What to Do With a Patient

Who Smokes

Steven A. Schroeder, MDSteven A. Schroeder, MD

Presentation courtesy of Presentation courtesy of

The Smoking Cessation Leadership Center The Smoking Cessation Leadership Center

and Rx for Changeand Rx for ChangeFebruary 2007February 2007

Topics for TodayTopics for Today

Facts about smokingFacts about smoking Nicotine and dependenceNicotine and dependence Aids for cessationAids for cessation Telephone quitlinesTelephone quitlines Next stepsNext steps

JAMA Article

Tobacco’s Deadly Toll

440,000 deaths in the U.S. each year440,000 deaths in the U.S. each year 4.8 million deaths world wide each year4.8 million deaths world wide each year 10 million deaths estimated by year 203010 million deaths estimated by year 2030 50,000 deaths in the U.S. due to second-50,000 deaths in the U.S. due to second-

hand smoke exposurehand smoke exposure 8.6 million disabled from tobacco in the U.S. 8.6 million disabled from tobacco in the U.S.

alonealone

*

17

81

4119 14

30

440

0

50

100

150

200

250

300

350

400

450

Comparative Causes of Annual Deaths in the United States

Nu

mb

er o

f d

eath

s (t

ho

usa

nd

s)

Source: Centers for Disease Control and Prevention

AIDS Alcohol Motor Homicide Drug Suicide Smoking Vehicle Induced

Also suffer from mental illness and/or substance abuse

*

Annual U.S. Deaths Attributable to Smoking, 1997–2001

Centers for Disease Control and Prevention. MMWR 2005;54:625–628.

31%28%23%9%8%

<1%

TOTAL: 437,902 deaths annually

Cardiovascular diseases

137,979

Lung cancer 123,836

Respiratory diseases 101,454

Second-hand smoke 38,112

Cancers other than lung

34,693

Other 1,828

Percent of all smoking-attributable deaths

Health Consequences of Smoking

U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon

General, 2004.

CancersCancers– Acute myeloid leukemia Acute myeloid leukemia – Bladder and kidneyBladder and kidney– CervicalCervical– EsophagealEsophageal– GastricGastric– LaryngealLaryngeal– LungLung– Oral cavity and pharyngealOral cavity and pharyngeal– PancreaticPancreatic

Pulmonary diseasesPulmonary diseases– Acute (e.g., pneumonia)Acute (e.g., pneumonia)– Chronic (e.g., COPD)Chronic (e.g., COPD)

Cardiovascular diseasesCardiovascular diseases– Abdominal aortic aneurysmAbdominal aortic aneurysm– Coronary heart diseaseCoronary heart disease– Cerebrovascular diseaseCerebrovascular disease– Peripheral arterial diseasePeripheral arterial disease

Reproductive effectsReproductive effects– Reduced fertility in womenReduced fertility in women– Poor pregnancy outcomes (e.g., Poor pregnancy outcomes (e.g.,

low birth weight, preterm delivery)low birth weight, preterm delivery)– Infant mortalityInfant mortality

Other effects: cataract, Other effects: cataract, osteoporosis, periodontitis, poor osteoporosis, periodontitis, poor surgical outcomessurgical outcomes

0

5

10

15

30 40 50 60

Yea

rs o

f lif

e ga

ined

Age at cessation (years)

Prospective study of 34,439 male British doctors

Mortality was monitored for 50 years (1951–2001) On average, cigarette

smokers die approximately 10 years younger than do

nonsmokers.

Among those who continue smoking, at least half will

die due to a tobacco-related disease.

Smoking Cessation: Reduced Risk of Death

Doll et al. (2004). BMJ 328(7455):1519–1527.

Reduction in cumulative risk of death from lung cancer in

men

Reprinted with permission. Peto et al. (2000). BMJ 321(7257):323–329.

