Download Winning the Tobacco Battle: One Smoker at a Time

Winning the Tobacco Battle:
One Smoker at a Time
Carol Southard, RN, MSN
Tobacco Treatment Specialist
[email protected]
312 926 2069
Disclosure Information:
The presenter, Carol Southard, RN, MSN,
has received honoraria as a guest speaker
for the following company:
•Pfizer
Presentation Objectives
At the conclusion of this program, the participant will be able to:
• Describe trends and issues regarding tobacco cessation
• Discuss tobacco cessation intervention
• Review treatment options in the management of tobacco cessation
• Explain current guidelines on tobacco cessation intervention
• Summarize appropriate tobacco cessation pharmacotherapy
• Incorporate tobacco cessation treatment into clinical practice
Historica Vital et Mortis 1622
“The use of tobacco…
conquers men with a certain secret pleasure
so that those
who have once been accustomed thereto
can hardly be restrained therefrom”
Sir Francis Bacon
“There is little doubt in my mind that if it were not for nicotine, in tobacco smoke, people
would be little more inclined to smoke than they are to blow bubbles or light sparklers”
Philip Morris Researcher 1976
Some Harmful Chemicals in Tobacco Smoke
Acetaldehyde
Acetone
Acetonitrile
Acetylene
Acrolein
Acrylonitrile
Ammonia
Aniline
Arsenic
Benzene
Benzopyrene
2,3 Butadione
Butylamine
Carbon Monoxide
Cyanide
Dimethylamine
Dimethylnitrosamine
Ethylamine
Formaldehyde
Hydrocyanic Acid
Hydrogen Cyanide
Hydrogen Sulfide
Methacrolein
Methanol
Methyl Alcohol
Methylamine
Methylfuran
Methylnapthalene
Nicotine
Nitric Oxide
Nitrogen Dioxide
Phenol
Pyridine
Tar
Toluene
Unique Qualities of Nicotine Addiction
Through Smoking
• Cigarette is a highly engineered drug-delivery system
• Inhaling produces a rapid distribution of nicotine to the
brain
• Drug levels peak within 10 seconds in the brain
• Acute effects dissipate within minutes, causing the
smoker to continue frequent dosing throughout the day
• Average smoker takes 200-300 boluses to the brain per
day
• Easy to get, easy to use, and it is legal!
Tobacco Facts
• #1 public health problem in the United States
• Most preventable cause of morbidity and mortality
• Causes more deaths each year than alcohol, motor
vehicle accidents, suicide, AIDS, homicide, illicit
drugs and fires combined
• One-third of all tobacco users will die prematurely
• If current trends hold, tobacco will kill a billion people
this century, 10 times more than the 20th century
Smoking Incidence & Scope
 The annual toll on the nation’s health and economy is staggering:
430,000 deaths, 8.6 million people suffering from at least one
serious illness related to smoking
• More than $289 billion a year, including at least $133 billion in
direct medical care for adults and more than $156 billion in lost
productivity
• $5.6 billion a year (2006 data) in lost productivity from exposure
to secondhand smoke
• Each day, more than 3,200 persons younger than 18 years of
age smoke their first cigarette.
• Each day, an estimated 2,100 youth and young adults who have
been occasional smokers become daily cigarette smokers
CDC (2/14).
U.S. Smoking Statistics
• About 42.1 million Americans are current smokers – 18.1%
• 20.5% of men and 15.8% of women smoke in US
(since 1974, the smoking prevalence in men has decreased by
about 1% a year, in women 0.33%)
• Prevalence
– Native Americans & Alaskan Natives (21.8%),
– Caucasians (19.7%)
– African Americans (18.1%)
– Hispanics (12.5%)
– Asians (10.7%)
CDC (2/14).
