Smoking Cessation: Treatment Options for Nicotine Addiction

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1 Smoking Cessation: Treatment Options for Nicotine Addiction Hilary Nierenberg, NP, MPH Center for Interventional Vascular Therapy Columbia University Medical Center

2 Disclosure Statement of Financial Interest I, Hilary Nierenberg DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.

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8 Key Patient Discussion Points Daily cigarette intake (1 cig =1 mg nicotine) Time after waking before first cigarette (are the cigarettes at the bedside table? Is the patient waking at night to smoke?) Identification of triggers: coffee, food, stress, work, friends, driving, boredom Cessation action plan regarding triggers In home smokers Support network

9 Nicotine Withdrawal: a preventable barrier to cessation peaks within hours of cessation; Can last for weeks in some patients. depressed mood insomnia irritability/restlessness anxiety difficulty concentrating

10 Pharmacotherapy for tobacco cessation Seven, FDA approved, effective, 1 st line agents: nicotine patch nicotine gum nicotine lozenge nicotine nasal spray nicotine inhaler bupriopion SR varenicline

11 Guidance for use of 1 st Line Medicines

12 Combination NRT Combining long acting nicotine patch with short acting ad lib agent (gum, lozenge, spray, inhaler) results in higher long-term abstinence rates. Encourages patient to be in control of cravings and withdrawal symptoms Improves compliance with treatment plan Achieves higher drug concentrations Allows further dose adjustments Provides an alternative to tobacco

13 Nicotine Patch Therapy Dosing Guidance Based on Baseline Cigarettes/Day <10 CPD 7-14 mg/d CPD mg/d CPD mg/d >40 CPD 42+ mg/d

14 Increase in nicotine concentration ( ng/ml ) Smoking produces higher nicotine levels much more rapidly than NRT Cigarette Gum 4 mg Gum 2 mg Patch 42 mg Inhaler Patch 21 mg Minutes Adapted from Balfour DJ & Fagerström KO. Pharmacol Ther :51-81.

15 Non-nicotine 1 st Line Medications Bupropion SR: generally well tolerated occasional reports of hypertension best outcomes when combined with NRT Varenicline: not contraindicated in cardiac patients Recommend that clinician elicit psych history and monitor should NOT be combined with NRT

16 FDA WARNINGS Varenicline now has a boxed warning highlighting potential neuropsychiatric symptoms including suicidiality, updates rare post-marketing reports of angioedema and reports of accidental injuries. Bupropion now has a similar boxed warning re neuropsychiatric events. Both boxed warnings state that Patients with serious psychiatric illness such as schizophrenia, bipolar disorder, and major depressive disorder did not participate in pre-marketing studies.. but the varenicline warning further states that the safety and efficacy of varenicline in such patients has not been established. Both warnings stress that the risks of the drugs must be balanced by the increased likelihood of abstinence from smoking and stress that the health benefits of quitting smoking are immediate and substantial.

17 Quit-Line Resources QUIT- NOW leads to a national quitline network that will route callers to a local quit-line. FAX TO QUIT enable clinicians or institutions to obtain consent and arrange for the quit-line to contact the patient directly to initiate intervention. Most quit-lines offer access to free NRT and guideline based counseling over the phone.

18 Light Smokers No true consensus on the definition of a light smoker. Guideline uses criteria of smoking less than 10 cigs per day. Does NOT include those who smoke light cigarettes in higher quantities. A large (N=42,722) study in Norway found an increased risk of death from ischemic HD and other tobacco related diseases for men and women who smoke only 1 to 4 cigarettes daily.

19 For the patient who has recently quit Elicit & address risk factors for relapse: Lack of support for cessation Negative mood or emerging depression Prolonged withdrawal symptoms Weight gain Smoking lapses

20 Special Populations Hospitalized Older smokers Women Psychiatric history

21 CMS Core Measures Document smoking cessation counseling provided for all patients with a history of smoking within the past year CMS considers all recent (within one year) quits to require documentation of smoking cessation counseling

22 Summary Elicit honest tobacco history Understand patient triggers Provide detailed information regarding treatment strategies Document all smoking cessation activities at every opportunity Smoking cessation counseling can be more than just instructing patients to stop

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