Cu

mu

lati

ve r

isk

(%)

Age in years

Causal Associations with Second-hand Smoke

DevelopmentalDevelopmental– Low birthweightLow birthweight– Sudden Infant Death Sudden Infant Death

SyndromeSyndrome– Pre-term deliveryPre-term delivery

RespiratoryRespiratory– Asthma inductionAsthma induction and and

exacerbationexacerbation– Eye and nasal irritationEye and nasal irritation– Bronchitis, pneumonia, Bronchitis, pneumonia,

otitis media in childrenotitis media in children

CarcinogenicCarcinogenic– Lung cancerLung cancer– Nasal sinus cancerNasal sinus cancer– Breast cancer (younger, Breast cancer (younger,

premenopausal women)premenopausal women)

CardiovascularCardiovascular– Heart disease mortalityHeart disease mortality– Acute and chronic Acute and chronic

coronary heart disease coronary heart disease morbiditymorbidity

– Altered vascular Altered vascular propertiesproperties

Compounds in Tobacco Smoke

– Carbon monoxideCarbon monoxide– Hydrogen cyanideHydrogen cyanide– AmmoniaAmmonia– BenzeneBenzene– FormaldehydeFormaldehyde

– NicotineNicotine– NitrosaminesNitrosamines– LeadLead– CadmiumCadmium– Polonium-210Polonium-210

An estimated 4,800 compounds in tobacco smoke, including 11 proven human carcinogensGases Particles

Nicotine does NOT cause the ill health effects of tobacco.

The Real Culprit

It is the smoke, tar, and additives that It is the smoke, tar, and additives that make people sicken and die. make people sicken and die.

Nicotine is dangerous because it leads to Nicotine is dangerous because it leads to addiction, and therefore increased addiction, and therefore increased exposure tobacco constituents.exposure tobacco constituents.

Therefore, nicotine replacement therapy is Therefore, nicotine replacement therapy is helpful, not harmful. It is a “clean” form of helpful, not harmful. It is a “clean” form of nicotine.nicotine.

California15.2%

New York 20.5%

Utah11.5%

Texas 20.0%

Illinois 19.9% Kentucky

28.7%

Nevada23.1%

Centers for Disease Control and Prevention. (2006). MMWR 55:1148–1151.

Florida 21.6%

Indiana27.3%

STATE-SPECIFIC PREVALENCE of SMOKING among ADULTS, 2005

TRENDS in ADULT SMOKING, by SEX—U.S., 1955–2005Trends in cigarette current smoking among persons aged 18 or older

Graph provided by the Centers for Disease Control and Prevention. 1955 Current Population Survey; 1965–2005 NHIS. Estimates since 1992 include some-day smoking.

Per

cen

t

70% want to quit

0

10

20

30

40

50

60

1955 1959 1963 1967 1971 1975 1979 1983 1987 1991 1995 1999 2003

Male

Female 23.9%

18.1%

20.9% of adults are

current smokers

Year

TRENDS in TEEN SMOKING, by ETHNICITY—U.S., 1977–2006

Trends in cigarette smoking among 12th graders: 30-day prevalence of use

0

10

20

30

40

50

1977 1982 1987 1992 1997 2002Year

Institute for Social Research, University of Michigan, Monitoring the Future Projectwww.monitoringthefuture.org

Per

cen

t

White

Hispanic

Black

TRENDS in ADULT CIGARETTE CONSUMPTION—U.S., 1900–2005

Annual adult per capita cigarette consumption and major smoking and health events

Centers for Disease Control and Prevention. (1999). MMWR 48:986–993.Per-capita updates from U.S. Department of Agriculture, provided by the American Cancer Society.

0

1,000

2,000

3,000

4,000

5,000

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000

First SurgeonGeneral’s Report

Great Depression

End of WW II

Federal cigarettetax doubles

MasterSettlementAgreement; California first state to enact ban on smoking in bars

Broadcastad ban

Cigarette price drop

Nonsmokers’ rights movement

beginsNu

mb

er o

f ci

ga

rett

es

Year

20 states have > $1

pack tax

PREVALENCE of ADULT SMOKING,

by RACE/ETHNICITY—U.S., 2005

0% 10% 20% 30% 40% 50%

13.3% Asian*

32.0% American Indian/Alaska Native*

21.5% Black*

21.9% White*

16.2% Hispanic

Centers for Disease Control and Prevention. (2006). MMWR 55:1145–1148.

