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Stop Smoking Now! Kevin Scott Ferentz, MD Associate Professor Department of Family & Community Medicine University of Maryland School of Medicine Cigarette smoking is the single most important cause of disease and premature death in the United States! Cigarette-Related Deaths 440,000 per year 12 million dead since first surgeon general’s report in 1964 Smokers die 13-14 years earlier Half of all long-term smokers will die a tobacco-related death Medical costs: $96 billion Lost productivity: $97 billion Costs: $ 40/pack Smoking in the U.S. - 2009 20.6% of adults (43% in 1966) Unchanged since 2004 West Virginia 26.6%, Utah 9.2% men (23.5%), women (17.9%) < HS diploma: 28.5%, graduate degree: 5.6% Rate dropping by < 1% per year 1.3 million quit each year 4,800 teens start each day adolescent smoking rate stable More ex-smokers than current smokers 2020 goal: 12% smokers Smoking Worldwide 1.3 billion smokers (1.7 by 2025) Kills 5 million yearly; 10 million by 2020 84% of smokers are in developing countries China - 300 million smokers – 1.7 trillion cigarettes/year (3 million/min) Worldwide – – 10 million cigarettes purchased each minute – 15 billion sold each day – 5 trillion produced and used annually One billion people will die this century unless serious global anti-smoking efforts are made! World Health Organization – 2007 Risks of Smoking Increased Cancer Risk 90% of lung cancer deaths 40% of all cancers Mouth, larynx, esophagus, stomach Kidney, bladder Pancreas Cervix Acute myeloid leukemia More women die of lung than breast cancer! Heart Disease Leading cause of death Smoking is major risk factor 3 times more likely to die of heart disease Step-wise increase with other risk factors Lung Disease 90% of Emphysema deaths Asthma Bronchitis Pneumonia Female Smokers Infertility Earlier Menopause Osteoporosis Birth Control Pills Vaginitis Pregnant Smokers Miscarriage Placenta problems Premature rupture of membranes Preterm labor Smaller babies Increased fetal respiratory rate Children of Smokers Respiratory Illness SIDS Cognitive Development Behavioral Development Cancer Increased Risk of Smoking Second-Hand Smoke 3,400 lung Cancer deaths, 22,700-69,600 cardiac deaths/yr 430 SIDS deaths in U.S./yr 35% of kids live with smokers 50-75% of kids in U.S. have detectable levels of cotinine No risk-free level of exposure to smoke – Platelets stick together – Damages lining of blood vessels – Decreases blood flow to coronary arteries – Increasing risk of heart attack Don’t walk through a cloud of cigarette smoke! American Lung Association, 2008 Smokeless Tobacco “Spit” tobacco Cancer of mouth, pharynx, esophagus Tooth discoloration Gums recede Periodontal bone destruction Death from juice ingestion SNUS Moist powder tobacco product Placed under upper lip for hours No need for spitting Steam-cured (not fire-cured), not fermented Much lower concentrations of nitrosamines More nicotine than cigarettes Probably less harmful than cigarettes Other Problems Fire Accidents Gingivitis Skin Wrinkles Impotence Decreased Stamina Colds, Flu Health Effects from Smoking Stroke Dementia Multiple Sclerosis Anxiety & Depression Cataracts Macular Degeneration Hearing Loss Sinus Problems Gum Disease Tooth Decay Heart Disease Lung Disease – COPD, asthma Osteoporosis Rheumatoid Arthritis Lupus Wound Healing Miscarriage SIDS Vascular Disease – Impotence, AAA Cancer – Lung, ENT, pancreas – Cervix – Skin (squamous cell) Smoking kills more people each year than alcohol cocaine crack heroin homicide suicide car accidents fires AIDS C O M B I N E D!!! © What’s in a cigarette? 4,000 chemicals Tar Carbon Monoxide Nicotine Cigarette: 8-9 mg (1-2 mg inhaled) Cigar: 100-400 mg Criteria for Addicting Drug Dependence Tolerance Withdrawal The effects on health from smoking are reversible if a smoker stops smoking. Health Benefits after Quitting Cough, shortness of breath resolve in weeks Exercise tolerance improves rapidly Bladder cancer: 50% reduction in 5 years Lung cancer: 50% reduction in 10 years Vascular disease: 50% reduction in 5 years Heart disease: 50% reduction in 1 year! No increased risk of heart disease by 10-15 years Mortality rates same as never smokers by 10-15 years Resources • printed materials • National Cancer Institute (1-800-4-CANCER) • www.smokefree.gov • Smokingstopshere.com • 1–800–QUIT–NOW (quit lines improve chances of quitting) Non-Health Reasons for Quitting COST!!! $ 6.50/pack/day = $ 2,372/year inconvenience Self-esteem Role Model Of course you can quit! millions of others have quit more ex-smokers than smokers most try many times before succeeding past attempts are learning experiences ways to deal with physical and psychological dependence Common Concerns Withdrawal short lived Cravings last 3-5 minutes, diminish rapidly Tension validate, normalize find other ways to cope Weight gain - not inevitable! 