Practical Smoking CessationPractical Smoking Cessation

Allan Prochazka, M.D., M.Sc.Allan Prochazka, M.D., M.Sc.

Denver VAMCDenver VAMC

OutlineOutline

5 A’s Approach5 A’s Approach– AskAsk– AdviseAdvise– AssessAssess– AssistAssist– ArrangeArrange

AHQR GuidelinesAHQR Guidelines

Released 6/00Released 6/00 Based on review of > 3,000 studiesBased on review of > 3,000 studies Nearly all are RCT’sNearly all are RCT’s Probably the most evidence-based guideline Probably the most evidence-based guideline

in medicinein medicine Resulted in the 5A’s approachResulted in the 5A’s approach

AskAsk

Ask all patients at each visit whether they Ask all patients at each visit whether they smokesmoke

Why every visit?Why every visit?– Relapse among ex-smokers occurs even years Relapse among ex-smokers occurs even years

after quittingafter quitting Makes smoking salient for patients and Makes smoking salient for patients and

providersproviders Triggers quit attempts by patients and Triggers quit attempts by patients and

advice/interventions by providersadvice/interventions by providers

ImplementationImplementation

Electronic recordsElectronic records– VA is all electronic, reminders are VA is all electronic, reminders are

automatically triggered, documentation of automatically triggered, documentation of smoking status and advice is a performance smoking status and advice is a performance measure for the hospital directormeasure for the hospital director

Paper SystemPaper System» Decide who will be responsible and how one will Decide who will be responsible and how one will

track compliancetrack compliance

AdviseAdvise

Strongest data are for physician adviceStrongest data are for physician advice– Other clinicians also likely to be effectiveOther clinicians also likely to be effective

Ideal to have a consistent approach across Ideal to have a consistent approach across providers to reinforce the messageproviders to reinforce the message– Patients will receive advice from multiple Patients will receive advice from multiple

sourcessources

Simple, direct messageSimple, direct message– ‘‘I’m your (doctor, nurse, therapist, health I’m your (doctor, nurse, therapist, health

educator…) and the best thing you can do for educator…) and the best thing you can do for your health is to quit smoking’your health is to quit smoking’

Avoid equivocationAvoid equivocation– ‘‘You might want to think about someday You might want to think about someday

perhaps considering quitting smoking’perhaps considering quitting smoking’

Increasing Advice EffectivenessIncreasing Advice Effectiveness

Link to patient’s healthLink to patient’s health– Make the connection to other health problemsMake the connection to other health problems

» Asthma/Bronchitis/EmphysemaAsthma/Bronchitis/Emphysema» Heart diseaseHeart disease» Reflux, ulcersReflux, ulcers» Skin changesSkin changes» Vision—macular degenerationVision—macular degeneration» Diabetes—accelerating effect of smoking on renal Diabetes—accelerating effect of smoking on renal

dysfunction, cardiovascular effectsdysfunction, cardiovascular effects» Peripheral Vascular DiseasePeripheral Vascular Disease

Use Ancillary Testing to Enhance Use Ancillary Testing to Enhance Motivation to QuitMotivation to Quit

– Pulmonary function testing and lung agePulmonary function testing and lung age» Portable units have greatly increased test qualityPortable units have greatly increased test quality

» $500 - $1500, can be billed$500 - $1500, can be billed

– Expired carbon monoxide testingExpired carbon monoxide testing» Instant feedbackInstant feedback

» No teaching required on meaning of CONo teaching required on meaning of CO

» Low initial costs ($500-800)Low initial costs ($500-800)

AssessAssess

Identify willingness to quitIdentify willingness to quit– Do you want to quit smoking?Do you want to quit smoking?– If yes, when do you want to quit?If yes, when do you want to quit?

» If ready now, then provide assistance on quitting at If ready now, then provide assistance on quitting at this visit and deal with other problems at the next this visit and deal with other problems at the next visitvisit

» If not ready, then work on motivation and on If not ready, then work on motivation and on barriersbarriers

AssessAssess

Identify Tobacco DependenceIdentify Tobacco Dependence– DSM IV R criteriaDSM IV R criteria

» Withdrawal with cessationWithdrawal with cessation

» Smoking in the face of medical illnessSmoking in the face of medical illness

– FagerstromFagerstrom» How soon after awakening do you smoke your first How soon after awakening do you smoke your first

cigarette?cigarette?