* non-Hispanic.

PREVALENCE of ADULT SMOKING,

by EDUCATION—U.S., 2005

0% 10% 20% 30% 40% 50%

10.7% Undergraduate degree

25.5% No high school diploma

43.2% GED diploma

24.6% High school graduate

22.5% Some college

7.1% Graduate degree

Centers for Disease Control and Prevention. (2006). MMWR 55:1145–1148.

Number of Smokers = New Smokers + Old Smokers -

Quitters

Number of Quitters =

Number of Quit Attempts X % of Quitters

Price

Clean indoor air

Clinician advice

Counseling

Medications

Counter Marketing

Ways to Help Smokers Quit

Raise prices (taxes)Raise prices (taxes) Clean indoor airClean indoor air Create counter-marketingCreate counter-marketing Provide cessation aids: counseling and Provide cessation aids: counseling and

pharmacotherapy, alone or in combinationpharmacotherapy, alone or in combination– Directly by clinician in individual or group Directly by clinician in individual or group

session (office or hospital)session (office or hospital)– Toll-free telephone quitlinesToll-free telephone quitlines

Reasons for Not Helping Patients Quit

1. Too busy1. Too busy

2. Lack of expertise2. Lack of expertise

3. No financial incentive3. No financial incentive

4. Most smokers can’t/won’t quit4. Most smokers can’t/won’t quit

5. Stigmatizing smokers5. Stigmatizing smokers

6. Respect for privacy6. Respect for privacy

7. Negative message might scare away 7. Negative message might scare away patientspatients

8. I smoke myself8. I smoke myself

Responses to Patient Who Smokes

Unacceptable: “I don’t have time.”Unacceptable: “I don’t have time.” AcceptableAcceptable

– Refer to a quit lineRefer to a quit line– Establish systems in your office and Establish systems in your office and

hospitalhospital– Become a cessation expertBecome a cessation expert

The 5 A’s: Review

ASK about tobacco USE

ADVISE tobacco users to QUIT

ASSESS readiness to make a QUIT attempt

ASSIST with the QUIT ATTEMPT

ARRANGE FOLLOW-UP care

Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS.

Measurements of Smoking Intensity

Fagerström Test for Nicotine Fagerström Test for Nicotine DependenceDependence

BiochemicalBiochemical– Serum, urinary, or saliva cotinine testingSerum, urinary, or saliva cotinine testing– Carbon monoxide testingCarbon monoxide testing

Fagerström Test for Nicotine Dependence

Item Response Options

Points

1.1. How soon after you awaken do you smoke your first How soon after you awaken do you smoke your first cigarette?cigarette?

within 5 minuteswithin 5 minutes 6-30 minutes6-30 minutes 30-60 minutes30-60 minutes after 60 minutesafter 60 minutes

33 22 11 00

2.2. Do you find it difficult to refrain from smoking in Do you find it difficult to refrain from smoking in places where it is forbidden?places where it is forbidden?

yesyes nono

11 00

3.3. Which cigarette would you hate most to give up?Which cigarette would you hate most to give up? first one in morningfirst one in morning any otherany other

11 00

4.4. How many cigarettes per day do you smoke?How many cigarettes per day do you smoke? 10 or less10 or less 11-2011-20 21-3021-30 31 or more31 or more

00 11 22 33

5.5. Do you smoke more frequently during the first hours Do you smoke more frequently during the first hours after waking up than during the rest of the day?after waking up than during the rest of the day?

yesyes nono

11 00

6.6. Do you smoke if you are so ill that you are in bed Do you smoke if you are so ill that you are in bed most of the day?most of the day?

yesyes nono

11 00

Heatherton TF, Kozlowski LT, Frecker RC, Fagerström K-O. The Fagerström Test for Nicotine Dependence: A revision of the Fagerström Tolerance Questionnaire. Br J Addict 1991;86:1119–1127.

Nicotine Absorption

Absorption is pH dependent In acidic media

– Ionized poorly absorbed across membranes In alkaline media

– Non ionized well absorbed across membranes

At physiologic pH (7.3–7.5),nicotine is readily absorbed.

