A Holistic Approach to Smoking Cessation

A Holistic Approach to Smoking Cessation 1 Disclosures David A. Baron, DO, the faculty who developed the content for this presentation, has disclosed that he has no actual or potential conflict of interest in regard to this activity The planning staff of CME Enterprise have nothing to disclose. The views and opinions expressed in this activity do not necessarily reflect the views of CME Enterprise 2 Learning Objectives Distinguish the effects of smoking on cardiovascular disease and life expectancy in your patients Apply proven strategies t for screening, motivating, and supporting patients in efforts to quit smoking Select appropriate pharmacologic and nonpharmacologic interventions for smoking cessation based on a patient s comorbidities and concomitant medications 3 1

Simon, the Ambivalent Elderly Preoperative Patient Simon is a 69-year-old African-American man, a retired engineer, who is scheduled for a total knee replacement in 1 month; he denies alcohol and drug use; Simon has smoked approximately 1 pack of cigarettes per day since age 18; his wife quit 10 years ago using nicotine patches; he no longer smokes in the house or in the car; he tried to quit with his wife 10 years ago using nicotine patches, but was unable to remain abstinent for more than 1 day; his wife would like him to quit; he is ambivalent about making a quit attempt at this time, stating, I am too old and I ve been smoking a long time ; physical exam is notable for a moderate right knee effusion and crepitus with flexion, but a normal range of motion 4 Of the Following Statements to Help Motivate Simon to Make a Quit Attempt, Which Is/Are Correct? 1. Quitting will accelerate his postsurgical healing 2. Quitting at any age improves respiratory and cardiac health 3. New medications are available to assist with quit attempts 4. Having a smoke-free home means he is unlikely to need pharmacotherapy to quit 5. Counseling is superior to pharmacotherapy in achieving abstinence 5 If every physician advised every patient at every visit not to smoke, 1 million Americans could escape nicotine addiction each year. - Michael Fiore, MD 6 2

Prevalence In the United States, 20% of adults still smoke Higher prevalence in men, Native Americans, and lower socioeconomic class 1/3 of people ages 18 to 24 smoke 2/3 of female smokers continue to smoke during pregnancy 7 Burden of Suffering Smoking causes 1 out of 5 deaths in the United States 420,000 Americans die each year from health consequence of smoking Smoking is the most prevalent preventable cause of premature death 8 Nearly 440,000 Average Annual Deaths Attributable to Cigarette Smoking United States, 1997-2001 Other Diagnosis 35,502 Second Hand Smoke Deaths 38,112 Other Cancers 34,693 Ischmeic Heart Disease 86,80 Stroke (Cerbovascular Disease) 17,43 Lung Cancer 123,836 Respiratory Diseases 101,45 CDC. MMWR Morb Mortal Wkly Rep. 2005;54(25):625-628. 9 3

Annual Deaths from Smoking Compared With Selected Other Causes in the United States 440 438 Number of Deat ths (Thousands) 400 360 320 280 240 200 160 120 80 40 0 14 21 45 AIDS Alcohol Motor Vehicle 18 Homicide 29 31 Drug Induced Suicide Smoking Hoyert DL, et al. Health E-Stats. Released January 19, 2006. 10 1 Out of 2 Lifelong Adult Smokers Will Die From a Smoking-Related Disease CDC. MMWR Morb Mortal Wkly Rep. 1996;45(44):971-974. 11 Smoking Cessation and the Heart Smoking cessation reduces the excess risk of dying from abdominal aortic aneurysm by 50% among former smokers Risk of coronary heart disease decreases by half 1-2 years after quitting After 15 years of quitting, coronary heart disease risk is nearly that of a nonsmoker Among persons diagnosed with cardiovascular heart disease, smoking cessation reduces risk of recurrent infarction and cardiovascular death After quitting, peripheral artery disease decreases USDHHS. The Health Benefits of Smoking Cessation; 1990. 12 4

Instant Gratification 20 Minutes 8 Hours 24 Hours 48 Hours Blood pressure decreases Pulse rate drops Improved peripheral circulation Carbon monoxide level drops to normal Risk of heart attack decreases Enhanced taste and smell 13 Intermediate Gratification 2 Weeks-3 Months Circulation improves Walking becomes easier Lung function improves 1-9 Months Cough, sinus congestion, fatigue and shortness of breath improve 1 Year Excess risk of heart disease is reduced by half 14 Long-Term Gratification 5-15 Years Stroke risk is reduced to baseline Lung cancer risk is half that of people who continue to smoke Risk of oral, esophageal, bladder, renal and pancreatic cancer decreases 15 Years CAD risk similar to those who never smoked Risk of death near baseline 15 5