» If < 5 minutes, then highly dependentIf < 5 minutes, then highly dependent

Why bother with dependence?Why bother with dependence?– Reminder to providersReminder to providers– Identifies those who surely need more than Identifies those who surely need more than

adviceadvice– Reminder to patients when the diagnosis is Reminder to patients when the diagnosis is

shared with themshared with them

Increasing MotivationIncreasing Motivation

RelevanceRelevance RisksRisks Rewards Rewards RoadblocksRoadblocks RepetitionRepetition

RelevanceRelevance– Personalize the effects of smokingPersonalize the effects of smoking

– Consider influence on family members (e.g. parents Consider influence on family members (e.g. parents smoking aggravating child’s asthma)smoking aggravating child’s asthma)

RisksRisks– Generic risks are not as influential as personal riskGeneric risks are not as influential as personal risk

– Short term risks are more salient than long term risks, Short term risks are more salient than long term risks, especially for young peopleespecially for young people

– Risks without benefits, sometimes lead to paralysis, so Risks without benefits, sometimes lead to paralysis, so emphasize the improvements that are possibleemphasize the improvements that are possible

RewardsRewards

PersonalPersonal– Taste/smell improveTaste/smell improve– Clothes, home, breath smell betterClothes, home, breath smell better

HealthHealth– Improvement in current medical conditionsImprovement in current medical conditions– Avoidance of complicationsAvoidance of complications

EconomicEconomic– Out of pocket costs of smoking can be significant expense for Out of pocket costs of smoking can be significant expense for

those on fixed incomethose on fixed income SocialSocial

– Example for childrenExample for children– Self-control, masterySelf-control, mastery

RoadblocksRoadblocks

Weight gainWeight gain Fear of failureFear of failure Withdrawal symptomsWithdrawal symptoms Lack of support from family/friendsLack of support from family/friends ‘‘The only thing I have left is smoking’The only thing I have left is smoking’

RepetitionRepetition

Key point is that messages need to be Key point is that messages need to be repeated over timerepeated over time

A person may not be ready to take action A person may not be ready to take action today, that doesn’t mean he/she won’t be today, that doesn’t mean he/she won’t be ready next week, next month or next yearready next week, next month or next year

Smokers also need to know that relapse Smokers also need to know that relapse after a quit attempt is normal, most will after a quit attempt is normal, most will need several solid efforts to be successfulneed several solid efforts to be successful

AssistAssist

Behavioral Behavioral Drug TherapyDrug Therapy Smokers wanting to quit need bothSmokers wanting to quit need both Dose of each one can be tailored to the Dose of each one can be tailored to the

patient’s needspatient’s needs

BehavioralBehavioral

Key element is time with patient and empathic Key element is time with patient and empathic counselorcounselor

More time, more benefit, but get results even with More time, more benefit, but get results even with small investmentssmall investments

GoalsGoals– Set a quit dateSet a quit date– Tell family, friends, coworkersTell family, friends, coworkers– Make the home smoke free, start acting like a non-Make the home smoke free, start acting like a non-

smokersmoker– Identify barriers to cessationIdentify barriers to cessation

Goal: total abstinence after quit dayGoal: total abstinence after quit day Review prior quit attempts, learn from themReview prior quit attempts, learn from them Anticipate triggers and challenges Anticipate triggers and challenges Encourage others in the home to quitEncourage others in the home to quit Provide optionsProvide options

– ReferralReferral– QuitlineQuitline– Self-help materialsSelf-help materials

Drug TherapyDrug Therapy

Nicotine Replacement Therapy (NRT)Nicotine Replacement Therapy (NRT)– Nicotine GumNicotine Gum– Nicotine PatchNicotine Patch– Nicotine Nasal SprayNicotine Nasal Spray– Nicotine InhalerNicotine Inhaler– Nicotine LozengeNicotine Lozenge

