Transcript UW CTI Treating Tobacco Use and Dependence

Treating Tobacco
Use and Dependence
July 2006
Learning Objectives
At the end of this session you should
understand:

The impact of tobacco dependence

Tobacco dependence as a chronic disease

Clinical interventions for tobacco users
willing to quit

Clinical interventions for tobacco users not
willing to make a quit attempt
Why should I treat
tobacco dependence?

Tobacco causes premature death of almost
half a million Americans each year

1/3 of all tobacco users in this country will
die prematurely from tobacco dependence
losing an average of 14 years

70% of smokers see a physician each year

70% of smokers want to quit
Are physicians intervening in
tobacco use?
In 38 primary care practices:
Tobacco was discussed in 21% of encounters.
Discussion was:
−
more common in the 58% of practices with standard forms for
recording smoking status
−
more common during new patient visits
−
less common with older patients
−
less common with physicians in practice more than 10 years.
Ellerbeck, Ahluwalia, et al. Direct observation of smoking cessation activities in primary care
practice. J Fam Pract. 2001;50:688-693
Barriers to treating
tobacco dependence
“Not enough time.”
“Patients don’t want to hear about it.”
“I can’t help patients stop.”
“Not enough time”
“Minimal interventions lasting less
than 3 minutes increase overall
tobacco abstinence rates.”
The PHS Guideline
(Strength of Evidence = A)
“Patients don’t
want to hear about it”
“Smoking cessation interventions during physician visits were
associated with increased patient satisfaction with their care
among those who smoke.”
1,898 patients in a study who reported that they had been
asked about tobacco use or advised to quit during the latest
visit had 10%greater satisfaction rating and 5% less
dissatisfaction than those not reporting such discussions
Mayo Clin Proc. 2001;76:138-143.
“I can’t help patients stop”
Effective clinical interventions exist:
The Public Health Service Clinical
Practice Guideline Treating Tobacco
Use and Dependence was published
in June, 2000 and offers effective
treatments for tobacco dependence.
Tobacco dependence is a
chronic disease

Tobacco dependence requires ongoing
rather than acute care

Relapse is a component of the chronic
nature of the nicotine dependence — not an
indication of personal failure by the patient
or the clinician
Tobacco results in a
true drug dependence

Tobacco dependence exhibits classic
characteristics of drug dependence

Nicotine is:
–
Causes physical dependence characterized by
withdrawal symptoms upon cessation
–
Psychoactive
–
Tolerance producing
How do I treat tobacco
users who are willing to quit?
The 5 A’s
For Patients Willing To Quit

ASK about tobacco use.

ADVISE to quit.

ASSESS willingness to make a quit attempt.

ASSIST in quit attempt.

ARRANGE for follow-up.
ASK
EVERY patient at EVERY visit
VITAL SIGNS
Blood Pressure: _______________________________
Pulse: ________________ Weight: _______________
Temperature: ________________________________
Respiratory Rate: _____________________________
Tobacco Use:
Current
Former
Never (circle one)
ADVISE

Once tobacco use status has been identified and
documented, advise all tobacco users to quit

Even brief advice to quit results in greater quit rates

Advice should be:
- clear
- strong
- personalized
“As your health care
provider, I must tell you that
the most important thing you
can do to improve your
health is to stop smoking.”
ASSESS
After providing a clear,
strong, and personalized
message to quit, you
must determine whether
the patient is willing to
quit at this time.
“Are you willing
to try to quit at
this time? I can
help you.”
ASSIST

Help develop a quit plan

Provide practical counseling

Provide intra-treatment social support

Help your patient obtain extra-treatment social
support

Recommend pharmacotherapy except in special
circumstances

Provide supplementary materials
Developing a quit plan

Set a quit date

Review past quit attempts

Anticipate challenges

Remove tobacco products

Avoid
–
Alcohol use
–
Exposure to tobacco
How do I
counsel patients to quit?
Counsel your patients to quit
“Minimal interventions lasting less than 3 minutes increase overall
tobacco abstinence rates”
The PHS Guideline
(Strength of Evidence = A)
“There is a strong dose-response relation between the session
length of person-to- person contact and successful treatment
outcomes. Intensive interventions are more effective than less
intensive interventions and should be used whenever possible.”
The PHS Guideline
(Strength of Evidence = A)
What pharmacotherapies are available to
ASSIST in the quit attempt?
By using the pharmacotherapies
found to be effective in the PHS
Guideline, you can double or
triple your patients’ chances of
abstinence.
First-line pharmacotherapies

Bupropion SR (Zyban, Welbutrin)

Nicotine gum

Nicotine inhaler

Nicotine nasal spray

Nicotine lozenge

Nicotine patch

Varenicline (Chantix)
Bupropion SR

One of two non-nicotine medications
approved by the FDA as an aid to smoking
cessation treatment

Available by prescription only (USA)

Mechanism of action: presumably blocks
neural reuptake of dopamine
Bupropion SR
Contraindications:
−
−
−
−
Seizure disorder
MAO inhibitor used within previous 2 weeks
Hx of anorexia nervosa or bulimia
Current use of Wellbutrin
Side effects:
−
−
Insomnia
Dry mouth
Bupropion SR
Dosing:
− start 1-2 weeks before quit date
− 150 mg orally once daily x 3 day
− 150 mg orally twice daily x 7-12 weeks
− no taper necessary at end of treatment
Maintenance:
− efficacious as maintenance medication for <6
months post-cessation
Varenicline (Chantix)

