Quitting Smoking. Nancy Mesiha, MD, FACC, MACM PD, CV Fellowship Program St John Hospital & Medical center Cardiology Associates of Michigan

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1 Quitting Smoking Nancy Mesiha, MD, FACC, MACM PD, CV Fellowship Program St John Hospital & Medical center Cardiology Associates of Michigan

2 Risk Factors for PAD Reduced Increased Smoking Diabetes Hypertension Hypercholesterolemia Hyperhomocysteinemia C-Reactive Protein Relative Risk Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.

3 Statistics & Facts q More than 400,000 deaths occur each year as a result of cigarette smoking. q Doubles risk of developing CVD q Responsible for 90% cases of lung cancer q Cigarette smoking is the leading preventable cause of mortality. q Quitting before age 50 reduces risk of dying by half. q Over 70% smokers want to quit. q 40% smokers have tried to quit over the past year. q 3-7% of smokers who have tried to quit, remain abstinent at one year. q Smoking cost the US over $ 193 billion in Stead LF.Combined pharmocotherapy and behavioural interventions for smoking cessation. Cochrane Database system. Rev 2012

4 More Statistics Cigarette smoke contains over 7000 chemicals, 69 of which known to cause cancer. In 2009, an estimated 46.6 million adults were smokers Males, Non-hispanic whites 19.5 percent of high school students were smokers, 2009.

5 I IIa IIb III Patients who are smokers or former smokers should be asked about status of tobacco use at every visit. I IIa IIb III Patients should be assisted with counseling and developing a plan for quitting that may include pharmacotherapy and/or referral to a smoking cessation program ACC/AHA Updated PAD Guidelines

6 I IIa IIb III Individuals with lower extremity PAD who smoke cigarettes or use other forms of tobacco should be advised by each of their clinicians to stop smoking and offered behavioral and pharmacological treatment. I IIa IIb III In the absence of contraindication or other compelling clinical indication, 1 or more of the following pharmacological therapies should be offered: varenicline, bupropion, and nicotine replacement therapy ACC/AHA Updated PAD Guidelines

7 The 5 A s ASK: Identify and document tobacco use ADVISE: In a clear, strong, personalized manner, urge smoker to quit ASSESS: Is the smoker ready to make a quit attempt? ASSIST: Use counselling and pharmacotherapy to help him/her quit ARRANGE: Schedule follow-up contact Preferably within 1 week after the quit date

8 Pharmocological Treatments q Nicotine Replacement Therapy q Long acting : Nicotine Patch q Short Acting: gum, lozenges, nasal spray, inhaler q E-Cigarettes (vapor) q Bupropion q Varenicline

9 Treatment NRT Gum/Lozenge: 2 mg, 4 mg (25 cig/day), up to q 1-2 hours for 3-6 months Nicotine inhaler: 6-16 cartridges per day, for 6-12 weeks Nicotine nasal spray: 1-2 sprays per hour PATCHES: 21 mg/day x 6 weeks, 14 mg/day x2 weeks, 7 mg/day 2 weeks. Combination therapy: is more effective than single type of NRT (RR 1.34, 95% CI 1.18 to 1.51) Nicotine replacement therapy for smoking cessation (Review) 1 Copyright 2012 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.

10 Pharmacological Therapy Buproprion: 150 mg/d x 3 days, 150 mg bid x 7-12 weeks - Central acting, blocks the re-uptake of dopamine and nor-epinephrine - SE: insomnia, agitation, dry mouth, headache Verenicline: 0.5 mg daily x 3 days, 0.5 mg BID x 4 days, 1 mg BID x 12 weeks. - Partial agonist alpha 4, beta 2 nicotinic acetycholine receptor - SE: nausea, insomnia, abnormal dreams, syncope, skin reactions, psychiatric

11 Treatment Comparisons

12 Treatment Comparisons

13 Alternative Therapies q Acupuncture q Found to be less effective than nicotine replacement q Aversive Therapy q Increase rate of smoking with goal of inducing a displeasure q Insufficient evidence q Financial Incentives q Some evidence of efficacy q Hypnosis q Potential benefits

14 Most Effective Treatment q Combined Behavioral and pharmacologic q Patient preference regarding pharmacologic approach: q Constant reassurance: q Free telephone counseling q Physician advice coupled with frequent follow-up achieves 1-year smoking cessation rates of approximately 5% compared with only 0.1% in those attempting to quit smoking without a physician s intervention

15 What Happens After You Stop Smoking 20 Minutes --- heart rate and BP drop 12 Hours --- CO level in blood normalizes 2 weeks to 3 months --- circulation and lung function improve 1 to 9 months --- Cough and SOB decrease 1 year --- Excess risk of coronary heart disease is halved 5 years --- Risk of cancer is halved, as well as CVA 10 years --- Risk of dying from lung cancer is halved 15 years --- Risk of CHD is that of a non-smoker s.

16 In Summary It is recommended that efforts be made to achieve smoking cessation in patients with lower extremity PAD. Although the cessation rates are low, physicians can make a difference.

17 Quitting Smoking Nancy Mesiha, MD, FACC, MACM PD, CV Fellowship Program St John Hospital & Medical center Cardiology Associates of Michigan

Smoking Cessation: Treatment Options for Nicotine Addiction

Smoking Cessation: Treatment Options for Nicotine Addiction Hilary Nierenberg, NP, MPH Center for Interventional Vascular Therapy Columbia University Medical Center Disclosure Statement of Financial Interest