Clinical Practice Guideline: Treating Tobacco Use and Dependence Update History 1996 Initial guideline Literature from 1975-1995 Approximately 3000 articles 2000 Revised guideline Literature from 1995-1999 Approximately 3000 articles 2008 Updated guideline Literature from 1999-2007 Approximately 2700 articles Approximately 8700 total articles 16 Development Process: Sponsors Agency for Healthcare Research and Quality National Cancer Institute National Heart Lung and Blood Institute National Institute on Drug Abuse Centers for Disease Control and Prevention The Robert Wood Johnson Foundation American Legacy Foundation University of Wisconsin Center for Tobacco Research and Intervention 17 17 Development Process (cont.) Summary of Strength of Evidence for Recommendations Strength of Evidence Classification Criteria Strength of evidence=a Multiple well designed randomized clinical trials, directly relevant to the recommendation, yielded a consistent pattern of findings Strength of evidence=b Strength of evidence=c Some evidence from randomized clinical trials supported the recommendation, but the scientific support was not optimal; for instance, few randomized trials existed, the trials that did exist were somewhat inconsistent, or the trials were not directly relevant to the recommendation Reserved for important clinical situations where the panel achieved consensus on the recommendation in the absence of relevant randomized controlled trials 18 6

The 5 A s Model for Treating Tobacco Use and Dependence 2008 Ask (strength of evidence=a) Advise (strength of evidence=a) Assess (strength of evidence=c) Assist (strength of evidence=a) Arrange (strength of evidence=c) Do you smoke? Record in every patient chart at every visit I strongly advise you to quit smoking for your health and the health of your friends Are you ready to quit within the next 30 days? Brief counseling Prescribe medications or recommend OTC medications Refer to 1.800.QUIT.NOW or a local tobaccocessation program Advise the patient to set a follow-up appointment with his/her PCP OTC=over the counter. PCP=primary care physician. 19 Algorithm for Treating Tobacco Use YES Does patient now use tobacco? See Chapter 2 NO YES Is patient now willing to quit? NO YES Did patient once use tobacco? NO Provide appropriate tobacco dependence treatments See Chapters 3A and 4 Promote motivation to quit See Chapter 3B Prevent relapse* See Chapter 3C Encourage continued abstinence *Relapse prevention interventions are not necessary in the case of the adult who has not used tobacco for many years. 20 The 5 A s: Treating Tobacco Dependence as a Chronic Disease ASK (Do you use tobacco) ADVISE (to quit) Current Smokers Former Smokers Never Smoker ASSESS Willing to quit? Recently quit? Yes No Yes No ASSIST Assist in Intervene to Provide relapse quit attempt increase motivation prevention ARRANGE for FOLLOW-UP 21 7

For the Patient t Unwilling to Quit 22 Treatment Recommendations for Smokers Not Willing to Make a Quit Attempt at This Time Clinicians should use motivational techniques to encourage smokers to consider making a quit attempt in the future (strength of evidence=b) Express empathy Develop discrepancy Highlight the discrepancy between the patient s present behavior and expressed priorities, values, and goals Reinforce and support change talk and commitment language Build and deepen commitment to change Roll with resistance Back off and use reflection when the patient expresses resistance Express empathy Ask permission to provide information Support self-efficacy Help the patient to identify and build on past successes Offer options for achievable small steps toward change 23 For the Patient Unwilling to Quit: The 5 Rs Relevance Encourage the patient to indicate why quitting is personally relevant, being as specific as possible Risks Ask the patient to identify potential negative consequences of tobacco use Rewards Roadblocks Repetition Ask the patient to identify potential benefits of stopping tobacco use Ask the patient to identify barriers or impediments to quitting and provide treatment (problem-solving counseling, medication) that could address barriers Repeat motivational intervention every time an unmotivated patient visits the clinic setting 24 8

For the Patient t Willing to Quit 25 Ask: Systematically identify all tobacco users at every visit Implement an office-wide system that ensures that, for EVERY patient at EVERY clinic visit, tobacco-use status is queried and documented Expand the vital signs to include tobacco use or use an alternative universal identification system VITAL SIGNS Blood Pressure: Pulse: Weight: Temperature: Respiratory Rate: Tobacco Use: Current Former Never (circle one) 26 Advise: Strongly urge all tobacco users to quit In a clear, strong, and personalized manner, urge every tobacco user to quit Advice should be Clear Strong Personalized 27 9

