Download Smoking Cessation and Chronic Mental Illness

Smoking Cessation
and Chronic Mental
Illness
CSAM
May 15, 2009
David Kan, M.D.
E-mail: [email protected]
San Francisco VA Medical Center
Asst. Clinical Professor, UCSF
Overview


Epidemiology
Nicotine & Tobacco


Aka: Dr. Jekyll & Mr. Hyde
Smoking Cessation


Psychosocial
Pharmacological
Epidemiology

Total

47.2 million adults (24.1%) were current smokers



24.8 million men and 22.4 million women.
82.4% of all smokers were everyday smokers
Age


The highest rate of smoking was in 18-24 year
olds: 27.9% and 25-44 year olds: 27.5%.
Smoking rates drop with Age
Source: CDC 1998 Survey
Epidemiology

Ethnicity




Native Americans/Alaska Natives: 40%,
25% of Caucasians and 24.7% of African
Americans smoke.
Hispanics: 19.1% and Asians/Pacific
Islanders:13.7%.
Education and income


More Education = Less Smoking
More Income = Less Smoking
Source: CDC Survey 1998
Smoking Rates
70.00%
55.30%
60.00%
50.00%
40.00%
30.00%
59%
41%
39.10%
34.80%
Current Smoking
Lifetime Smoking
22.50%
20.00%
10.00%
0.00%
No Mental Illness
Lifetime Mental
Illness
Past-Month Mental
Illness
Smoking and Mental Illness, Lasser, et al. JAMA. 2000;284:2606-2610.
Smoking Rates &
Mental Illness

In general 2x Non-Mentally Ill
Diagnosis In Past
Month
US
Population, %
Current
Smokers, %
Lifetime
Smokers, %
Quit Rate, %
Major Depression
4.9
44.7
60.4
26
Non Affective
Psychosis
0.2
45.3
45.3
0
Drug Abuse or
Dependence
1
67.9
87.5
22.4
Bipolar Disorder
0.9
60.6
81.8
25.9
National Comorbidity Study – 1989 US NHIS
Nicotine vs. Tobacco
Nicotine

Ideal CNS Drug
Very Effective
Very Safe

Neurochemical Effects
Slide Courtesy: David Sachs, M.D.
Why Cigarettes?

Ideal Drug Delivery
System
Very Rapid Delivery
 High Dose
 Highly Concentrated

What is the Problem
with Cigarettes?

Toxic Delivery System
SMOKE is the PROBLEM
NOT NICOTINE!!!
Smoking Related Illness
1/3rd of Smokers will die prematurely of tobacco-related illness
Tobacco – Drug
Interactions

Pharmacokinetic



Polycyclic aromatic hydrocarbons (PAHs) are some
of the major lung carcinogens found in tobacco
smoke
PAHs - potent inducers of the hepatic cytochrome
P-450 (CYP) isoenzymes 1A1, 1A2, and, possibly,
2E1
CYP 1A2 – largest effect
Kroon, L “Drug interactions with smoking.” Am J Health Syst Pharm. 2007 Sep 15;64(18):1917-21
Tobacco – Drug
Interactions

Drugs Affected





Clozapine
Fluvoxamine
Olanzapine
Caffeine
Tacrine
UP TO 50% REDUCTION IN
BLOOD LEVELS
Kroon, L “Drug interactions with smoking.” Am J Health Syst Pharm. 2007 Sep 15;64(18):1917-21
Tobacco – Drug
Interactions

Hormone Contraceptives


Increased risk of Stroke and
Heart Attack
Inhaled Corticosteroids

Decreased Efficacy
Kroon, L “Drug interactions with smoking.” Am J Health Syst Pharm. 2007 Sep 15;64(18):1917-21
What About Quitting?
Tobacco Dependence In
Perspective

Approximately 35% try to quit each year

70% to 80% try to quit “cold turkey”



Most Relapse — 95%
Cold turkey quit rates at 1 year are 5%
Physician-assisted quit rates (short-term
counseling + medications) at 1 year are 10%
to 30%
Fiore MC, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: US Dept of Health &
Human Services. Public Health Service. June 2000. (www.surgeongeneral.gov/tobacco/default.htm)
Disease Model of
Tobacco Dependence
Acute Disease
 Short-Term Disorder
 Severe
 Sudden in Onset
 Single, Time-limited
intervention
 Examples:


Common Cold
Broken Bone
Chronic Disease
 Long-Term Disorder
 Periods of relapse and
remission
 Requires ongoing rather
than acute care
 Examples:

Diabetes
Hypertension
Addiction

Smoking!


