Transcript What to Do With a Patient Who Smokes Steven A. Schroeder, MD Presentation courtesy of The Smoking Cessation Leadership Center and Rx for Change February 2007

What to Do With a Patient
Who Smokes
Steven A. Schroeder, MD
Presentation courtesy of
The Smoking Cessation Leadership Center
and Rx for Change
February 2007
Topics for Today
Facts about smoking
 Nicotine and dependence
 Aids for cessation
 Telephone quitlines
 Next steps

JAMA Article
Tobacco’s Deadly Toll





440,000 deaths in the U.S. each year
4.8 million deaths world wide each year
10 million deaths estimated by year 2030
50,000 deaths in the U.S. due to second-hand
smoke exposure
8.6 million disabled from tobacco in the U.S. alone
Comparative Causes of Annual
Deaths in the United States
440
450
400
350
300
250
200
*
150
81
100
50
41
17
19
14
30
0
AIDS
Alcohol
Motor Homicide Drug
Suicide Smoking
Vehicle
Induced
suffer from
* Also
mental illness and/or
Source: Centers for Disease Control and Prevention
substance abuse
Annual U.S. Deaths Attributable to
Smoking, 1997–2001
Percent of all smokingattributable deaths
Cardiovascular diseases
Lung cancer
Respiratory diseases
Second-hand smoke
Cancers other than lung
Other
137,979
123,836
101,454
38,112
34,693
1,828
31%
28%
23%
9%
8%
<1%
TOTAL: 437,902 deaths annually
Centers for Disease Control and Prevention. MMWR 2005;54:625–628.
Health Consequences of Smoking

Cancers
–
–
–
–
–
–
–
–
–


Acute myeloid leukemia
Bladder and kidney
Cervical
Esophageal
Gastric
Laryngeal
Lung
Oral cavity and pharyngeal
Pancreatic
Pulmonary diseases
– Acute (e.g., pneumonia)
– Chronic (e.g., COPD)
Cardiovascular diseases
–
–
–
–

Abdominal aortic aneurysm
Coronary heart disease
Cerebrovascular disease
Peripheral arterial disease
Reproductive effects
– Reduced fertility in women
– Poor pregnancy outcomes (e.g.,
low birth weight, preterm delivery)
– Infant mortality

Other effects: cataract, osteoporosis,
periodontitis, poor surgical outcomes
U.S. Department of Health and Human Services.
The Health Consequences of Smoking: A Report of the Surgeon General, 2004.
Smoking Cessation:
Reduced Risk of Death
Prospective study of 34,439 male British doctors
Mortality was monitored for 50 years (1951–2001)


Years of life gained
15
On average, cigarette
smokers die approximately
10 years younger than do
nonsmokers.
10
5
0
30
40
50
60
Among those who continue
smoking, at least half
will die due to a
tobacco-related disease.
Age at cessation (years)
Doll et al. (2004). BMJ 328(7455):1519–1527.
Cumulative risk (%)
Reduction in
cumulative risk of
death from lung
cancer in men
Age in years
Reprinted with permission. Peto et al. (2000). BMJ 321(7257):323–329.
Causal Associations with
Second-hand Smoke

Developmental

– Low birthweight
– Sudden Infant Death
Syndrome
– Pre-term delivery

Respiratory
– Asthma induction and
exacerbation
– Eye and nasal irritation
– Bronchitis, pneumonia,
otitis media in children
Carcinogenic
– Lung cancer
– Nasal sinus cancer
– Breast cancer (younger,
premenopausal women)

Cardiovascular
– Heart disease mortality
– Acute and chronic coronary
heart disease morbidity
– Altered vascular properties
Compounds in Tobacco Smoke
An estimated 4,800 compounds in tobacco smoke,
including 11 proven human carcinogens
Gases
–
–
–
–
–
Carbon monoxide
Hydrogen cyanide
Ammonia
Benzene
Formaldehyde
Particles
–
–
–
–
–
Nicotine
Nitrosamines
Lead
Cadmium
Polonium-210
Nicotine does NOT cause the ill health effects of tobacco.
The Real Culprit

It is the smoke, tar, and additives that make
people sicken and die.