Nicotine Distribution

Data from Henningfield et al., Drug Alcohol Depend 1993;33:23-29. Graph reprinted with permission, Rx for Change, The Regents of the University of

California, University of Southern California, and Western University of Health Sciences.

0

10

20

30

40

50

60

70

80

0 1 2 3 4 5 6 7 8 9 10

Minutes after light-up of cigarette

Pla

sma n

icoti

ne (

ng/m

L) Arterial

Venous

Nicotine reaches the brain within 11 seconds

Metabolizedand excreted

in urine

Nicotine Metabolism

CH3N

H 10–20% excreted

unchangedin urine

Adapted and reprinted with permission. Benowitz et al. J Pharmacol Exp Ther 1994;268:296–303.

70–80% cotinine

~ 10% other

metabolites

N

Nicotine Pharmacodynamics

Central nervous systemCentral nervous system– PleasurePleasure– Arousal, enhanced vigilanceArousal, enhanced vigilance– Improved task performanceImproved task performance– Anxiety reliefAnxiety relief

OtherOther– Appetite suppressionAppetite suppression– Increased metabolic rateIncreased metabolic rate– Skeletal muscle relaxationSkeletal muscle relaxation

Cardiovascular systemCardiovascular system Heart rateHeart rate Cardiac outputCardiac output Blood pressureBlood pressure– Coronary Coronary

vasoconstrictionvasoconstriction– Cutaneous Cutaneous

vasoconstrictionvasoconstriction

Nicotine enters brain

Stimulation of nicotine receptors

Dopamine release

Dopamine Reward PathwayDopamine Reward PathwayPrefrontal

cortex

Nucleus accumbens

Ventral tegmental

area

Chronic Administration of Nicotine: Effects on the Brain

Perry et al. J Pharmacol Exp Ther 1999;289:1545–1552.

Nonsmoker Smoker

Human smokers have increased nicotine receptors in the prefrontal

cortex.

High

Low

Image courtesy of George Washington University / Dr. David C. Perry

Damage to the Insula Disrupts Damage to the Insula Disrupts Addiction to Cigarette Addiction to Cigarette

Smoking*Smoking* 19 smokers with brain damage to insula 19 smokers with brain damage to insula

region, compared with 50 smokers with region, compared with 50 smokers with brain damage elsewherebrain damage elsewhere

Smoking rates lower in insula-damaged Smoking rates lower in insula-damaged patients (odds ratio=2.94) but not patients (odds ratio=2.94) but not statistically significant (low #s)statistically significant (low #s)

But addictive cravings much lower in But addictive cravings much lower in insula damaged patients (OR=22; insula damaged patients (OR=22; p<.0005)p<.0005)

*Naqvi et al. Science 2007; 315:531-534

Depression Insomnia Irritability/frustration/anger Anxiety Difficulty concentrating Restlessness Increased appetite/weight gain Decreased heart rate Cravings*

Nicotine Pharmacodynamics: Withdrawal Effects

American Psychiatric Association. (1994). DSM-IV. Hughes et al. (1991). Arch Gen Psychiatry 48:52–59.

Hughes & Hatsukami. (1998). Tob Control 7:92–93.

Most symptoms peak 24–48 hr after quitting and subside within 2–4

weeks.

* Not considered a withdrawal symptom by DSM-IV criteria.

Nicotine Addiction Cycle

Reprinted from Med Clin N Am 76(2), Benowitz NL, Cigarette smoking and nicotine addiction, pp. 415–437, Copyright 1992, with permission from Elsevier.

