Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
In the Clinic Smoking Cessation © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (3): ITC3-1. What health problems have definite links to tobacco use? Cancer (≈ 1/3 U.S cancer deaths attributable to smoking) COPD and asthma exacerbations CAD, cerebrovascular disease, PVD, aortic aneurysms Low birthweight and premature babies, possible increased risk for miscarriage Ectopic pregnancy and orofacial clefts Heart attack, stroke, and VTE while on birth control pills GERD Type 2 diabetes Age-related macular degeneration, cataracts Compromised immune system © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (3): ITC3-1. Which health problems are associated with secondhand smoke exposure? Adults Cancer CAD, stroke Adult-onset asthma Children Asthma, respiratory infection, reduced lung function Chronic otitis media Sudden infant death syndrome Low birthweight, premature birth © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (3): ITC3-1. What health benefits can smokers who quit anticipate? Symptoms Minutes-days: Lower BP; lower carbon monoxide; better stamina, smell, taste Lung function 2–4 weeks: Decreased respiratory infections 4–12 weeks: Improved lung function Cardiovascular disease 2–3 months: Improved circulation 1 year: 50% reduction for heart attack 5–15 years: Cardiovascular risk = never-smokers Cancer 10 years: risk for lung cancer reduced by half © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (3): ITC3-1. Is there an age after which smoking cessation no longer yields benefit? Smoking cessation benefits people of all ages Regardless of smoking history Older smokers may have: Increased motivation from health concerns and symptoms of tobacco-related illness Experience with what has been successful in past quit attempts Better access to treatment resources. © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (3): ITC3-1. CLINICAL BOTTOM LINE: Health Consequences of Smoking... Tobacco use affects nearly every organ system in the body Leads to heart disease, stroke, cancer, vascular disease, respiratory infections, diabetes, GERD Second-hand smoke also increase health risks Benefits of quitting start in minutes and continue for years Even after decades of smoking, stopping significantly reduces risk for death, slows deterioration of lung function Risk-reduction benefits especially significant for smokers with CAD, COPD, or those who are pregnant © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (3): ITC3-1. Why is it difficult for smokers to quit? Nicotine is highly addictive Severity of dependence often predicted by number of cigarettes smoked + time to first cigarette of the day Withdrawal symptoms include: Depressed mood, anxiety, irritability, restlessness, insomnia, increased appetite, difficulty concentrating Symptoms peak in first week, can continue ≥6 weeks Psychological cravings for nicotine can last longer Quitting smoking also requires behavior change Smoking is a comforting habit to many smokers © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (3): ITC3-1. How should clinicians screen for tobacco use, and when should they provide cessation counseling? Send a clear message to patients that the best prevention strategy is never to start Ask all patients if they smoke Most adults smokers became daily users before age 18, so opportunities for primary prevention greater for physicians who care for children For tobacco users seen in clinical settings: use “5 As” Brief clinical intervention: see next slide © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (3): ITC3-1. The 5 As ASK—About tobacco use at every encounter Identify and document tobacco use Consider systematic process (e.g., vital signs) ADVISE—To quit tobacco use Strong, clear, personalized message ASSESS—Willingness to quit If not ready, offer motivational counseling ASSIST—In quitting Set a quit date Address behavioral changes, pharmacotherapy, support ARRANGE—follow-up Monitor progress, side effects, withdrawal © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (3): ITC3-1. What effects do electronic cigarettes (e-cigarettes) have on public health? FDA: does not regulate these “tobacco products” No standardization in manufacturing process E-cigarette vapor Contains some toxins also found in tobacco smoke but at much lower levels No combustion of tobacco, thus no smoke or Carbon monoxide Because of the chemicals found in e-cigarette vapor, they cannot be declared safe © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (3): ITC3-1. Public health concerns about e-cigarettes What are the long-term health effects of e-cigarette use? Are they substantially less harmful than tobacco cigarettes? Could “less harmful” be misinterpreted as “safe”? Do the flavored e-cigarettes appeal to young people? Could they act as a “gateway product” to tobacco cigarettes or lead former smokers back to cigarettes? Do they renormalize smoking behavior in public? Could dual-use e-cigarettes with tobacco cigarettes maintain addiction in person who might otherwise quit? Are e-cigarettes useful as a smoking cessation product? © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (3): ITC3-1. CLINICAL BOTTOM LINE: Prevention of Smoking-Related Disease... Routinely ask all patients if they use tobacco Send a clear message that no level of tobacco use is safe Stopping smoking is most important health improvement smokers can achieve Physicians should utilize tobacco treatment resources E-cigarettes pose challenging public health issue not only for current smokers but for society in general © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (3): ITC3-1. What is the role of health care professionals in tobacco treatment? Variety of health care providers can reduce the impact of tobacco use in our society Physicians, dentists, psychologists, social workers, nurses, licensed professional counselors, respiratory therapists, pharmacists, health educators, addiction counselors, family therapists, health coaches Treatment team also includes certified tobacco treatment specialists