Tobacco is Not an Equal Opportunity Killer
• Affects young, the poor, depressed, uninsured, less
educated, blue-collar, and minorities most in the US
• Addiction affects those with the least information about
health risks, with the fewest resources to resist
advertising, and the least access to cessation services
• Those below poverty line are >30% more likely to
smoke than those above poverty line
Smoking-Related Disease Smoking Prevalence
•
•
•
•
•
•
Smoking-related chronic disease - 36.9%
Smoking-related cancers (other than lung) - 38.8%
Stroke - 30.1%
CHD - 29.3%
Emphysema - 49.1%
Chronic bronchitis - 41.1%
Cessation Facts
• 70% of smokers say they are “interested” in quitting
• Only 32% consult a health care provider about quitting
• The majority of smokers try to quit on their own
• Overall, self-quitters have a success rate of 4 to 6%
OF 3 BILLION OFFICE VISITS 2005-2009*:
• 62.7% of patients were screened for tobacco use
• 17.6% were current tobacco users
• 20.9% received cessation counseling
• 7.6% received cessation medication
*MMWR/June 15, 2012/Vol. 61
Treatment Facts
• The efficacy of several tobacco cessation therapies is well
established
• All proven treatments appear to be equally effective: quit rates
are at least doubled
• Evidence suggests that all smokers should be offered
pharmacotherapy and assisting with treatment produces better
outcomes
• The Agency for Health Care Policy and Research (AHCPR)
published updated smoking cessation guidelines in 2008 for
primary care clinicians
US PHS Clinical Practice Guideline
Fiore M, Jaen CR, Baker TB, et al.
Treating tobacco use and
dependence 2008 update.
Rockville MD: USDHHS, PHS,
2008.
http://www.surgeongeneral.gov/tobacco/
Based on approximately 8,700 articles
published between 1975 and 2007
Five A’s
1. Ask - initial step is to identify if client uses tobacco
2. Advise - deliver clear, strong, personal, and
straightforward advice about the importance of quitting;
emphasize five R's: relevance, risks, rewards,
roadblocks, repetition
3. Assess - willingness to make a quit attempt
4. Assist - set quit date, offer pharmacologic and
behavioral support
5. Arrange - follow-up to prevent relapse
Ask. Advise. Refer. = 5 A’s
Ask
Ask.
Advise
Every patient about tobacco use.
Assess
Assist
Advise.
Every tobacco user to quit.
Arrange
Refer. Provide information on
treatment programs.
Refer for Treatment
Ask. Advise. Refer.
Systematic Approach
Does patient now
use tobacco?
If YES:
Is patient willing
to quit?
If YES:
Provide appropriate
referral.
If NO:
Promote motivation
to quit.
If NO:
Did patient once
use tobacco?
If YES:
Prevent Relapse
If NO:
No intervention required.
Encourage continued
abstinence.
The “5 R’s” to Enhance Motivation
for Patients Unwilling To Quit*
•
•
•
•
•
Relevance
– Tailor advice and discussion to each patient – encourage patient to
identify why quitting is personally relevant
Risks
– Discuss risks of continued smoking – ask patient to identify potential
negative consequences
Rewards
– Discuss benefits of quitting – ask patient to identify potential benefits
Roadblocks
– Identify barriers to quitting (targets for counseling and medication)
Repetition
– Reinforce the motivational message at every visit
*Most effective when combined with MI
approach and strategies
Assessing Nicotine Dependence
1.
2.
3.
How soon after you wake do you smoke your first cigarette or
take you first dip?
• <30 minutes
2
• 31 - 60 minutes
1
• >60 minutes
0
How many cigarettes per day or tins per week do you use?
• <10 cigarettes or <1 tin
0
• 11 - 20 cigarettes or 1 - 2 tins
1
• 21-30 cigarettes or >2-3 tins
2
• >30 cigarettes or > 3 tins
3
Do you find it difficult to refrain from using tobacco in places
where it is forbidden (e.g., movies, work, etc.)?