Nicotine is dangerous because it leads to
addiction, and therefore increased exposure
tobacco constituents.

Therefore, nicotine replacement therapy is
helpful, not harmful. It is a “clean” form of
nicotine.
STATE-SPECIFIC PREVALENCE of
SMOKING among ADULTS, 2005
Illinois
19.9%
California
15.2%
Kentucky
28.7%
Nevada
23.1%
New York
20.5%
Utah
11.5%
Texas
20.0%
Indiana
27.3%
Florida
21.6%
Centers for Disease Control and Prevention. (2006). MMWR 55:1148–1151.
TRENDS in ADULT SMOKING, by
SEX—U.S., 1955–2005
Trends in cigarette current smoking among persons aged 18 or older
60
50
20.9% of adults
are current
smokers
Male
Percent
40
30
23.9%
Female
20
18.1%
10
0
1955
1959
1963
1967
1971
1975
1979
1983
1987
1991
1995
1999
2003
Year
70% want to quit
Graph provided by the Centers for Disease Control and Prevention. 1955 Current Population
Survey; 1965–2005 NHIS. Estimates since 1992 include some-day smoking.
TRENDS in TEEN SMOKING, by
ETHNICITY—U.S., 1977–2006
Trends in cigarette smoking among 12th graders: 30-day prevalence of use
50
40
Percent
White
30
Hispanic
20
Black
10
0
1977
1982
1987
1992
1997
2002
Year
Institute for Social Research, University of Michigan, Monitoring the Future Project
www.monitoringthefuture.org
TRENDS in ADULT CIGARETTE
CONSUMPTION—U.S., 1900–2005
Annual adult per capita cigarette consumption and major smoking and health events
First Surgeon
General’s Report
Number of cigarettes
5,000
Broadcast
ad ban
End of WW II
4,000
Master
Settlement
Agreement;
California
first state to
enact ban on
smoking in
bars
3,000
Nonsmokers’
rights movement
begins
2,000
Cigarette
price drop
20 states
have > $1
pack tax
1,000
Federal cigarette
tax doubles
Great Depression
0
1900
1910
1920
1930
1940
1950
1960
1970
1980
1990
2000
Year
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.
PREVALENCE of ADULT SMOKING,
by RACE/ETHNICITY—U.S., 2005
32.0% American Indian/Alaska Native*
21.9% White*
21.5% Black*
16.2% Hispanic
13.3% Asian*
0%
10%
20%
30%
40%
50%
* non-Hispanic.
Centers for Disease Control and Prevention. (2006). MMWR 55:1145–1148.
PREVALENCE of ADULT SMOKING,
by EDUCATION—U.S., 2005
25.5% No high school diploma
43.2% GED diploma
24.6% High school graduate
22.5% Some college
10.7% Undergraduate degree
7.1% Graduate degree
0%
10%
20%
30%
40%
50%
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
Price
Clinician
advice
Counter
Marketing
Clean indoor
air
% of Quitters
Counseling
Medications
Ways to Help Smokers Quit
Raise prices (taxes)
 Clean indoor air
 Create counter-marketing
 Provide cessation aids: counseling and
pharmacotherapy, alone or in combination

– Directly by clinician in individual or group session
(office or hospital)
– Toll-free telephone quitlines
Reasons for Not Helping Patients Quit
1.
2.
3.
4.
5.
6.
7.
8.
Too busy
Lack of expertise
No financial incentive
Most smokers can’t/won’t quit
Stigmatizing smokers
Respect for privacy
Negative message might scare away patients
I smoke myself
Responses to Patient Who Smokes
Unacceptable: “I don’t have time.”
 Acceptable

– Refer to a quit line
– Establish systems in your office and hospital
– Become 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 Dependence
Biochemical
– Serum, urinary, or saliva cotinine testing
– Carbon monoxide testing
Fagerström Test for Nicotine Dependence
Item
Response Options
1.

How soon after you awaken do you smoke your first
cigarette?



2.
3.
Do you find it difficult to refrain from smoking in places where
it is forbidden?
Which cigarette would you hate most to give up?