New medication was FDA-approved in May 2006
and on the market July 2006

Varenicline, a pill, is available by prescription only

Varenicline is neither a nicotine replacement therapy nor
an anti-depressant drug

Unique: Varenicline acts on nicotine receptors with two
types of action: It blocks some of the rewarding effects of
nicotine (acts as an antagonist) and at the same time
stimulates the receptors in a way that reduces withdrawal
(acts as an agonist).
Varenicline (Chantix)
Side Effects:

Generally well tolerated

The most common side effects are nausea, headache, trouble sleeping and abnormal dreams
Dosage:

Start varenicline one week before the quit date for maximum
effectiveness. Recommended treatment is 12 weeks:
–
–
–
⇒ Days 1-3: …………….1 pill (0.5 mg) per day;
⇒ Days 4-7: …………….1 pill (0.5 mg) twice a day (a.m. and p.m.)
⇒ Day 8 to the end: ……1 pill (1 mg) twice a day (a.m. and p.m.)


For best results, quit smoking on Day 8
An additional course of 12 weeks for maintenance can be considered.
Pfizer pre-packages Chantix so the pills are laid out day-by-day, in a
“Starting Month” package (four weeks) and “Continuing Month”
packages thereafter.
Varenicline (Chantix)
Precautions:
 Use with caution and consider dose reduction in
patients:
–
–
With significant renal impairment
Undergoing dialysis
Cost Varies:
 Cost varies, but it is approximately $120 per month
($4 per day).
 Varenicline is covered by many health care plans.
Nicotine Replacement Therapy (NRT)

Nicotine is active ingredient

Supplied as steady dose (patch) or selfadministered (gum, inhaler, nasal spray)

Self-administered products should be used
on scheduled basis initially before tapered to
ad lib use and eventual discontinuation
Nicotine Replacement Therapy (NRT)

No evidence of increased cardiovascular
risk with NRT

Medical contraindications:
−
−
−
−
immediate myocardial infarction (< 2 weeks)
serious arrhythmia
serious or worsening angina pectoris
accelerated hypertension
Nicotine Replacement Therapy (NRT)

Nicotine gum

Nicotine patch

Nicotine inhaler

Nicotine nasal spray

Nicotine lozenge
Nicotine gum

2 mg vs. 4 mg

Chew and park

Absorbed in a basic environment

Use enough pieces each day
Nicotine patch

Available as both prescription and OTC

A new patch is applied each morning

Rotating placement site can reduce
irritation
Nicotine inhaler

Available by prescription

Frequent puffing is required

Eating or drinking before and during
administration should be avoided
Nicotine nasal spray

Available by prescription

Patient should not sniff, swallow, or inhale
the medication

Initial dosing should be 1 to 2 doses per
hour, increasing as needed

Dosing should not exceed 40 per day
Nicotine lozenge

Available over the counter
−
Treatment period is up to 12 weeks
−
Lozenges should not be chewed or swallowed,
but should slowly dissolve in the mouth
−
Dosage: 2mg or 4 mg (if smoke less than 30
minutes after waking)
−
Use lozenges on a regular schedule, using at
least 9 lozenges per day during the first 6 weeks
Combination Pharmacotherapy

Combination NRT
−
Patch + gum or patch + nasal spray are more
effective than a single NRT
−
Encourage use in patients unable to quit using
single agent
−
Caution patients on risk of nicotine overdose
−
Currently, not an FDA-approved treatment option
ARRANGE

Schedule a follow-up contact within one
week after the quit date
− Telephone contact
− Quit lines

The majority of relapse occurs in the first
two weeks after quitting
The Quit Line and the 5 A’s

ASK about tobacco use.

ADVISE to quit.

ASSESS willingness to make a quit attempt.

ASSIST in quit attempt.

ARRANGE follow-up.
Relapse

Preventing Relapse
–
–
–
Congratulate success
Encourage continued abstinence
Discuss with your patient:


“How has stopping
tobacco use helped
you?”
benefits of quitting
barriers

If your patient has used tobacco, remind him or her
that the relapse should be viewed as a learning
experience

Relapse is consistent with the chronic nature of
tobacco dependence; not a sign of failure
How do I treat tobacco users who are
not willing to make a quit attempt?
Treating patients who are not ready to
make a quit attempt

RELEVANCE: Tailor advice and discussion to
each patient.

RISKS: Outline risks of continued smoking.

REWARDS: Outline the benefits of quitting.

ROADBLOCKS: Identify barriers to quitting.

REPETITION: Reinforce the motivational
message at every visit.
Assessment of Tobacco Use
Patient presents to a
health care provider
Does patient currently
use tobacco?
YES
Is the patient currently
willing to quit?
YES
Provide
appropriate
treatments
(5 As)
NO
Promote
motivation
to quit
(5 Rs)
NO
Did the patient previously
use tobacco?
YES
Prevent
relapse
NO
Encourage
continued
abstinence
Web Sites

USPHS Guideline and materials:
www.surgeongeneral.gov/tobacco

Wisconsin Tobacco Control:
www.tobwis.org

UW-Center for Tobacco Research &
Intervention: www.ctri.wisc.edu
www.ctri.wisc.edu
“Not since the polio vaccine has this nation
had a better opportunity to make a
significant impact in public health.”
David Satcher, MD, PhD,
Former U.S. Surgeon General