Yes
1
No
0
Scoring: 0 - 2 (LOW)
3 - 4 (MEDIUM)
5 - 6 (HIGH)
Nicotine Withdrawal Symptoms
• Constant craving of
cigarettes
• Insomnia
• Irritability
• Fatigue
• Frustration
• Anger
•
•
•
•
•
•
Depression
Difficulty concentrating
Restlessness
Decreased heart rate
Increased appetite
Anxiety
Withdrawal lasts anywhere from 3 to 6 months
Pharmacotherapy
• Seven first-line FDA approved therapies reliably
increase long-term smoking abstinence rates
• All apt least double the rate of cessation when
compared to placebo
• All help with symptoms of withdrawal
Medications
• Nicotine Replacement (gum, patch, inhaler, spray,
lozenge)
• Bupropion (Zyban ®, Wellbutrin ®)
• Varenicline (Chantix®)
Nicotine Gum
• Available since 1984
• OTC 1995
• 2 mg recommended for
patients smoking less than 1
pack per day
• 4 mg for patients smoking
over 1 pack/day
• Full dose absorbed in about
20 minutes
• Cost $6.00+ per day
Nicotine Patch
• Available since 1994
• OTC 1996
• 21 mg recommended for
patients smoking 1 pack per
day
• 14 mg for patients smoking
1/2 pack/day
• 7 mg for patients smoking 5
or less cigarettes a day
• Full dose absorbed in about 2
hours
• Cost $4.00+ per day
Nicotine Inhaler®
• Available since 1998 - Rx
• Each cartridge delivers 4 mg
of nicotine over 80
inhalations
• Full dose absorbed in about
20 minutes
• Cost $10.00+ per day
• Designed to combine
pharmacological and
behavioral substitution
Nicotine Nasal Spray Nicotrol NS®
• Available since 1996 – Rx
• Each spray delivers 0.5 mg of nicotine
• Full dose absorbed in less than 5 minutes
• Minimum recommended treatment is 8
doses per day
• Cost $5.00+ per day
• May be most beneficial to highly
dependent smokers
Nicotine Lozenge
• Available since 2002 - OTC
• 2 mg recommended for patients
who smoke more than 30
minutes after waking
• 4 mg for patients who smoke
within 30 minutes of waking
• Full dose absorbed in about 20
minutes
• Cost $5.00+ per day
Combination Nicotine Replacement Therapy
Combining the nicotine patch and a self-administered NRT
(either nicotine gum or nicotine nasal spray) is more
efficacious than a single form of NRT
Nicotine Delivery Systems:
Plasma Concentrations
Plasma nicotine (ng/mL)
30
Cigarette
25
20
Gum (4
mg)
15
10
Gum (2 mg)
Inhaler
5
Nasal spray
Patch
0
0
10
20
30
Minutes
40
50
60
Reprinted with permission from Schneider et al., Clinical Pharmacokinetics 2001;40(9):661–684. Adis International, Inc.
Non-Nicotine Medications
Bupropion®
• An atypical antidepressant with
dopaminergic and
noradrenergic activity
• First FDA approved non-NRT
• Risk of seizure is 0.1% or less
• Can be used in combination
with NRT
• Is effective in those with no
current or past depressive
symptoms
Bupropion SR®
•
•
•
Available by prescription only (USA)
Dosing:
– Start 1-2 weeks before quit date
– 150 mg orally once daily x 3 day
– 150 mg orally twice daily x 7-12 weeks
– No taper necessary at end of treatment
Maintenance: consider as a maintenance therapy for up to 6 months postcessation
Side effects
•
Dry mouth and insomnia
•
Risk of seizure: approximately 1 in 1,000
–
Contraindicated for patients with seizure disorder or predisposing
factors that increase seizure risk (head injury, active substance abuse)
Non-Nicotine Medications
Varenicline®
• A partial nicotinic
acetylcholine receptor
agonist
• Specifically indicated for use
as an aid in smoking
cessation
• Provides some nicotine
effects to ease withdrawal
symptoms
• Blocks effects of nicotine
Varenicline® (Chantix)
Recommended dosage:
•
Start 1 week before quit date
•
0.5 mg for 3 days
•
Then 0.5 mg BID for 4 days
•
Then 1 mg BID for up to 12 weeks
Efficacy:
•
Six clinical trials N=3659
•
Self-report verified by CO measurement
•
1 in 5 quit at 1 year
Side effects:
•
Nausea and vivid dreams
•
Pregnancy Category C
NO Contraindications though does have Black Box status
Extended Use of Pharmacotherapy
•
•
•
•
•
First-line tobacco dependence medications may be
considered for extended use, especially in patients
with persistent withdrawal symptoms
Evidence shows that a minority of patients continue
ad libitum NRT agents
Does not present known health risks
FDA has approved bupropion SR for a long-term
maintenance indication
