces the incidence of: • Cardiovascular complications • Respiratory complications • Wound-related complications

  23. SHORT-TERM CARDIOVASCULAR BENEFITS OF SMOKING CESSATION • Nicotine • Half life, approximately 1–2 hours • Decreases in heart rate and systolic blood pressure within 12 hours • Carbon monoxide • Half life, approximately 4 hours • Carboxyhemoglobin level near normal at 12 hours • Preoperative abstinence decreases the frequency of intraoperative ischemia* *Woehlck et al. (1999). Anesth Analg 89:856-860.

  24. SMOKING CESSATION REDUCES POSTOPERATIVE COMPLICATIONS • 120 orthopedic patient randomized to tobacco intervention or control, 6–8 weeks prior to surgery • ~80% of intervention patients were able to quit or reduce smoking Møller et al. (2002). Lancet 359:114–117.

  25. Quitting Smoking Improves Surgical Outcomes Surgery May Promote Quitting Smoking WHY SHOULD SURGICAL CARE CLINICIANS BOTHER?

  26. SURGERY PROMOTES TOBACCO CESSATION • Opportunity for providers to intervene • Contact with healthcare system • Forced abstinence in smoke-free facilities • Major medical interventions improve quit rates • Occurs even in the absence of tobacco interventions • May also improve the effectiveness of tobacco interventions

  27. SMOKING CESSATION AFTER SURGERY Percent abstinent at 1 year

  28. BARRIERS TO PERIOPERATIVE SMOKING CESSATION • “Quitting just before surgery increases pulmonary complications.” • “Nicotine replacement therapy is dangerous.” • “Surgical patients are already too stressed.” • “Patients don’t want to hear about their smoking—they have enough to worry about.”

  29. RECENT SMOKING CESSATION DOES NOT INCREASE PULMONARY COMPLICATIONS • 300 patients for lung cancer resection • “Recent” quitters: >1 week, <2 months • “Past” quitters: >2 months Percent (n=13) (n=39) (n=184) (n=64) Barrera et al. (2005). Chest 127:1977–1983.

  30. NICOTINE REPLACEMENT THERAPY AND WOUND HEALING • 48 smokers randomized to continuous smoking or abstinence, with or without nicotine replacement • Standardized wounds over a 12-week period Percent Sorensen et al. (2003). Ann Surg 238:1–5.

  31. PERIOPERATIVE STRESS IN SURGICAL PATIENTS • 141 smokers, 150 non-smokers for elective surgery • Perceived stress measured from before surgery up to one week postoperatively (POD=postop day) • Smoking status does not affect changes in perceived stress • No evidence for significant cigarette cravings Time Warner et al. (2004). Anesthesiology 199:1125–1137.

  32. WHAT DO PATIENTS WHO SMOKE EXPECT? • Essentially all smokers are aware of general health hazards • Most are not aware of how it might affect their surgery – and want to know! • They want information and options • Almost all will not be offended if you discuss their smoking… • But they do not want a sermon Warner et al., unpublished observations.

  33. THE REAL BARRIERS TO INTERVENTION “I don’t know how.” “I don’t have time.” “It’s not my job.”

  34. TOBACCO DEPENDENCE:A 2-PART PROBLEM The addiction to nicotine The habit of using tobacco Treatment Treatment Medications for cessation Behavior change program Tobacco Dependence Physiological Behavioral Treatment should address the physiological and the behavioral aspects of dependence.

  35. TOBACCO DEPENDENCE and MEDICATIONS for QUITTING

  36. WHAT IS ADDICTION? ”Compulsive drug use, without medical purpose, in the face of negative consequences” Alan I. Leshner, Ph.D. Former Director, National Institute on Drug Abuse National Institutes of Health

  37. NICOTINE DISTRIBUTION Arterial Venous Nicotine reaches the brain within 11 seconds. Henningfield et al. (1993). Drug Alcohol Depend33:23–29.