Nicotine Addiction

Tobacco users maintain a minimum serum nicotine concentration in order to

– Prevent withdrawal symptoms– Maintain pleasure/arousal– Modulate mood

Users self-titrate nicotine intake by– Smoking more frequently– Smoking more intensely– Obstructing vents on low-nicotine brand

cigarettes

Cognitive Strategies for Cessation

Reframe the way a patient thinks about smoking

Review commitment to quit, focus on downsides of tobacco use

Distractive thinking Positive self-talks, “pep talks” Relaxation through imagery Mental rehearsal, visualization

Behavioral Strategies for Cessation (Avoiding Stimuli that Trigger

Smoking)

Stress – Anticipate future challenges– Develop substitutes for tobacco

Alcohol – Limit or abstain during early stages of

quitting Other tobacco users

– Stay away– Ask for cooperation from family and friends

Behavioral Strategies for Cessation (Part 2)

Oral gratification needs – Use substitutes: water, sugar-free chewing

gum or hard candies Automatic smoking routines

– Anticipate routines and develop alternative plans, e.g., with morning coffee

Weight gain after cessation – Anticipate; use gum or bupropion; exercise

Cravings – Distractive thinking; change activities

Pharmacologic Methods: First-line Therapies

Three general classes of FDA-approved drugs for smoking cessation: Nicotine replacement therapy (NRT)

– Nicotine gum, patch, lozenge, nasal spray, inhaler

Psychotropics– Sustained-release bupropion

Partial nicotinic receptor agonist– Varenicline

Currently, no medications have an FDA indication for use in spit tobacco cessation.

Nicotine Gum

Disadvantages

Gum may not be socially acceptable.

Gum is difficult to use with dentures.

Patients must use proper chewing technique to minimize adverse effects.

Advantages Gum use may satisfy

oral cravings. Gum use may delay

weight gain. Patients can titrate

therapy to manage withdrawal symptoms.

Transdermal Nicotine Patch

Disadvantages

Patients cannot titrate the dose.

Allergic reactions to adhesive may occur.

16-hr patch may lead to morning nicotine cravings.

Patients with dermatologic conditions should not use.

Advantages The patch provides

consistent nicotine levels.

The patch is easy to use and conceal.

Fewer compliance issues are associated with the patch.

Nicotine Lozenge

Disadvantages Gastrointestinal side

effects (nausea, hiccups, and heartburn) may be bothersome.

Advantages Lozenge use may

satisfy oral cravings. The lozenge is easy to

use and conceal. Patients can titrate

therapy to manage withdrawal symptoms.

Nicotine Nasal Spray

Disadvantages Nasal/throat irritation Dependence can result. Patients must wait 5

minutes before driving or operating heavy machinery.

Patients with chronic nasal disorders or severe reactive airway disease should not use the spray.

Advantages Patients can easily

titrate therapy to rapidly manage withdrawal symptoms.

Nicotine Inhaler

Disadvantages Initial throat or mouth

irritation. Can’t store cartridges

in very warm conditions or use in very cold conditions.

Patients with underlying bronchospastic disease must use with caution.

Advantages Patients can easily

titrate therapy to manage withdrawal symptoms.

The inhaler mimics hand-to-mouth ritual of smoking.

Combination NRT

Combination NRT– Long-acting formulation (patch)

Produces relatively constant levels of nicotine

PLUS– Short-acting formulation (gum, lozenge, inhaler, nasal spray)

Allows for acute dose titration as needed for withdrawal symptoms

Bupropion SR + NRT The safety and efficacy of combination of

varenicline with NRT or bupropion has not been established.Because many of the remaining smokers are very addicted, Because many of the remaining smokers are very addicted,

use of combination therapies is becoming normalized.use of combination therapies is becoming normalized.

Nicotine Agonist—VARENICLINE

Chantix, marketed by PfizerChantix, marketed by Pfizer Partial nicotinic receptor agonistPartial nicotinic receptor agonist

– Approved by the FDA May 2006, to hit the market in the Approved by the FDA May 2006, to hit the market in the fall of 2006fall of 2006

– Much DTC marketing anticipated in 2007Much DTC marketing anticipated in 2007

Early trials (JAMA) show better results than Early trials (JAMA) show better results than bupropionbupropion

Lessens withdrawal symptoms and inhibits Lessens withdrawal symptoms and inhibits the “buzz” from a smokethe “buzz” from a smoke

Main side effect is nauseaMain side effect is nausea

VARENICLINE:Mechanism of Action

Binds with high affinity and selectivity at 42 neuronal nicotinic acetylcholine receptors