Non-Nicotine TherapyNon-Nicotine Therapy– Bupropion (Zyban)Bupropion (Zyban)

NRTNRT

Overall success rate comparable among the Overall success rate comparable among the productsproducts

Doubles the quit rate over advice aloneDoubles the quit rate over advice alone– (e.g. 5-8% to 10-15%)(e.g. 5-8% to 10-15%)

Selection based on side effects, patient Selection based on side effects, patient preference, insurance coveragepreference, insurance coverage

PDR duration of therapy 8-12 weeksPDR duration of therapy 8-12 weeks Selected patients need longer therapy or Selected patients need longer therapy or

higher doseshigher doses

Nicotine GumNicotine Gum

2 forms (2 mg and 4mg), 4 mg best for most 2 forms (2 mg and 4mg), 4 mg best for most smokerssmokers

Available OTC and in Generic formsAvailable OTC and in Generic forms Absorption is buccal, so park and chewAbsorption is buccal, so park and chew Regular dosing better than ad libRegular dosing better than ad lib Typical patient will use 5-8 pieces per dayTypical patient will use 5-8 pieces per day Cost $35-50 for 108 piecesCost $35-50 for 108 pieces

Side EffectsSide Effects– Dental trauma, jaw pain, nausea, upset stomachDental trauma, jaw pain, nausea, upset stomach

Duration of UseDuration of Use– 8-12 weeks8-12 weeks– 2-5% have trouble quitting gum2-5% have trouble quitting gum– Long term use combined with behavioral Long term use combined with behavioral

therapy (up to 5 years) safe and effective, 25% therapy (up to 5 years) safe and effective, 25% validated quit rate in Lung Health Studyvalidated quit rate in Lung Health Study

Transdermal NicotineTransdermal Nicotine

3 strengths (21, 14, 7 mg/24hr)3 strengths (21, 14, 7 mg/24hr) Some patients require higher doses (e.g. Some patients require higher doses (e.g.

very heavy smokers), but for typical pack a very heavy smokers), but for typical pack a day smoker 21mg is the starting doseday smoker 21mg is the starting dose

4-6 weeks on 21 mg, 2-4 weeks on 14 mg, 4-6 weeks on 21 mg, 2-4 weeks on 14 mg, then 2-4 weeks on 7 mgthen 2-4 weeks on 7 mg

Costs $35-50 per 14 day supplyCosts $35-50 per 14 day supply

Side EffectsSide Effects– Skin irritation (30%)Skin irritation (30%)– Skin allergy (1-4%)Skin allergy (1-4%)– Poor sleep/nightmares (10%)Poor sleep/nightmares (10%)– Arm pain (2-4%)Arm pain (2-4%)

Nasal Nicotine SprayNasal Nicotine Spray

Very rapid absorption of nicotineVery rapid absorption of nicotine Dosing 0.5 mg per spray, one spray in each Dosing 0.5 mg per spray, one spray in each

nostril is one dose (about the amount of nostril is one dose (about the amount of nicotine in one cigarette)nicotine in one cigarette)

Typical patient uses 3-6 doses per dayTypical patient uses 3-6 doses per day Side Effects: mostly irritation, face pain, Side Effects: mostly irritation, face pain,

perhaps more likely to result in difficulty perhaps more likely to result in difficulty stopping use due to fast absorptionstopping use due to fast absorption

Costs $46.99 per 10 ml vial (100 doses)Costs $46.99 per 10 ml vial (100 doses)

Nicotine InhalerNicotine Inhaler

Each cartridge 10 mg nicotine, 4 mg Each cartridge 10 mg nicotine, 4 mg released, 2 mg absorbedreleased, 2 mg absorbed

Best with continuous puffing (80 deep Best with continuous puffing (80 deep inhalations over 20 minutes give 2 mg inhalations over 20 minutes give 2 mg nicotine)nicotine)

Dosage 6-16 cartridges per dayDosage 6-16 cartridges per day Side Effects: mouth/nose irritationSide Effects: mouth/nose irritation Costs $51.69 per 42 cartridgesCosts $51.69 per 42 cartridges