FDA has recommended varenicline for a minimal 3month term indication; 6-month term optimal
Electronic Cigarettes
• No conclusive scientific evidence that e-cigarettes promote successful longterm quitting
• Some evidence that current smokers are using e-cigarettes as a way to
ingest nicotine in places where smoking is restricted which may delay or
even prevent quit attempts
• American tobacco companies are now manufacturing electronic cigarettes
“….no evidence is available to support the claim that e-cigarettes will help smokers
to quit or reduce their harm without unintentional societal effects through large
increases in nicotine addiction”
The Lancet Oncology, Volume 15, Issue 3, Page e104, March 2014
Practical Counseling
• Set quit date within two weeks - starting on the quit date,
total abstinence is essential
• Tell others (family, friends, co-workers) and request
understanding and support
• Anticipate challenges - identify what helped and what hurt in
previous quit attempts
• Remove tobacco products and paraphernalia from the
environment (e.g., home)
• Provide basic information (e.g., withdrawal)
• Help recognize triggers for smoking or relapse (events,
activities, emotional states) – discuss challenges/triggers
and how patient will successfully overcome them
Coding for Treatment of Tobacco Use
and Dependence
Insurers:
ICD-9 Code 305.1 - Tobacco Dependence
CPT Code 99406 - Intermediate (3-10 minutes)
CPT Code 99407 - Intensive (more than 10 minutes)
Medicare:
G0436 – Intermediate
G0437 - Intensive
Affordable Health Care Act
• Tobacco use screening for all adults and cessation
interventions for tobacco users must be covered without the
patient having to pay a copayment or co-insurance or meet a
deductible
• Applies to new health insurance plans or insurance policies
beginning on or after September 23, 2010
• Only applicable when these services are delivered by a
network provider
Group Program Agenda
Session 1
Session 2
Session 3
Session 4
•
•
•
•
•
•
•
•
•
Orientation & Introductions
Understanding addiction
Preparation_________________
Benefits of Quitting
Withdrawal Symptoms
Cessation Strategies__________
QUIT DAY_________________
Motivation Reinforcement
Support Systems
Group Program Agenda (continued)
Session 5
Session 6
Session 7
Session 8
•
•
•
•
•
•
•
Lifestyle issues:
Nutrition/Weight
Exercise__________________
Stress Management
Relaxation Skills
New Self-image____________
Ex-smokers
panel_____________
• Graduation & Celebration
• Relapse Prevention
Online Smoking Cessation Assistance
• On-line smoking cessation services now available for
smokers who prefer using computers over telephones
• Anonymity is a plus, as with telephone quitlines
• Early studies show promising efficacy
www.smokefree.gov
www.becomeanex.org
www.quitnet.com
www.quityes.com
http://www.lungusa.org/stop-smoking/
www.lungchicago.org/quit-smoking
http://www.cancer.org/
www.everydayhealth.com/smoking-cessation
Power of Intervention
• The costs of providing brief interventions is $3 per
smoker
• Implementing such interventions could quadruple the
national annual cessation rate, translating to roughly
4.8 million quitters
• Adding brief behavioral counseling and medication can
increase the cessation rate six fold, translating to
roughly 7.2 million quitters
• “If every physician advised every patient at every visit not to
smoke, one million Americans could escape nicotine
addiction each year.” –Michael Fiore, MD
• “Lives saved from smoking cessation would swamp all the
benefits accrued if each year every person underwent every
cancer screening procedure recommended by the American
Cancer Society.”– Steven A. Schroeder, MD
Health professionals shouldn’t grade themselves on how
many people they can “get” to quit, but rather how many
times they give the message when the opportunity
arises.
Under these criteria, there is no reason not to have
an intervention success approaching 100%
Dr. Gro Harlem Bruntland,
Director General,
World Health Organization:
“If we do not act decisively, a hundred years from
now our grandchildren and their children will look
back and seriously question how people claiming to
be committed to public health and social justice
allowed the tobacco epidemic to unfold unchecked.”
