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.

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:NorepinephrineBeta-EndorphinAcetylcholineSerotoninGlutamateVasopressin

Physiological

• Enhance:– Concentration– Alertness– Memory

• Decrease:– Tension– Anxiety

Promotes feeling of well being

SMOKING CESSATION

Why should we stop smoking?

Benefits:GeneralCardio-cerebrovascularCancerPulmonary

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:GeneralCardio-cerebrovascularCancerPulmonary

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 9 fold increase– Throat 9 fold increase– Esophagus 75% in smokers– Bladder 7 fold increase– Kidney 5 fold increase– Pancreas 2 fold increase– Stomach 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:GeneralCardio-cerebrovascularCancerPulmonary

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 Minimal 55% 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

AskAdviseAssessAssistArrange

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 21%

Gum 20%

Spray 24%

Inhaler 24%

Arch. Int. Med. September 27, 1999

Nicotine Replacement

Gum – 1984

Advantages

•Neutral PH

•More Rapid

•Adjunct

Disadvantages

•Heartburn and Indigestion

•Throat and Mouth Irritation

•Sore Jaw

•Flatulence

Nicotine Replacement

Patch – 1991Advantages

•Convenient

•Best Compliance

•30-40% while on patch

•10% at 1 year

Disadvantages

•Skin Irritation

•Over the counter

Nicotine Replacement

Nasal Spray

Advantages

•Alone or Combination

•Fast Acting - Urge

Disadvantages

•Irritation

•Low Compliance

Nicotine Replacement

Inhaler

Advantages

•Hand-Mouth

Disadvantages

•Low Compliance

•Less Nicotine

•Delivery

Nicotine Replacement

Lozenge – 2002

Bupropion

• Placebo 23%

• Nicotine Replacement 36%

• Bupropion 300 MA 49%

• Bupropion + Nicotine 58%

• Long Term 25-35%

SMOKING CESSATION

N 12 MO KG

• Placebo 160 15.6% 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

BUPROPION450 Smokers

(Failed Treatment)

Again Placebo

27% 5%

Gonzales DH, Clin. Pharm Therapy 2001; 69

SMOKING CESSATION

BUPROPIONDuration

784 PATIENTS

7 WEEKS

TREATMENT PLACEBO12 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