Transcript Nicotine Dependence

“Difficult to identify any other
condition that presents such a
mix of lethality, prevalence,
and neglect, despite effective
and readily available
interventions”
Fiore et al, U.S. Dept of Health and
Human Services, June 2000
“Smoking kills.
If you're killed,
you've lost a
very important
part of your life.”
Brooke Shields
Tobacco-related deaths within Australia
compared with other causes – 2003
(AIHW)
Smoking
15,511
Breast Cancer
2,995
Infectious and parasitic diseases
2,416
Suicide
2,279
1,705
Drug dependence
Falls
1,668
1,662
Road traffic accidents
1,084
Alcohol dependence (incl. cirrhosis)
661
Poisoning
Homicide and violence
278
213
Drowning
AIDS
119
Smoking rates 2007
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Young people aged 16-24
Single parent (female)
Aboriginal people
People in prison
People with a mental illness
Homeless adults
Drug treatment groups
25-30%
45%
50%
75% +
70-90%
70-100%
74-100%
Classification of nicotine dependence
305.1 Nicotine Dependence (substance use
disorder)
• Nicotine dependence and withdrawal can develop
with all forms of tobacco
• Cessation produces well-defined withdrawal
syndrome
• Use nicotine to relieve or avoid withdrawal
symptoms on waking or after situation where use
restricted
• Continued use despite knowledge of medical
problems related to smoking
Diagnostic & Statistical Manual of Mental Disorders (DSM-IV).
(American Psychiatric Association)
What Do They Say
It’s different...
It’s population health issue...
Poor people got enough to deal with...
Got a right to smoke…
Have a choice to smoke…
Anyway the staff smoke…
Great way to form therapeutic relationship...
BUT...
Barriers to Tobacco Dependence
Treatment
• Lack of staff training
• “not my role” – go to primary care
• Staff fear that patient’s will misuse NRT or
smoke while taking NRT
• Staff who smoke – normalize smoking, staff
may help patient’s access cigarettes, program
may sell cigarettes
• Restrictive formulary
• Limited income and cannot afford OTC
medications
Consequences & Costs of Not Treating
Nicotine Dependence
• Increased Mortality
• Increased Morbidity
• Increased use of health care
resources
• Decreased Quality of Life
• Increased Societal Costs, including
costs to employers
The Vicious Cycle of Smoking and
Disadvantage
Social Disadvantage and Deprivation:
 Adverse circumstances (Unemployment,
lone parenthood, homelessness etc)
 Stress
 Isolation
 Smoking as “normal”
 Unsafe neighbourhoods
Limited recreation
Makes Circumstances Worse:
 Less money for essentials
 Greater financial stress
 Poorer health and wellbeing
Creates Vulnerability to Smoking:
 As a means of coping with difficult
circumstances
 As a response to stress and exclusion
 As an ‘affordable’ recreation
Smoking prevalence:
 Increased smoking
 Less quitting
 Higher relapse
(Cancer Council, 2008)
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Motivating clients to stay smoke
free
• Health may not be primary motivator
• Other factors might be:
-stigma related to being a smoker
-restricted access to places, activities
-cost of smoking
-being able to reduce medication
-relief from stress related to
neuroadaptation to nicotine, withdrawal,
topping up, withdrawal etc (addiction cycle)
Nicotine Dependence and Major Depressive
Disorder (MDD)
(Breslau et al 1993)
• A clear relationship has been identified
between smoking and depression.
• Presence of MDD increases the probability
of persistent smoking, decreases the rate
of smoking cessation and increases the
rate of relapse.
Health Effects
Smoking causes:
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Heart attack
Stroke
Cancer
Emphysema
Bronchitis
Asthma
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Ulcers
Premature ageing
Impotence
miscarriage
Drivers of smoking - physical addiction
• The brain is ‘switched on’ by nicotine, releasing ‘feel good’
chemicals (dopamine), as nicotine hijacks the role of acetylcholine
to release dopamine at the receptor
– Can occur after smoking one cigarette per day over
few days
– Inhaled and delivered to blood in seven seconds
– Hits the brain in ten seconds
• Short ‘half-life’ of only 20 to 40 minutes, meaning smokers need to
be constantly ‘topped up’
• The cycle of ‘feel good’, withdrawal, and ‘top up’
reinforces addiction
Drivers of smoking - the behavioural aspect
• Smoking-associated environmental stimuli
(cues)play a role in reinforcing nicotine
dependence8
• Stressors and triggers may lead to unexpected
cigarette use after quitting. These may lead to a
full relapse and failed cessation attempts
• The most effective treatment includes both
pharmacological and behavioural therapy
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Caggiula AR et al. Importance of nonpharmacological factors in nicotine selfadministration. Physiol Behavior 2002; 77:683–687
How addictive is
Nicotine?