Psychiatric Conditions

Psychiatric Conditions


Depressed Smokers


2x as likely to smoke
More Depression less likely to quit
Psychiatric Conditions


Data mixed or lacking as to long-term outcomes
Many studies show interventions work as well as
with those not mentally ill
Ranny, et al: Systematic review: smoking cessation intervention strategies for adults and adults in
special populations. Ann Intern Med. 2006 Dec 5;145(11):845-56. Epub 2006 Sep 5. Review.
Substance Abuse

Alcohol & Tobacco
Alcohol Use Triggers /
exacerbates tobacco use
 Quitting both led to higher quit
rates for both

Joseph, AM et al A randomized trial of concurrent versus delayed smoking intervention
for patients in alcohol dependence treatment. Stud Alcohol. 2004 Nov;65(6):681-91
Indications for Longer/More
Intensive Treatment

High Nicotine Dependence


High Serum Cotinine


>250ng/ml
Depression


FTQ >5
Beck Depression Inventory > 9
Smoker in Household

Decreases chances by 50%
Sachs DPL. “Tobacco Dependence: Pathophysiology & Treatment” Pulmonary
Rehabilitation Guidelines to Success, 3rd Edition 2000:261-301
Indications for Longer/More
Intensive Treatment

Smoking Initiation at Younger Age


<17 years old
Heavy Smoker

>1 Pack Per Day

# of Prior quit attempts

Alcohol or Drug Abuse

Psychotic Spectrum Illness
Sachs DPL. “Tobacco Dependence: Pathophysiology & Treatment” Pulmonary
Rehabilitation Guidelines to Success, 3rd Edition 2000:261-301
Treatment
Recommendations
Psychosocial Interventions

Counseling

Behavioral Therapy

Quit Line (1-800-NO-BUTTS)

Motivational Enhancement
FDA Approved Medications

CONTROLLER MEDICATIONS




Bupropion SR (Zyban, Wellbutrin SR, Wellbutrin
XL)
Nicotine Patch
Varenicline (Chantix)
RESCUE MEDICATIONS




Nicotine
Nicotine
Nicotine
Nicotine
Inhaler
Nasal Spray - Fastest
Polacrilex Gum (Nicorette) – pH dependent
Polacrilex Lozenge (Commit) – pH dependent
Slide Courtesy: David Sachs, MD
Success Strategies

Combined Strategies

Behavioral + Medication

Always at least 1 controller

Almost always need Rescue
Nicotine Replacement
“Clean vs. Dirty”1

Start with Patch

Add lozenge, gum, nasal spray, inhaler

Target 30-60 days smoke free prior to
tapering


Taper short acting first
Weeks to YEARS!
1. Peter Banys, MD – Personal Communication
Nicotine Replacement

Dosing?



80% of 1-PPD smokers not adequately replaced with 21mg
nicotine patch
Clear Dose-Response Curve1
Serum Cotinine


24-Hour half-life of nicotine metabolism
Dose to level

No absolute maximum

10-15% smoke free at one year
1. Sachs DPL. J Smoking-Related Dis 1994;5: 183-193
Bupropion
(Wellbutrin/Zyban)

Mechanism


Dosing




Affects dopaminergic projections
Start 1 week before quit date
150mg SR x 3-6 days then 150mg BID
Psychosocial treatment recommended
Contraindications


Seizure Disorder
Eating Disorder
Bupropion
(Wellbutrin/Zyban)

Common SE






Insomnia – 28-35% vs. 22%*
Headache – 30% vs. 28%
Dry Mouth – 15% vs. 5%*
Dizziness – 8-9% vs. 8%
Nausea – 5-7% vs. 5%
Uncommon SE




Seizures (1/1000 patients)
Psychosis
Hypertension
Suicidal Ideation
* Statistically significant
Varenicline
(Chantix)

Mechanism


Α4β2 - Nicotinic Receptor Partial Agonist
Dosing




0.5mg PO qd x 3 days
0.5mg PO BID x 4 days
1mg BID thereafter
Quit date is day #8
Varenicline
(Chantix)

Duration
3 months initial
 6 months total (if pt. can get
10 days smoke-free in first 3
months

Varenicline Warnings

Common SE:





Nausea
Abnormal Sleep / Dreams
Dizziness
Fatigue
Uncommon AE but reported:



Aggressive and erratic behavior
Suicidal thoughts
Possible suicide attempts
Varenicline vs. Bupropion
Weeks 9-52 Abstinence
Varenicline Maintenance
Conclusions &
Recommendations
1.
2.
3.
4.
5.
6.
Tobacco Use is the #1 preventable cause of
death
Psychiatric Patients carry a large disease
burden both medical and physical
Tobacco is the problem - NOT Nicotine
Tobacco Use Disorder is a Chronic Illness
needing repeated intervention
Smoking Cessation Works
Combine your treatments