4.
How many cigarettes per day do you smoke?




5.
6.
Do you smoke more frequently during the first hours after
waking up than during the rest of the day?
Do you smoke if you are so ill that you are in bed most of the
day?




within 5 minutes
6-30 minutes
30-60 minutes
after 60 minutes
yes
no
first one in morning
any other
10 or less
11-20
21-30
31 or more
yes
no
yes
no
Points
















3
2
1
0
1
0
1
0
0
1
2
3
1
0
1
0
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
Nicotine reaches the brain within 11 seconds
Plasma nicotine (ng/mL)
80
70
Arterial
60
50
40
30
Venous
20
10
0
0
1
2
3
4
5
6
7
8
9
10
Minutes after light-up of cigarette
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.
Nicotine Metabolism
H
N
N
70–80%
cotinine
CH3
10–20%
excreted
unchanged
in urine
~ 10% other
metabolites
Metabolized
and excreted
in urine
Adapted and reprinted with permission. Benowitz et al. J Pharmacol Exp Ther 1994;268:296–303.
Nicotine Pharmacodynamics
Central nervous system
– Pleasure
– Arousal, enhanced vigilance
– Improved task performance
– Anxiety relief
Other
– Appetite suppression
– Increased metabolic rate
– Skeletal muscle relaxation
Cardiovascular system
–  Heart rate
–  Cardiac output
–  Blood pressure
– Coronary vasoconstriction
– Cutaneous vasoconstriction
Dopamine Reward Pathway
Prefrontal
cortex
Dopamine release
Stimulation of
nicotine receptors
Nucleus
accumbens
Ventral
tegmental
area
Nicotine enters
brain
Chronic Administration of Nicotine:
Effects on the Brain
Human smokers have increased nicotine
receptors in the prefrontal cortex.
High
Low
Nonsmoker
Smoker
Image courtesy of George Washington University / Dr. David C. Perry
Perry et al. J Pharmacol Exp Ther 1999;289:1545–1552.
Damage to the Insula Disrupts
Addiction to Cigarette Smoking*
19 smokers with brain damage to insula region,
compared with 50 smokers with brain damage
elsewhere
 Smoking rates lower in insula-damaged patients
(odds ratio=2.94) but not statistically significant
(low #s)
 But addictive cravings much lower in insula
damaged patients (OR=22; p<.0005)

*Naqvi et al. Science 2007; 315:531-534
Nicotine Pharmacodynamics:
Withdrawal Effects

Depression

Insomnia

Irritability/frustration/anger

Anxiety

Difficulty concentrating

Restlessness

Increased appetite/weight gain

Decreased heart rate

Cravings*
* Not considered a withdrawal symptom by DSM-IV criteria.
Most symptoms
peak 24–48 hr
after quitting and
subside within
2–4 weeks.
American Psychiatric Association. (1994). DSM-IV.
Hughes et al. (1991). Arch Gen Psychiatry 48:52–59.
Hughes & Hatsukami. (1998). Tob Control 7:92–93.
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
Advantages



Disadvantages
Gum use may satisfy
oral cravings.
 Gum may not be socially
acceptable.
Gum use may delay
weight gain.
 Gum is difficult to use with
dentures.
Patients can titrate
therapy to manage
withdrawal symptoms.
 Patients must use proper
chewing technique to
minimize adverse effects.
Transdermal Nicotine Patch
Advantages



The patch provides
consistent nicotine
levels.
Disadvantages

The patch is easy to
use and conceal.

Fewer compliance
issues are associated
with the patch.