Nicotine LozengeNicotine Lozenge

Approved 11/02Approved 11/02 Available OTC, 2 mg and 4 mgAvailable OTC, 2 mg and 4 mg Allow lozenge to slowly dissolve, no chewing or Allow lozenge to slowly dissolve, no chewing or

swallowing of the lozenge—need to be careful not swallowing of the lozenge—need to be careful not to develop too much salivato develop too much saliva

20-30 minutes per lozenge20-30 minutes per lozenge Dose 20 max per dayDose 20 max per day Side effects: hiccups, nausea, stomach upset, Side effects: hiccups, nausea, stomach upset,

palpitationspalpitations Cost $42.00 for box of 72 lozengesCost $42.00 for box of 72 lozenges

Non-Nicotine TherapyNon-Nicotine Therapy

Bupropion (Zyban)Bupropion (Zyban) Antidepressant, works in normal, non-Antidepressant, works in normal, non-

depressed smokersdepressed smokers Slower onset of action (7-10 days)Slower onset of action (7-10 days) Dosage: 150 mg a day for 3 days, then 150 Dosage: 150 mg a day for 3 days, then 150

mg bid, but not much difference in mg bid, but not much difference in effectiveness between 150 and 300 mg /dayeffectiveness between 150 and 300 mg /day

Duration: 3 months, but longer term therapy Duration: 3 months, but longer term therapy is safe and effectiveis safe and effective

Costs VA $53 for one monthCosts VA $53 for one month Side EffectsSide Effects

– CommonCommon» Shaky,tremorShaky,tremor

» HeadacheHeadache

» Dry mouthDry mouth

– Rare but seriousRare but serious» SeizuresSeizures

» Avoid in those with epilepsy, active drug use, concomitant Avoid in those with epilepsy, active drug use, concomitant psychiatric medications, bulemia, MAOI usepsychiatric medications, bulemia, MAOI use

Combined with NRTCombined with NRT– Borderline significance, but 9% better with patch Borderline significance, but 9% better with patch

combined with bupropioncombined with bupropion Very useful in healthy populations (e.g. worksite) Very useful in healthy populations (e.g. worksite)

and in those with active cardiac diseaseand in those with active cardiac disease Hard to use in populations with lots of psychiatric Hard to use in populations with lots of psychiatric

comorbidity/substance abuse due to risk of comorbidity/substance abuse due to risk of seizures, precipitation of mania and need to add to seizures, precipitation of mania and need to add to already complex drug regimensalready complex drug regimens

May be better in those with a depressive tendencyMay be better in those with a depressive tendency Less weight gain than with patchLess weight gain than with patch

Has been tested in several populations Has been tested in several populations including patients with COPD, African including patients with COPD, African Americans; effect appears to be robustAmericans; effect appears to be robust

Bottom Line: very useful agent for many Bottom Line: very useful agent for many populationspopulations

ArrangeArrange

Followup greatly enhances cessation resultsFollowup greatly enhances cessation results Can be in person or on the telephoneCan be in person or on the telephone Linkage to Quitline in Colorado and other Linkage to Quitline in Colorado and other

states may allow more intensive followup states may allow more intensive followup that would usually be available in primary that would usually be available in primary care settingscare settings

Congratulate on successCongratulate on success Review lapsesReview lapses Emphasize total abstinenceEmphasize total abstinence Review drug therapyReview drug therapy Consider referral if neededConsider referral if needed

Cost EffectivenessCost Effectiveness$ per QALY$ per QALY

No NRTNo NRT NRTNRT

BriefBrief 31813181 21202120

Individual Individual IntensiveIntensive

18221822 14551455

Group IntensiveGroup Intensive 11081108 11711171

ConclusionsConclusions

Implement the 5A’sImplement the 5A’s Use combined drug and behavioral Use combined drug and behavioral

approachesapproaches Select drugs based on patient preference Select drugs based on patient preference

and associated medical conditionsand associated medical conditions Followup and allow patients to recycleFollowup and allow patients to recycle Make a long term commitmentMake a long term commitment