• “If it weren’t for the nicotine in tobacco smoke
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people would be little more inclined to smoke as
they are to blow bubbles” MH Russell, tobacco
researcher, 1974
Criteria for addiction?
Smoke to obtain blood level of nicotine - cease
smoking - withdrawal symptoms - relapse
Continue to smoke despite negative consequences
(social, medical, financial).
User: Addict ratio
Alcohol: 20:1
Heroin: 5:1
Nicotine: 2:1
Genetic predisposition?
• In the majority of cases, smokers attending the
clinic will report at least one parent was a
smoker.
• Recent research has implicated the Beta-II
subunit of the nicotinic receptor in smokers.
• It has also been argued that neonates exposed
to tobacco smoke develop upregulated nicotine
receptors, leading to susceptibility to nicotine
dependence.
Brief Intervention +
Pharmacotherapy
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Ask about tobacco use
Advise to stop smoking
Assess willingness to quit
Assist with quit plan
Arrange follow up
Clinical Practice Guidelines :Treating Tobacco Use and Dependence, U.S. Dept of Health
and Human Services , Public Health Service 2000
ASK
• Routine screening on forms - tick boxes
for current smoker, non-smoker and exsmoker (and when last smoked)
• If a known smoker, ask “how do you feel
about your smoking at present?”
• ALWAYS RECORD!
ADVISE
• Clear ,personalised, clinically-linked
advice about quitting smoking from a
health professional increases abstinence
rates
• “When you stop smoking, your
diabetes/cardiac/respiratory symptoms will
improve”
• “The best thing for your health would be to
quit smoking”
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Clinical Practice Guidelines :Treating Tobacco Use and Dependence, U.S. Dept of
Health and Human Services , Public Health Service 2000
ASSESS
1.Willingness to quit
“are you interested in quitting?”
“would you be interested in a ‘cut down then
stop’ approach?”
2.Level of dependence
-Fagestrom Test for Nicotine Dependence
-Shortened Fagestrom
Assessment
2 simple questions to assess for
extreme dependence are:
• “How soon after waking up do you
smoke your first cigarette?”
• “How many cigarettes a day do you
smoke?”
Assessment
• Information about low nicotine products or
reducing amounts of cigarettes are less
relevant as people titrate to achieve their
normal blood nicotine levels by:
– smoking faster
– taking deeper breaths
– smoking more of the cigarette
ASSIST
• Help includes:
-Information on why smoking/nicotine is
addictive
-Regular sessions
-Empathy and support
- Advice on the use of a pharmacotherapy
ASSIST
• Plan ahead
• Triggers can happen quickly so have a plan on
how to deal with them e.g. write the plan down
and keep in wallet/purse to help in these
situations
• Make sure you have some oral NRT (if using) with
you at all times to help with triggers and cravings
• Ask what worked and what didn’t with previous quit
attempts
• Don’t quit before a party, wedding, or stressful event
• Quit with a family or friend
• Plan spending extra $$$ as a reward
• Organise medication
The Fagerstrom test for nicotine
dependence (full version)
Source: NSW Health (2005) “Let’s take a moment” quit smoking brief intervention – a guide for all health professionals. Sydney: NSW Health.
The Fagerstrom test for nicotine
dependence (short version)
Source: NSW Health (2005) “Let’s take a moment” quit smoking brief intervention – a guide for all health professionals. Sydney: NSW Health.
Nicotine
Withdrawal
Usually at worst in the first 24 - 48 hours, then decline in
intensity gradually over next 2 weeks.