  38. DOPAMINE REWARD PATHWAY Prefrontal cortex Dopamine release Stimulation of nicotine receptors Nucleus accumbens Ventral tegmental area Nicotine enters brain

  39. BIOLOGY of NICOTINE ADDICTION: ROLE of DOPAMINE Pleasurable feelings Repeat administration Tolerancedevelops Nicotine addiction Nicotine stimulates dopamine release is not just a bad habit. Discontinuation leads to withdrawal symptoms. Benowitz. (2008). Clin Pharmacol Ther 83:531–541.

  40. NICOTINE PHARMACODYNAMICS: WITHDRAWAL EFFECTS • Irritability/frustration/anger • Anxiety • Difficulty concentrating • Restlessness/impatience • Depressed mood/depression • Insomnia • Impaired performance • Increased appetite/weight gain • Cravings Most symptoms manifest within the first 1–2 days, peak within the first week, and subside within 2–4 weeks. HANDOUT Hughes. (2007). Nicotine Tob Res 9:315–327.

  41. NICOTINE ADDICTION Tobacco users maintain a minimum serum nicotine concentration in order to Prevent withdrawal symptoms Maintain pleasure/arousal Modulate mood Users self-titrate nicotine intake by Smoking/dipping more frequently Smoking more intensely Obstructing vents on low-nicotine brand cigarettes Benowitz. (2008). Clin Pharmacol Ther 83:531–541.

  42. FDA-APPROVED MEDICATIONS for SMOKING CESSATION Nicotine polacrilex gum (OTC) – brand (Nicorette), generic Nicotine lozenge (OTC) –brand (Commit), generic Nicotine transdermal patch (OTC, Rx) – brand (NicoDerm CQ, OTC), generic (OTC, Rx) Nicotine nasal spray (Rx) – brand (Nicotrol NS) Nicotine inhaler (Rx) – brand (Nicotrol Inhaler) Bupropion SR (Rx) – brand (Zyban), generic Varenicline (Rx) – brand (Chantix) OTC = Over the counter These are the only medications that are FDA-approved for smoking cessation.

  43. PHARMACOTHERAPY “Clinicians should encourage all patients attempting to quit to use effective medications for tobacco dependence treatment, except where contraindicated or for specific populations* for which there is insufficient evidence of effectiveness.” * Includes pregnant women, smokeless tobacco users, light smokers, and adolescents. Medications significantly improve success rates. Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.

  44. NRT: RATIONALE for USE Reduces physical withdrawal from nicotine Eliminates the immediate, reinforcing effects of nicotine that is rapidly absorbed via tobacco smoke Allows patient to focus on behavioral and psychological aspects of tobacco cessation NRT products approximately doubles quit rates.

  45. PLASMA NICOTINE CONCENTRATIONS for NICOTINE-CONTAINING PRODUCTS Cigarette Moist snuff 0 10 20 30 40 50 60 Time (minutes)

  46. NICOTINE GUM Resin complex of nicotine and polacrilin Sugar-free chewing gum base Contains buffering agents to enhance buccal absorption of nicotine Available: 2 mg, 4 mg; original, cinnamon, fruit, mint (various), and orange flavors

  47. NICOTINE LOZENGE Nicotine polacrilex formulation Delivers ~25% more nicotine than equivalent gum dose Sugar-free mint (various), cappuccino or cherry flavor Contains buffering agents to enhance buccal absorption of nicotine Available: 2 mg, 4 mg

  48. TRANSDERMAL NICOTINE PATCH Nicotine is well absorbed across the skin Delivery to systemic circulation avoids hepatic first-pass metabolism Plasma nicotine levels are lower and fluctuate less than with smoking Available: Brand or generic; nicotine delivery over 24 hours 21 mg, 14 mg, 7 mg

  49. NICOTINE NASAL SPRAY Aqueous solution of nicotine in a 10-ml spray bottle Each metered dose actuation delivers 50 mcL spray 0.5 mg nicotine ~100 doses/bottle Rapid absorption across nasal mucosa Available: Rx only

  50. NICOTINE INHALER Nicotine inhalation system consists of: Mouthpiece Cartridge with porous plug containing 10 mg nicotine and 1 mg menthol Delivers 4 mg nicotine vapor, absorbed across buccal mucosa Available: Rx only

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