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.
Nicotine Lozenge
Advantages



Lozenge use may satisfy
oral cravings.
The lozenge is easy to
use and conceal.
Patients can titrate
therapy to manage
withdrawal symptoms.
Disadvantages

Gastrointestinal side effects
(nausea, hiccups, and
heartburn) may be
bothersome.
Nicotine Nasal Spray
Advantages

Patients can easily
titrate therapy to
rapidly manage
withdrawal symptoms.
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.
Nicotine Inhaler
Advantages
 Patients can easily
titrate therapy to
manage withdrawal
symptoms.
 The inhaler mimics
hand-to-mouth ritual of
smoking.
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.
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,
use of combination therapies is becoming normalized.
Nicotine Agonist—VARENICLINE
 Chantix, marketed by Pfizer
 Partial nicotinic receptor agonist
– Approved by the FDA May 2006, to hit the market in the fall of
2006
– Much DTC marketing anticipated in 2007
 Early trials (JAMA) show better results than
bupropion
 Lessens withdrawal symptoms and inhibits the
“buzz” from a smoke
 Main side effect is nausea
VARENICLINE:
Mechanism of Action

Binds with high affinity and selectivity at 42
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
Initial
dose
titration
Dose
Day 1 to day 3
0.5 mg qd
Day 4 to day 7
0.5 mg bid
Day 8 to end of treatment*
1 mg bid
* 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
ADVANTAGES
 Varenicline is an oral
formulation with twice-aday 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.
DISADVANTAGES
 May induce nausea in up to
one third of patients.
 Post-marketing surveillance
data not yet available.
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
Patients should begin therapy 1 to 2 weeks PRIOR
to their quit date to ensure that therapeutic plasma
levels of the drug are achieved.
Initial treatment

150 mg po q AM x 3 days
Then…


150 mg po bid
Duration, 7–12 weeks
BUPROPION SR:
Advantages and Disadvantages
Advantages



Easy to use.
Bupropion SR can be
used with NRT.
Might be beneficial for
patients with
depression.
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
–
–
–
–
–
Combination Therapy for the Heavily
Addicted Smoker—Mayo Clinic Style

Nicotine patch
– Strongest dose, can use more than one

Shorter acting nicotine replacement

Bupropion SR
Comparative Daily Costs of
Pharmacotherapy
Inhaler
$6.07
Gum
$5.81
Bupropion SR
$5.73
Lozenge
$5.26
Cigarettes (1 pack/day)
$4.26
Varenicline
$4.22
Patch
$3.91
Nasal spray
$3.67
0
2
4
6
Cost per day, in U.S. dollars
8
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
30
Active drug
Placebo
Percent quit
25
20
23.9
22.5
20.0
19.5
17.1
16.4
14.6
15
11.8
11.5
10
8.6
9.1
8.8
10.2
9.4
5
0
Nicotine gum
Nicotine
patch
Nicotine
lozenge
Nicotine
nasal spray
Nicotine
inhaler
Bupropion
Varenicline
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.
Combination Therapy:
Patch Plus Bupropion SR
Percentage of patients quit at 12 months after cessation
Nicotine patch
plus bupropion
35.5%
Bupropion
30.3%
Nicotine patch
16.4%
Placebo
15.6%
0%
5%
10%
15%
20%
25%
30%
35%
40%
Jorenby et al. N Engl J Med 1999;340(9):685–691.
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.
Estimated abstinence at
5+ months
30
20
2.2
1.7
10
1.0
1.1
(1.5,3.2)
(1.3,2.1)
(0.9,1.3)
0
No clinician
Self-help
Non-physician clinician
Type of clinician
Physician clinician
n = 29 studies
Fiore et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. USDHHS, PHS, 2000.
New Medications in the Pipeline

Rimonabant
–
–
–
–
–

Cannabinoid receptor inhibitor
Blocks reinforcing effects of nicotine
Also suppresses appetite
In phase III trials
Not approved for smoking cessation by FDA
Nicotine Vaccine
– Produces antibodies to nicotine
– Reduces nicotine levels in animals

CYP246 Inhibitors
– CYP246 is a hepatic enzyme that metabolizes nicotine
– Higher blood nicotine levels per cigarette smoked
– Could also increase potency of NRT
JCAHO Core Measures
Community-Acquired Pneumonia
 Acute MI
 CHF
 Pediatrics