US Department of Health and Human Services. Women and Smoking: A Report of
the Surgeon General. Washington, DC: Public Health Service, 2001.
What about Joe Camel?
What about Joe Camel?
Role of the Health Care Professional
Tobacco-cessation counseling by clinicians is
effective in improving tobacco quit rates among
adults has been recommended for adolescents.
• 3% quit/year if you do nothing
• 6% quit for 6 months with 3 minute
counseling or practice system
USPHSR, 2008
Case Presentation: Mr. E.M.
• 66 years old; PMHx CAD with stent 2006; carotid artery
disease with stent 1999; CVA 1998; type 2 DM; colon cancer
with resection 2011
• Retired teamster
• Lives with wife and 2 dogs; wife has MS
• Rarely drinks ETOH; smokes 1.5 ppd since teenage years
• Patient takes usual secondary prevention medications (ASA,
statin, clopidogrel, ACEI, beta blocker, omega-3)
• LDL is at goal; was at goal before need for coronary stent
• Type 2 DM is well-controlled (metformin)
• Height: 5’10”; weight 208 lbs; BMI 29.8
Case Continued
• Reports eating “only organic” foods
• Physical activity: walks dogs twice a day; swims in backyard
pool during the summer
• Expresses that he is NOT interested in quitting smoking
– Providers have related his progressive CVD to smoking
– When addressing the effects of secondhand smoke on his
wife, he responded, “Then she shouldn’t have married me!”
• Of his risk factors, smoking, BP control, and weight are most
urgent (LDL and A1C are at goal)
• E.M. is typically willing to make diet and physical activity
changes
• How do you engage this patient with significant CVD and
multiple risk factors to consider quitting smoking?
Summary
•
•
Brief tobacco dependence treatment is effective and every
patient who uses tobacco should be identified, urged to
quit, and offered at least one of these treatments:
 Patients willing to quit should be provided treatments
identified as effective
 Patients unwilling to quit should be provided an
intervention to increase their motivation to quit
Intensive interventions should be provided whenever
possible
•
Systems level interventions including reimbursement for
effective treatments are essential
•
It is inconsistent to provide health care and —at the
same time— remain silent (or inactive) about a major
health risk!
References
• CDC, “Annual Smoking-Attributable Mortality, Years of Potential life
Lose, and Economic Costs – United States 1995-1999,” MMWR,
April 11, 2012.
• Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and
dependence. Rockville, MD.: Department of Health and Human
Services, Public Health Service, 2008.
• US Department of Health and Human Services. The Surgeon
General’s Report on Women and Smoking. US Department of Health
and Human Services, Public Health Service, 2001.
• US Department of Health and Human Services. The Surgeon
General’s Report on The Health Consequences of Smoking. US
Department of Health and Human Services, Public Health Service,
2004.
Questions/Comments?
True or False
The majority of tobacco
users are interested in
quitting smoking.
True
70% of smokers would
quit if they knew how and
site a provider's advice to
quit as an important
motivator!
True or False
Nicotine is capable of
creating tolerance,
physical dependence and
withdrawal syndrome in
habitual users.
True
Nicotine acts on nicotinic
acetylcholine receptors in both the
central nervous system and the
peripheral nervous system
resulting in a physical and biologic
basis for physical dependence.
True or False
Nicotine addiction is the
most powerful of all
addictions to overcome.
True
It is harder to break the
addiction of nicotine
than the addiction of
alcohol, heroin or
cocaine.
True or False
Cessation
pharmacotherapy should
be used with all patients
attempting to quit using a
tobacco product.
True
There are no longer any
true contraindications.
Pharmacotherapy
approximately double the
rate of cessation when
compared to placebo.
True or False
As with other types of drug
dependencies,
psychosocial or self-help
therapies are essential medication alone is
ineffective.
False
Currently, this is not the case with
nicotine dependence though adding
psychosocial therapy certainly
increases quit rates. Insistence on
adjunctive therapy as a condition for
receiving pharmacotherapy is not
based on medical evidence.