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SMOKING CESSATION • Leading Preventable Cause of Death • 400,000 to 500,000 deaths per year in USA • 3 Million deaths world wide • 1 of every 6 deaths in USA Directly attributable to smoking • Yet — 46 Million continue to smoke SMOKING “A cigarette is a finely tuned drug delivery system” Katherine E. Hartman, MD SMOKING “Smoking is not a bad habit --- It is a chronic medical condition” Michael C. Fiore, MD SMOKING CESSATION • Why do we smoke? • Why should we stop/benefits? • How do we stop? Nicotine Dependence slide “As an addictive substance, nicotine, on a milligram for milligram basis, is 10 times more potent than heroin…” Sachs DPL. Advances in Smoking Cessation Treatment In: Simmons, ed. Current Pulmonology, Chicago; Year Book Medical Publishers, 1991, 12:139-198 SMOKING CESSATION Why Do We Smoke? 3-Pronged Dependency • Physiological • Psychological • Behavioral Why Do We Smoke? Physiological • Nicotine to brain – 7 seconds • Binds to nicotine receptors resulting in secretion of Dopamine • Causes a pleasurable sensation and cognitive arousal Physiological Increased Levels of: Norepinephrine Beta-Endorphin Acetylcholine Serotonin Glutamate Vasopressin Physiological • Enhance: – Concentration – Alertness – Memory • Decrease: – Tension – Anxiety Promotes feeling of well being SMOKING CESSATION Why should we stop smoking? Benefits: General Cardio-cerebrovascular Cancer Pulmonary SMOKING CESSATION • Long term tobacco use raises the risk of premature death by 50% * • Quitting at any age increases longevity • Those who quit smoking by age 50 decrease their risk of dying over the next 15 years by 50% compared with those who do not stop ** * W.H.O. Tobacco Dependency Fact Sheet #222 1999 ** U.S. Dept of Health & Human Services publication #90-8416 SMOKING CESSATION Why should we stop smoking? Benefits: General Cardio-cerebrovascular Cancer Pulmonary Why should we stop smoking? • 30% of all Cancer Deaths related to Smoking • 4000 Chemicals in Tar – 43 Carcinogenic Why should we stop smoking? • Lung Cancer – Most Common in Cancer – Oral – Throat – Esophagus – Bladder – Kidney – Pancreas – Stomach 9 fold increase 9 fold increase 75% in smokers 7 fold increase 5 fold increase 2 fold increase 1.5 fold increase Why should we stop smoking? Lung Cancer • Life Long risk in Non-Smoker – 1% • 15-25% risk in heavy smokers • Each Cigarette cuts 6 minutes off of life SMOKING CESSATION Why should we stop smoking? Benefits: General Cardio-cerebrovascular Cancer Pulmonary How Do We Stop Smoking? Problems • • • • Patient Motivation Physician Interest Medications Support Systems SMOKING CESSATION Patient Motivation • 70% want to quit • 2 large studies • Appropriate moment SMOKING CESSATION The Right Moment Acute MI Intervention 55% Minimal 34% Dornelas, E.A. Prev Med 2000; 30, 216-228 The Negatives • Physicians advising patients to stop 1975 – 38% 1983 – 42% 1991 – 48% • 1672 Ex-Smokers – 3.6% Physician Helped • 70% smokers see physician yearly SMOKING • 38 Family Practices • 2963 Smokers - Addressed in 21% • Increased to 58% if Doctor used standard forms for recording smoking status • When smokers identified – smoking cessation therapy started in only 38% • 68% of the offices had smoking cessation material J. Fam. Pract. 2001; 50: 688-9 Physicians Role in Smoking Cessation The Positives • • • • • Admit Nicotine is an Addiction Provide information Show an interest Train office personnel Select the opportunity SMOKING CESSATION The 5 A’s Ask Advise Assess Assist Arrange Planning a Program • Establish degree of nicotine dependency – Serum Cotinine Level – Fagerstrom Test • • • • Quit Date Support Group Behavioral Modification Discuss Relapses & Weight Gain Pharmacologic • Nicotine Replacement • Bupropion Planning A Program • Low Dependency – Nicotine Replacement • High Dependency – Bupropion + – Nicotine Replacement x 2 Nicotine Replacement N=504 Patch Gum Spray Inhaler 21% 20% 24% 24% Arch. Int. Med. September 27, 1999 Nicotine Replacement Gum – 1984 Advantages Disadvantages •Neutral PH •Heartburn and Indigestion •More Rapid •Throat and Mouth Irritation •Adjunct •Sore Jaw •Flatulence Nicotine Replacement Patch – 1991 Advantages Disadvantages •Convenient •Skin Irritation •Best Compliance •Over the counter •30-40% while on patch •10% at 1 year Nicotine Replacement Nasal Spray Advantages Disadvantages •Alone or Combination •Irritation •Fast Acting - Urge •Low Compliance Nicotine Replacement Inhaler Advantages Disadvantages •Hand-Mouth •Low Compliance •Less Nicotine •Delivery Nicotine Replacement Lozenge – 2002 Bupropion • • • • • Placebo Nicotine Replacement Bupropion 300 MA Bupropion + Nicotine Long Term 23% 36% 49% 58% 25-35% SMOKING CESSATION • Placebo N 160 12 MO 15.6% KG 2.1 • Nicotine Patch 244 16.4% 1.6 • Bupropion 244 30.3% 1.7 • Bupropion + patch 245 35.5% 1.1 JORENBY - N.E.J.M. 3/4/99 SMOKING CESSATION BUPROPION 450 Smokers (Failed Treatment) Again Placebo 27% 5% Gonzales DH, Clin. Pharm Therapy 2001; 69 SMOKING CESSATION BUPROPION Duration 784 PATIENTS 7 WEEKS TREATMENT PLACEBO 12 MONTHS 55% 42% Hays, JT. Ann Intern Med. 2001 135 SUMMARY • Smoking KILLS • Physicians can and should play a role in helping patients stop smoking • Effective tools are available and they work SUMMARY • • • • • Include Smoking as a Vital Sign Use the 5 A’s Use multiple modalities Use them long enough Be Persistent