National Rates for AMI, Heart Failure and Pneumonia
Adult Smoking Cessation Counseling Measures
1
0.9
0.8
0.6
0.5
0.4
0.3
0.2
0.1
AMI
Heart Failure
Pneumonia
2Q
20
05
20
05
1Q
20
04
4Q
20
04
3Q
20
04
2Q
20
04
1Q
20
03
4Q
20
03
3Q
20
03
2Q
20
03
1Q
20
02
4Q
20
02
0
3Q
Rate
0.7
Adult Smoking Cessation Counseling
for Acute MI Patients
1
0.9
0.8
0.6
0.5
0.4
0.3
0.2
0.1
JCAHO (Nat'l)
UHC
UCSF
2Q
20
05
20
05
1Q
20
04
4Q
20
04
3Q
20
04
2Q
20
04
1Q
20
03
4Q
20
03
3Q
20
03
2Q
20
03
1Q
20
02
4Q
20
02
0
3Q
Rate
0.7
Adult Smoking Cessation Counseling
for CHF Patients
1
0.9
0.8
0.6
0.5
0.4
0.3
0.2
0.1
JCAHO (Nat'l)
UHC
UCSF
2Q
20
05
20
05
1Q
20
04
4Q
20
04
3Q
20
04
2Q
20
04
1Q
20
03
4Q
20
03
3Q
20
03
2Q
20
03
1Q
20
02
4Q
20
02
0
3Q
Rate
0.7
Adult Smoking Cessation Counseling
for PN Patients
1
0.9
0.8
0.6
0.5
0.4
0.3
0.2
0.1
JCAHO (Nat'l)
UHC
UCSF
2Q
20
05
20
05
1Q
20
04
4Q
20
04
3Q
20
04
2Q
20
04
1Q
20
03
4Q
20
03
3Q
20
03
2Q
20
03
1Q
20
02
4Q
20
02
0
3Q
Rate
0.7
Treating Tobacco Dependence: 2003
Community
•TOFCO
•Oregon Quitline
•Business Case
Hospital-Based
Health System
•Inpatient Program
•Behavioral Health/CD
•Research > $800K
•Leadership: ATMC
RWJF, CDC, AAHP
•Formal HSI Program
Target Groups
•Disease Management
•PHS employees
•Web-Based
•Women & Children
•Clinical Programs
Cessation
SMOKER
(who wants to quit)
Providers
•5 A’s Training/Education
•Reimbursement
•Physician Leadership
•Group Classes
•Free Medications
•Telephone Support
•Self-Help Materials
•Prov-RN
Clinics
Evaluation
•C.O.R.E.
•Utilization
•Grant Writing
•5 A’s Training
•EMR Resources
•Dissemination (TAR)
•Resources: Primary Care,
Specialties, Pediatrics, OB/GYN
Smoking Prevalence:
Providence Health Plan vs. Oregon
24%
23%
22%
21%
20%
19%
18%
17%
16%
15%
'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.
†Based on Silagy et al. (2004) and Stead et al. (2004). The Cochrane Library.
Knowledge of Tobacco Cessation Programs Among
California Smokers†
Unaided 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)
--
METHOD
† Data from the California Tobacco Survey, 1999. For the unaided recall 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 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-NOFUME) phone number?”
* CI = confidence interval.
Call Volume to the Quitline in response to New
York City Free Patch Give-Away Program
236840
(>425,000 calls in first 3 days!!!)
300000
250000
150000
41182
100000
50000
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
99558
200000
0
/0
2
/
4
3
/0
9
/
4
3
/03
6
4/1
/03
3
4/2
/03
0
4/3
/0
7
/
5
3
/03
4
5/1
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
Partnership for Prevention: Additional QALYs
Saved if Current % Receiving Services Increased*
Services (short name)
Current % receiving
services nationally
Additional QALYs saved if
current % receiving services
increased to 90%
Tobacco Use Screening and
Brief Intervention
35%
1,300,000
Colorectal Cancer Screening
35%
310,000
Influenza Vaccine—Adults
35% among adults 50-64 yrs
65% among adults 65+ yrs
110,000
Breast Cancer Screening
68%
91,000
Cervical Cancer Screening
79%
29,000
Pneumococcal Vaccine—Adults
56%
16,000
Cholesterol Screening
87%
12,000
*Priorities for America’s Health: Capitalizing on Life-Saving Cost-Effective Preventive Services.
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!