Symptoms may include craving for tobacco (can be strong, but typically
come in bursts - only last a short time) plus 4 (or more) of the following
within 24 hours of cessation, often causing significant distress :
• Depressed mood
• Dizziness
• Increased appetite or weight
gain
• Coughing
• Irritability, frustration or anger
• Appetite changes
• Anxiety
• Constipation
• Difficulty in concentrating
• Decreased heart rate
• Restlessness
• Insomnia
• Tingling sensations in extremities
ARRANGE FOLLOW-UP
• Is client returning to you for follow-up?
• Do they need a referral to GP/Community
Health/cessation expert?
• Have you made Quitline fax referral?
• If they don’t want a referral, have they
taken a “Quitline” brochure?
Treatment of nicotine dependence
Commonly used methods for quitting smoking:
• Cold turkey; although a high proportion of
smokers attempt quitting this way, most will
relapse and require multiple attempts to achieve
permanent abstinence.
• Hypnotherapy and acupuncture; There is no
actual reported evidence that acupuncture has
any effect on withdrawals or abstinence rates.
Similar with hypnotherapy.
• Nicotine Fading; Many smokers attempt to
reduce nicotine intake to assist quitting. As
mentioned earlier, smokers are likely to titrate
their nicotine dose. Another consequence is
the increased rewarding effect of each
cigarette smoked.
• Pharmacotherapies; Currently the most
effective tool for treatment of nicotine
dependency. NRT has been well evaluated
and has shown efficacy well above placebo
effect. Zyban and Champix good option for
some pts
Treating the addiction
• Approved pharmacotherapies
• Nicotine replacement therapy (NRT)
• Bupropion hydrochloride (Zyban)
• Varenicline (Champix)
GENERAL INFORMATION about Nicotine
Replacement Therapy products
NRT relieves cravings & withdrawal
symptoms whilst the smoker deals with
breaking their habits around smoking.
GENERAL INFORMATION about Nicotine
Replacement Therapy products
• A very low risk of nicotine toxicity from NRT.
• A very low risk of addiction to NRT.
• All the evidence states that nicotine obtained
from NRT is safer than that obtained from
smoking tobacco.
• There is sufficient evidence that using NRT to
abstain from smoking in situations where
smoking is prohibited is well tolerated.
FOR HEAVY SMOKERS!!
It is better to put patch on before
going to bed so that the nicotine
level in the blood is high on
waking especially if you reach for
cigarette on waking
May need to put on
another patch in the
morning
NRT Side Effects - patch
• Skin reaction / rash
Treat area with cortisone cream
• Vivid dreaming / insomnia
Apply patch before retiring OR
remove patch during sleeping hours
• Pain in upper arm
Use alternate NRT mechanisms for
a few days
NRT Side Effects - Gum
Jaw pain, hiccups
Try alternate NRT products
for a few days.
Nausea
Remind/educate
on proper use….
(Remember –
‘mouth patch’).
CORRECT USE OF GUM
• Start immediately on • No drinks while gum
waking
in mouth
• Liberal usage
• If enough gum is
used, smoking will not
• Use as often as
be necessary
“feel” like smoking
• Heavy smokers need
• Don’t chew - bite
high gum usage
infrequently
• Half an hour per
gum, then discard
NRT Side Effects - lozenge
Hiccups, heartburn, nausea
Alternate between
delivery devices for a few
days.
Check correct use –
dissolve in mouth, DO NOT
CHEW.
INHALER
Lets you control the amount
of nicotine you get when
you get a craving to smoke
Less concentrated &
less addictive than if you
smoke
Leaves out the poisons
found in cigarette smoke
Inhaler
• -attach the cartridge to the tube, and inhale for
the next 20-30 minutes. Throw cartridge out
• You can put it down and pick it up during that
time, but if you leave it for more than 1 hour , 1.5
hr max, the vapour (volatile substance) has
gone and is not viable
• People often use the one cartridge all day , but
this is only a placebo effect.
• Use 6-12 cartridges / day for best effect
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Plasma nicotine levels –
NRT vs. cigarettes9
Cigarette
Plasma nicotine (mg/ml)
20
15
Spray
Gum/Inhaler/Tablet
10
5
Patch
0
10
20
30
40
50
60
Time (minutes)
9. Royal College of Physicians of London. Nicotine addiction in Britain: A Report of the Tobacco Advisory Group of the Royal College of Physicians.