– Stimulates low-level agonist activity

– Competitively inhibits binding of nicotine

Clinical effects

symptoms of nicotine withdrawal

– Blocks dopaminergic stimulation responsible for reinforcement & reward associated with smoking

VARENICLINE: Dosing

Patients should begin therapy 1 week PRIOR to their

quit date. The dose is gradually increased to minimize treatment-related nausea and

insomnia.Treatment Day Dose

Day 1 to day 3Day 1 to day 3 0.5 mg 0.5 mg qdqd

Day 4 to day 7Day 4 to day 7 0.5 mg 0.5 mg bidbid

Day 8 to end of treatment*Day 8 to end of treatment* 1 mg bid1 mg bid

Initial dose titration

* Up to 12 weeks

VARENICLINE:Adverse Effects

Common side effects (≥5% and twice the rate observed in placebo-treated patients) include:

– Nausea

– Sleep disturbances (insomnia, abnormal dreams)

– Constipation

– Flatulence

– Vomiting

VARENICLINE:Advantages and Disadvantages

DISADVANTAGES May induce nausea in up

to one third of patients.

Post-marketing surveillance data not yet available.

ADVANTAGES Varenicline is an oral

formulation with twice-a-day dosing.

Varenicline offers a new mechanism of action for persons who previously failed using other medications.

Early industry-sponsored trials suggest this agent is superior to bupropion SR.

BUPROPION SR: Mechanism of Action

Atypical antidepressant thought to affect levels of various brain neurotransmitters

– Dopamine

– Norepinephrine

Clinical effects

– craving for cigarettes

– symptoms of nicotine withdrawal

BUPROPION SR: DOSING

Initial treatment 150 mg po q AM x 3 days

Then… 150 mg po bid Duration, 7–12 weeks

Patients should begin therapy 1 to 2 weeks PRIOR

to their quit date to ensure that therapeutic plasma levels of the drug are achieved.

BUPROPION SR: Advantages and Disadvantages

Disadvantages Seizure risk is increased. Bupropion SR should be

avoided or used with caution in patients with:– History of seizures or cranial trauma– Anorexia or bulimia nervosa– Medications that lower seizure threshold– Severe hepatic cirrhosis– Concurrent use of any form of Wellbutrin,

or any MAO inhibitor in preceding 14 days

– Patients undergoing abrupt discontinuation of alcohol or sedatives

Advantages Easy to use. Bupropion SR can

be used with NRT. Might be beneficial

for patients with depression.

Combination Therapy for the Heavily Addicted Smoker—Mayo

Clinic Style

Nicotine patchNicotine patch

– Strongest dose, can use more than oneStrongest dose, can use more than one

Shorter acting nicotine replacementShorter acting nicotine replacement

Bupropion SRBupropion SR

Comparative Daily Costs of Pharmacotherapy

Cost per day, in U.S. dollars

0 2 4 6 8

Nasal spray

Patch

Varenicline

Cigarettes (1 pack/ day)

Lozenge

Bupropion SR

Gum

Inhaler $6.07

$5.81

$5.73

$5.26

$3.91

$3.67

$4.22

$4.26

Graph reprinted with permission, Rx for Change, The Regents of the University of California, University of Southern California, and Western University of Health Sciences.

Long-Term (6 month) Quit Rates for FDA-Approved Cessation

Medications

0

5

10

15

20

25

30

Nicotine gum Nicotinepatch

Nicotinelozenge

Nicotinenasal spray

Nicotineinhaler

Bupropion Varenicline

Active drugPlacebo

Data adapted from Silagy et al. (2004). Cochrane Database Syst Rev; Hughes et al., (2004). Cochrane Database Syst Rev.; Gonzales et al., (2006). JAMA and Jorenby et al., (2006). JAMA

Graph reprinted with permission, Rx for Change, The Regents of the University of California, University of Southern California, and Western University of Health Sciences.

Per

cen

t q

uit 19.5

14.6

11.5

8.6

16.4

8.8

23.9

11.8

17.1

9.1

20.0

10.2 9.4

22.5

Combination Therapy: Patch Plus Bupropion SR

15.6%

16.4%

30.3%

35.5%

0% 5% 10% 15% 20% 25% 30% 35% 40%

Placebo

Nicotine patch

Bupropion

Nicotine patchplus bupropion

Jorenby et al. N Engl J Med 1999;340(9):685–691.