1/3 gain: 5-8 lbs. You have to quit!!! (cutting down doesn’t work) Go to a group if you think it will help (but you can do it alone!) Think about the positive aspects of quitting – don’t focus on the dangers of continuing to smoke… Behavior Modification Components of Addiction Physiological Psychological Behavioral Behavior Modification Review reasons for quitting (index card) Identify triggers (4 day diary) Plans to avoid or cope with each trigger Sample Plan Trigger Technique after meals on the phone in the car at desk tension coffee breaks other smokers crisis leave table draw chew gum carrot sticks deep breathing juice non-smokers self-talk Behavior Modification Review reasons for quitting (index card) Identify triggers (4 day diary) Plans to avoid or cope with each trigger Change habit: packs only, different brands Develop support system (tell everyone) Self rewards (day, week, month, year) Written commitment to quit day START - Behavior Modification S = Set quit date (within 2 weeks) T = Tell family, friends, co-workers A = Anticipate and plan for challenges you’ll face while quitting R = Remove cigarettes - home, car, work T = Talk to your doctor Pharmacological Treatment All smokers should consider taking medication NRT - “methadone for the smoker” Gum Patch Lozenge Nasal Spray Inhaler Bupropion (Zyban®) Varenicline (Chantix®) All decrease cravings, withdrawal 20-25% quit rates at 1 year Nicotine Replacement - Gum Available since 1984 2 mg., 4 mg. (for > 25 cigs/day) “chew, park, chew, park” Use one every 1-2 hours 24 pieces maximum/day Wean after 3 months, 6 months maximum $ 0.50/piece Use with patches, bupropion Nicotine Replacement - Patches 21, 14, 7 mg: wean over 8 weeks 22 mg, 11 mg single dose regimen First patch - night before quit day Rashes, abnormal dreams No increased risk of heart attack $ 3.50 per patch © Nicotine Nasal Spray One dose: 2 sprays (1 mg) Minimum: 8 doses/day Maximum: 40 doses/day (1/2 bottle) If still smoking by week 4 - stop Use for 3 – 6 months Nasal irritation limits use $ 0.50 per dose Nicotine Inhaler nicotine deposited in mouth 80 puffs in 20 minutes 6 - 16 cartridges/day 3 months then wean over 3 months 40% throat irritation $ 1.15 per cartridge Nicotine Lozenges (Commit®) 2 mg, 4 mg (if smoke w/in 30 min of waking) 12 week program Weeks 1-6: 1 lozenge every 1 to 2 hours Weeks 7-9: 1 lozenge every 2 to 4 hours Weeks 10-12: 1 lozenge every 4 to 8 hours At least 9 per day for the first 6 weeks Hiccups, heartburn, nausea No more than 5 in 6 hours, 20 per day $ 0.50 per lozenge Can work when patch, gum failed E Cigarette Looks like a traditional cigarette No tar or chemicals Non –flammable; produces water vapor Rechargeable lithium battery No second-hand smoke Nicotine cartridges: 0, 6, 11, 16 mg – 20 cigarettes worth – $ 100 per cigarette – $ 2 per cartridge No efficacy data Bupropion (Zyban) Increases dopamine in “pleasure center” 150 mg a day for 3 days then 150 mg twice a day for 4 days, then QUIT Continue for 7 - 12 weeks If not stopped by 8 weeks, discontinue Can use with nicotine replacement $ 3/day Bupropion - Contraindications seizure disorder prior or current eating disorder MAO inhibitors concurrent use of Wellbutrin® Varenicline (Chantix®) Stimulates nicotine receptor and blocks binding of other nicotine “like inhaling sandpaper” 0.5 mg for 3 days, then 0.5 mg twice a day for 4 days, then 1 mg twice a day – quit day Stop smoking after 7 days on medicine Use for up to 6 months – preferable Nausea, constipation, abnormal dreams Black box warning: watch for behavior change, hostility, agitation, depression, and suicidality – possibly due to nicotine withdrawal Cost: $ 3-4/day Varenicline (Chantix®) 6/2011 – Chantix may increase the risk of cardiac events in people with and without a history of heart disease Stay tuned… Pharmacotherapies for smoking cessation: a meta-analysis of randomized controlled trials (70 trials, 32,908 patients) Therapy varenicline nicotine nasal spray nicotine inhaler bupropion nicotine lozenge transdermal nicotine nicotine gum Odd ratio 2.55(1.99-3.24) 2.37 (1.57-3.60) 2.18 (1.38-3.45) 2.12 (1.76-2.56) 2.06 (1.47-2.87) 1.88 (1.60-2.22) 1.65 (1.37-2.01) Eisenberg MJ, et al. CMAJ. 2008; 179(2):135-44 Medications should always be used in along with behavior modification. Factors which help ex-smokers remain ex-smokers Maintenance Relapse Rates are same as for heroin, alcohol At least 70% relapse within first year 2/3 within first 3 months largest group within first week Factors: Early: withdrawal, cravings, habit Late: other smokers, food, alcohol, coffee negative emotions, crisis Preventing Relapse use and refinement of coping strategies “if you don’t want to slip, stay away from slippery places” positive self-talks in response to slips Slips happen: Hungry, Angry, Lonely Tired continued commitment (one day at a time) The Future Nicotine vaccine (NicVAX) • Five shots in six months • Antibodies attach to nicotine in bloodstream, prevent crossing blood-brain barrier • Six months after last shot — – 14-16% quit rate, 6% w/placebo The 5 “A’s” ASK - identify tobacco users at all visits ADVISE - strongly urge all smokers to quit ASSESS - willing to make an attempt? REFER ASSIST - information, medication ARRANGE - schedule follow-up visit For Those Unwilling to Quit – the 5 “R’s” Relevance - why quitting is personally relevant Risks - patient identifies negative consequences of tobacco use Acute, long-term, environmental risks Rewards - patient identifies benefits of stopping Roadblocks - patient identifies barriers to quitting Repetition - motivational intervention every visit