London: Royal College of Physicians, 2000.
Changes to NRT indications20
• More than one form of NRT can be used
concurrently
• NRT can be used by pregnant and lactating
smokers
• All forms of NRT can be used by patients with
cardiovascular disease
• All forms of NRT can be used by smokers aged
12 to 17 years
20. ASH Australia. Nicotine replacement therapy – Guidelines for Healthcare
Professionals on using NRT for smokers not yet ready to stop smoking. February
2007.
Cut down then stop21
• the evidence supports the following conclusions:
• Nicotine replacement helps smokers unwilling or
unable to stop achieve sustained reduction in
cigarette consumption
• This reduction is accompanied by a reduction in
smoke intake (biochemically validated)
• There is minimal risk of significant adverse
reactions to smoking concurrently with nicotine
replacement
• Smoking reduction using NRT increases
motivation to stop smoking
• Smoking reduction using NRT increases
subsequent cessation
Adapted from reference 21. ASH Australia. Nicotine replacement therapy – Guidelines for Healthcare Professionals on using NRT for smokers not yet ready to stop
smoking. February 2007.
Cut down then stop
• Good for people who may not be ready to
quit but who want to move towards it, or
who smoke high volume
• Smoker chooses one cigarette to miss,
same time every day for a week or , using
oral NRT instead
• Next week, choose another cig to drop
• Over 6 months aim to reduce by half
• Stops smokers titrating dose and creating
positive reinforcement
Combination therapy
• Combined forms of NRT
• Combine rapid onset form (e.g. gum, lozenge, inhaler) with
slower delivery
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form (e.g. patch)
• More effective than single form of NRT in dependent
smokers2
• Offer if smoker experiences withdrawal symptoms, or
quitting unsuccessful on single form of NRT
• Combined NRT patch and bupropion
• More effective than NRT patch alone
• Consider if quitting unsuccessful with monotherapy
Adapted from reference 2. Australian Government Department of Health and Aging. Smoking Cessation Guidelines For Australian General Practice.
Practice Handbook 2004. Available from www.quitnow.info.au.
Buproprion - Zyban
• The most frequently reported adverse effects were
insomnia, headache, dry mouth, nausea, dizziness and
anxiety
• Bupropion is contraindicated in the following patients
• Past or current seizures
• Known CNS tumours
• Undergoing abrupt withdrawal from alcohol or
benzodiazepines
• Current or previous history of bulimia or
anorexia nervosa
• Those taking monoamine oxidase inhibitors or
who have taken them within the last 14 days
(bupropion hydrochloride). Approved Product Information. eMIMS. Last updated Sept 2007.
•23. ZYBAN
TheSRsafety
of bupropion in pregnancy has not been established
®
Varenicline (Champix®)
designed for smoking cessation
• Varenicline was designed specifically for
targeting the nicotinic
receptor responsible for nicotine dependence:
the 42 nicotinic
acetylcholine receptor24
• First in class with novel mode-of-action
• Champix® is PBS reimbursed in Australia
Adapted from 24. Coe JW et al. Varenicline: an alpha4beta2 nicotinic receptor partial agonist for smoking cessation. J Med Chem 2005; 48:3474-3477.
Varenicline: A selective 42 acetylcholine receptor
partial agonist25,26
Partial agonist
Antagonist
• Binds with high affinity to the 42
• Prevents stimulation of the receptor
receptor, only partially stimulating
dopamine release
• Provides relief from craving and
withdrawal symptoms
by nicotine
• This reduces the pleasurable effects
of smoking and potentially the risk of
full relapse after a temporary lapse
25. Jorenby DE. et al. Efficacy of varenicline, an α4β2 nicotinic acetylcholine receptor partial agonist, vs placebo or sustained-release bupropion for smoking cessation.
JAMA 2006; 296:56-63.
26. Gonzales D et al. Varenicline, an α4β2 nicotinic acetylcholine receptor partial agonist, vs sustained-release bupropion and placebo for smoking cessation.
JAMA 2006;296:47-55.