Percentage of patients quit at 12 months after cessation

0

10

20

30

No clinician Self-help Non-physician clinician Physician clinician

Estimated abstinence at 5+ months

1.0 1.1(0.9,1.3)

1.7(1.3,2.1)

2.2(1.5,3.2)

n = 29 studiesType of clinician

Fiore et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. USDHHS, PHS, 2000.

Effects of Clinician Interventions

Compared to smokers who receive no assistance from a clinician, smokers who receive such assistance are 1.7–2.2 times as likely to quit successfully for 5 or more months.

New Medications in the Pipeline

RimonabantRimonabant– Cannabinoid receptor inhibitorCannabinoid receptor inhibitor– Blocks reinforcing effects of nicotineBlocks reinforcing effects of nicotine– Also suppresses appetiteAlso suppresses appetite– In phase III trialsIn phase III trials– Not approved for smoking cessation by FDANot approved for smoking cessation by FDA

Nicotine VaccineNicotine Vaccine– Produces antibodies to nicotineProduces antibodies to nicotine– Reduces nicotine levels in animalsReduces nicotine levels in animals

CYP246 InhibitorsCYP246 Inhibitors– CYP246 is a hepatic enzyme that metabolizes nicotineCYP246 is a hepatic enzyme that metabolizes nicotine– Higher blood nicotine levels per cigarette smokedHigher blood nicotine levels per cigarette smoked– Could also increase potency of NRTCould also increase potency of NRT

JCAHO Core Measures

Community-Acquired PneumoniaCommunity-Acquired Pneumonia Acute MIAcute MI CHFCHF PediatricsPediatrics

National Rates for AMI, Heart Failure and Pneumonia Adult Smoking Cessation Counseling

Measures

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Rat

e

AMI Heart Failure Pneumonia

Adult Smoking Cessation Counseling Adult Smoking Cessation Counseling for Acute MI Patients for Acute MI Patients

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Rat

e

JCAHO (Nat'l) UHC UCSF

Adult Smoking Cessation Counseling Adult Smoking Cessation Counseling for CHF Patients for CHF Patients

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Rat

e

JCAHO (Nat'l) UHC UCSF

Adult Smoking Cessation Counseling Adult Smoking Cessation Counseling for PN Patients for PN Patients

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Rat

e

JCAHO (Nat'l) UHC UCSF

Treating Tobacco Dependence: 2003

Providers•5 A’s Training/Education•Reimbursement •Physician Leadership

Cessation•Group Classes•Free Medications•Telephone Support•Self-Help Materials•Prov-RN

Clinics•5 A’s Training•EMR Resources•Dissemination (TAR)•Resources: Primary Care, Specialties, Pediatrics, OB/GYN

Health System•Research > $800K•Leadership: ATMCRWJF, CDC, AAHP•Formal HSI Program

Target Groups•Disease Management•PHS employees•Web-Based•Women & Children•Clinical Programs

Community•TOFCO•Oregon Quitline•Business Case

Hospital-Based•Inpatient Program•Behavioral Health/CD

Evaluation•C.O.R.E.•Utilization•Grant Writing

SMOKER(who wants to quit)

Smoking Prevalence: Providence Health Plan vs. Oregon

15%16%17%18%19%20%21%22%23%24%

'88 '89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 2000

State of Oregon (BRFS) Providence Health Plan: Oregon

The National Quitline Card

—

Toll-free Quitline Numbers

1-800 NO BUTTS (California number)

1-800 QUIT NOW (National number)

Efficacy and Average Sample Size of Tobacco Cessation Studies

Reviewed by the Cochrane Library†

Type of Intervention Odds Ratio (95% CI*)Average Sample Size,

per trial

Nicotine Replacement Therapy (NRT, n=98*)

1.74 (1.64, 1.86) 385

Telephone Counseling (TC, n=13*)

1.56 (1.38, 1.77) 1,100

*n indicates number of studies; CI. Confidence interval.*n indicates number of studies; CI. Confidence interval.††Based on Silagy et al. (2004) and Stead et al. (2004). Based on Silagy et al. (2004) and Stead et al. (2004). The Cochrane Library.The Cochrane Library.