Advanced training in evidence-based treatment Deliver interventions in individual and group settings Smoking cessation training programs increase likelihood physicians perform smoking cessation tasks © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (3): ITC3-1. Can smokers quit without any intervention? Some smokers succeed in stopping on their own Abstinence rate for unaided cessation < 5% Even simple advice from a physician or basic clinical interventions can aid cessation For more meaningful abstinence rates, comprehensive tobacco dependence treatment is best Strong dose-response relationship between duration and frequency of contact and successful treatment © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (3): ITC3-1. What behavioral interventions are effective? Utilize the “5 As” at every clinic visit Self-help therapy Apps, Web, and mobile interventions Motivational interviewing (collaborative, goal-oriented style of communication with focus on personal reasons for change) Individual therapy (training in practical problem-solving skills) Telephone therapy (quitlines provide access to support, and call-back counseling enhances their usefulness) Group therapy (provides mutual support from others) Acupuncture, hypnosis (evidence is insufficient) © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (3): ITC3-1. Which pharmacologic therapies are effective? Nicotine replacement therapy OTC: gum, patch, and lozenge form Prescription: oral inhaler and nasal spray Alleviate cravings and withdrawal symptoms Bupropion Nonnicotine drug inhibits serotonin, norepinephrine, and dopamine Varenicline Nonnicotine drug acts at the α4-β2–nicotinic receptor as a partial agonist and antagonist Pharmacotherapy + behavioral therapy increases success Combining some of these medications may have added benefit © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (3): ITC3-1. When should clinicians consider pharmacologic interventions, and how should they select a therapy? All smokers should receive pharmacotherapy unless it is contraindicated Efficacy of all 1st-line FDA-approved medications similar Choice should be guided by patient preference, clinician familiarity, comorbidities and side effect profile, patient experiences, access, cost When patients are paying out-of-pocket, generic patch and gum are less expensive options Explain how each of these medications work and show patient how to use them © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (3): ITC3-1. Are there conditions that contraindicate or caution against pharmacologic therapy? NRT Concern re: concomitant smoking less valid than believed Use caution within 2 weeks of recent MI, severe angina, or life-threatening arrhythmias Bupropion Contraindicated: recent history of seizures Drug interactions with antipsychotics and MAO inhibitors or drugs with MAO inhibitor-like activity Associated with hypertension (monitor blood pressure) Varenicline Concerns regarding neuropsychiatric effects (erratic and hostile behavior) and possibly cardiovascular events Use cautiously in patients with renal impairment © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (3): ITC3-1. How long should patients use pharmacologic therapy before it is considered ineffective? Use for as long as clinically necessary NRT: typically prescribed for 8-12 weeks Some who quit continue to use NRT to prevent relapse Bupropion: typically prescribed for 8-12 weeks Safely used for long periods in treatment of depression Approved for long-term maintenance of cessation Varenicline: can be used up to 24 weeks to prevent relapse Safety established for up to 1 year Pretreatment with varenicline may be beneficial © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (3): ITC3-1. What strategies are effective to prevent relapse after quitting? Relapse is part of natural history of tobacco dependence Many patients require several attempts before achieving durable abstinence Relapse prevention can be useful in certain settings Behavioral intervention: insufficient evidence to support the use of any specific intervention to avoid relapse Strongest evidence is for interventions focused on identifying and resolving tempting situations Pharmacotherapy: mixed evidence for extended treatment © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (3): ITC3-1. Should patients switch to other tobacco products or e-cigarettes if they are unable to stop tobacco use? Overall goal: abstain from all forms of tobacco Combusted tobacco products likely the most harmful But less harmful is not equivalent to safe Smokeless tobacco products sometimes perceived as “safer than cigarettes” Amount of nicotine, carcinogens, other toxins varies Associated with CVD, cancer, dental and periodontal disease, pregnancy-related problems, nicotine addiction E-cigarettes: evidence needed that they’re both safe and effective for increasing tobacco cessation rates Focus treatment on evidence-based, FDA-approved treatments © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (3): ITC3-1. Are there adverse effects of smoking cessation that clinicians should prepare patients for? Weight Gain Can trigger resumption of smoking, and often used as an excuse not to quit in the first place Depression Depressive symptoms may develop due to nicotine withdrawal and may be severe enough to warrant treatment Bupropion and nortriptyline recommended for smokers with depression who are trying to quit © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (3): ITC3-1. CLINICAL BOTTOM LINE: Treatment... Routinely ask all smokers about tobacco use, advise them to quit, and assess their readiness to do so Tobacco dependence is a chronic condition Not just “bad habit” that can be ameliorated by willpower Dopamine release makes nicotine extremely addictive Use comprehensive, evidence-based treatment FDA-approved medications Behavioral counseling Social support Consider patient preferences, medical comorbidities, side effects, cost, access, smoking behaviors, prior quit attempts © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (3): ITC3-1.