Safety and tolerability of varenicline
• Varenicline has a favourable safety and tolerability profile. It can
even be safely administered for up to one year28
• The most frequently reported adverse events with varenicline
were nausea, headache, insomnia and abnormal dreams29
• Nausea was reported by approximately 30% of patients treated
with varenicline 1mg bid25,26,29
– discontinuation rate due to nausea was low (<3%) and
generally described as mild or moderate and decreased over
time
• Varenicline has not been studied in pregnancy, childhood or in
patients with history of, or intercurrent psychiatric illness
• Serious neuropsychiatric symptoms have occurred in patients
being treated with varenicline.
– Although a causal association has not been established, in
some reports the association cannot be excluded
25. Jorenby DE et al. Efficacy of varenicline, an α4β2 nicotinic acetylcholine receptor partial agonist, vs placebo or sustained-release bupropion for
smoking cessation.
JAMA
2006; 296:56-63.being treated with varenicline should be observed
– All
patients
26. Gonzales D et al. Varenicline, an α4β2 nicotinic acetylcholine receptor partial agonist, vs sustained-release bupropion and placebo for smoking
for neuropsychiatric symptoms
cessation. JAMA 2006;296:47-55
29. Champix® (varenicline tartrate) Approved Product information. Pfizer Australia Pty Ltd
Varenicline – dosing29
• Varenicline is indicated as an aid
for smoking cessation in adults
over 18 years
• The patient should set a date to
stop smoking: varenicline dosing
should start 1-2 weeks before this
date
Days 1-3
0.5mg once
daily
• Varenicline tablets should be
swallowed whole with water
Days 4-7
0.5mg
twice daily
Day 8 –
end of
treatment
1mg twice
daily
• Varenicline tablets can be taken
with or without food
• Varenicline tablets for oral use
with titration as shown
• Varenicline is supported with a
patient support programme
29. Champix® (varenicline tartrate) Approved Product information. Pfizer Australia Pty Ltd
Cue conditioning
• Behavioural rituals
closely associated with
smoking provide
opportunities for
secondary conditioning
• These rituals become
associated with
smoking and lead to
craving.
Relapse factors
• In the first week of quitting
• Partner or others at home smoke
• Alcohol intake not modified(initial
stages)
• Person has “just one puff” or “just one
cigarette”
• More likely in afternoon/evening
Drug Interactions
• Some medications need to be reduced as
client reduces nicotine e.g. some antipsychotics, antihypertensives, insulin.
• Same meds will need to be increased if
client relapses
• halve caffeine intake
• limit or stop alcohol for a couple of
weeks(relapse factors)
Environmental Tobacco Smoke
(ETS)
• Sidestream smoke: drifts from the end of
a burning cigarette
• Mainstream smoke: breathed out by the
smoker
• Tobacco smoke contains over 4,000
harmful chemicals including 69
compounds known to cause cancer
Environmental Tobacco Smoke
• Just because you can’t see it , that
doesn’t mean that it can’t harm you.
• Some components of smoke linger in the
air for hours, breaking down into even
more harmful chemicals.
• Particulate matter (tiny pieces of solid
material) can cling to clothing and be
inhaled by the non-smokers
Ventilation
• Smoking by the back door or near an
open window doesn’t remove the
exposure to ETS
• Total removal of tobacco smoke through
ventilation or filtration is both technically
and economically impractical
• Vehicles are another enclosed space to
consider
Quitline Fax Referrals
•Takes advantage of smoker’s motivation
at the time of a brief intervention
•Can provide the high level of support
needed at beginning of quitting process
•Patient feels that some practical help has
been offered
Emma
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26 years old
Smokes 20-30/day
Has had numerous attempts at stopping smoking
First cigarette aged 8, no break since that time
Partner smokes
2 months pregnant
History of depression, recalls becoming depressed after
last quit attempt
• What issues will you need to consider for this client?
John
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55 y.o.
Currently smokes 35-40/day
Diagnosed with schizophrenia age 20
Fagerstrom score 11/11
Drinks 4-5 cups of coffee and 2-4 cans of cola daily
Taking medication for mental illness
Some cognitive impairment
• What issues will you need to consider for this client?
Martin
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39 yrs old
Single dadsmoking since age 12
20-30 cigs/day
On the methadone program
Has had only one serious quit attempt 2 yrs ago
Some nights drinks 5-6 cans of beer
• What issues do we need to consider?