Knowledge of Tobacco Cessation Programs Among Knowledge of Tobacco Cessation Programs Among California SmokersCalifornia Smokers††

METHODUnaided Recall Aided Recall

% (95% CI*) % (95% CI*)

Telephone quitline 4.5 (1.1) 38.7 (2.6)

NRT 59.5 (2.5) --

Hypnosis 9.8 (1.5) --

SmokEnders 4.5 (1.1) --

Others 46.3 (2.9) --

† † Data from the California Tobacco Survey, 1999. For the unaided recall Data from the California Tobacco Survey, 1999. For the unaided recall question, survey respondents were asked, “Can you name up to 3 programs question, survey respondents were asked, “Can you name up to 3 programs that are helpful to people who are trying to quit smoking?” The aided recall that are helpful to people who are trying to quit smoking?” The aided recall question was asked only in reference to the quitline: “Have you ever heard of question was asked only in reference to the quitline: “Have you ever heard of the 1-800-NO-BUTTS (or, in Spanish, 1-800-45-NO-FUME) phone number?”the 1-800-NO-BUTTS (or, in Spanish, 1-800-45-NO-FUME) phone number?”

* CI = confidence interval.* CI = confidence interval.

Call Volume to the Quitline in response to New York City Free Patch Give-Away

Program41

182

2368

4099

558

5877

969

3010

1526

1258

1326

991

389

251

749

844

875

801

5374

1269

674

2034

1025

993

856

799

391

301

874

810

705

661

595

1984

287

894

862

636

611

2342

428

1368

910

613

613

0

50000

100000

150000

200000

250000

300000

4/2/034/9/03

4/16/034/23/03

4/30/035/7/03

5/14/03

(>425,000 calls in first 3 days!!!)

Barriers to Successful Cessation

Provider inattention/pessimism Co-dependency and mental illness No coverage for cessation medications Improper use of the medications Ignorance of toll-free tobacco quitlines

Strategies for Increasing Quit Rates

Reframe expectations of success Help businesses to help their employees

quit Focus on mental health/substance abuse

population Improved marketing of quitlines Develop new medications Create better systems Provide clinical champions

Services (short name)Services (short name) Current % receivingCurrent % receiving Additional QALYs saved if Additional QALYs saved if services nationallyservices nationally current % receiving services current % receiving services

increased to 90%increased to 90%

Tobacco Use Screening andTobacco Use Screening and 35%35% 1,300,0001,300,000

Brief InterventionBrief Intervention

Colorectal Cancer ScreeningColorectal Cancer Screening 35%35% 310,000310,000

Influenza Vaccine—AdultsInfluenza Vaccine—Adults 35% among adults 50-64 yrs35% among adults 50-64 yrs 110,000110,000

65% among adults 65+ yrs65% among adults 65+ yrs

Breast Cancer ScreeningBreast Cancer Screening 68%68% 91,00091,000

Cervical Cancer ScreeningCervical Cancer Screening 79%79% 29,00029,000

Pneumococcal Vaccine—AdultsPneumococcal Vaccine—Adults 56%56% 16,00016,000

Cholesterol ScreeningCholesterol Screening 87%87% 12,00012,000

*Priorities for America’s Health: Capitalizing on Life-Saving Cost-Effective Preventive *Priorities for America’s Health: Capitalizing on Life-Saving Cost-Effective Preventive Services.Services.

Partnership for Prevention: Additional QALYs Saved if Current % Receiving Services Increased*

Power of Intervention

⅓ to ½ of the 44.5 million smokers will die from the habit. Of the 31 million who want to quit, 10 to 15.5 million will die from smoking.

Increasing the 2.5% cessation rate to 10% would save 1.2 million additional lives.

If cessation rates rose to 15%, 1.9 million additional lives would be saved.

No other health intervention could make such a difference!