Assess: Determine willingness to make a quit attempt Assess every tobacco user s willingness to make a quit attempt at this time If the patient is willing to make a quit attempt at this time, provide assistance If the patient will participate in an intensive treatment, deliver such a treatment or link/refer to an intensive intervention If the patient is a member of a special population (eg, adolescent, pregnant smoker, racial/ethnic minority), consider providing additional information If the patient clearly states he or she is unwilling to make a quit attempt at this time, provide an intervention shown to increase future quit attempts 28 Assist: For the patient willing to quit Help the patient with a quit plan Set a quit date Tell family, friends, and coworkers Anticipate challenges Remove tobacco products from your environment Provide practical counseling (problem-solving/skills training) Provide intra-treatment social support Provide supplementary materials, including information on quitlines 1.800.QUIT.NOW 29 Assist: For the patient willing to quit (cont.) Recommend the use of approved medication, except where contraindicated or with specific populations for which there is insufficient evidence of effectiveness (ie, pregnant women, smokeless tobacco users, light smokers, and adolescents) Both counseling and medication should be provided to patients trying to quit smoking (strength of evidence=a) 30 10

Arrange: Ensure follow-up contact for the patient willing to quit Arrange for follow-up contacts, either in person or via telephone Timing Follow-up contact should begin soon after the quit date, preferably during the first week A second follow-up contact is recommended within the first month Actions during follow-up contact t Identify problems already encountered and anticipate challenges in the immediate future Assess medication use and problems. Remind patients of quitline support (1.800.QUIT.NOW) Treat tobacco use as a chronic disease; for patients who are abstinent, congratulate them on their success If tobacco use has occurred, review circumstances and elicit recommitment to total abstinence; consider use of or link to more intensive treatment 31 Relapse Rate Over Time ers (%) Abstaine 100 90 80 70 60 50 40 30 20 10 0 0 1 2 3 4 5 6 7 8 9 10 11 12 Time (Months) 2 Weeks USDHHS. The Health Consequences of Smoking: Nicotine Addiction. A Report of the Surgeon General; 1988. Alcohol Smoking Heroin 32 For the Patient Who Has Recently Quit Congratulate former tobacco users and strongly encourage them to remain abstinent Ask about The benefits from cessation Successes (duration of abstinence, reduction in withdrawal, etc) Problems encountered (eg, depression, weight gain, alcohol, other tobacco users in the household, significant stressors) Medication check-in 33 11

For the Patient Who Has Recently Quit (cont.) Addressing problems encountered by former smokers Lack of support for cessation Negative mood or depression Strong or prolonged withdrawal symptoms Weight gain Smoking lapses 34 Treatment Recommendations: Counseling 35 Treatment Recommendations: Counseling Intensity of clinical interventions Recommendations Every tobacco user should be offered at least a minimal intervention (lasting less than 3 minutes), whether or not he or she is referred to an intensive intervention (strength of evidence=a) Intensive interventions are more effective than less intensive interventions and should be used whenever possible (strength of evidence=a) If feasible, clinicians should strive to meet 4 or more times with individuals quitting tobacco use (strength of evidence=a) 36 12

Treatment Recommendations: Counseling (cont.) Formats of psychosocial treatments Recommendations Proactive telephone counseling, group counseling, and individual counseling formats are effective (strength of evidence=a) Smoking cessation interventions that are delivered in multiple formats increase abstinence rates (strength of evidence=a) Tailored materials, both print and Web based, appear to be effective in helping people quit (strength of evidence=b) 37 Treatment Recommendations: Counseling (cont.) Combining counseling and medication Recommendations Whenever feasible and appropriate, both counseling and medication should be provided to patients trying to quit smoking (strength of evidence=a) To the extent possible, clinicians should provide multiple counseling sessions, in addition to medication, to their patients who are trying to quit smoking (strength of evidence=a) 38 Treatment Recommendations: Medications 39 13

Treatment Recommendations: Medications Recommendation: Clinicians should encourage all patients attempting to quit to use effective medications for tobacco dependence treatment (strength of evidence=a) Except where contraindicated or for specific populations for which h there is insufficient i evidence of effectiveness Pregnant women Smokeless tobacco users Light smokers Adolescents 40 Medication 7 first-line medications shown to be effective: Bupropion SR (strength of evidence=a) Nicotine gum (strength of evidence=a) Nicotine inhaler (strength of evidence=a) Nicotine lozenge (strength of evidence=b) Nicotine nasal spray (strength of evidence=a) Nicotine patch (strength of evidence=a) Varenicline (strength of evidence=a) 41 Most Common Side Effects Associated With Nicotine Replacement Therapy Medication Cautions Side Effects Nicotine gum Nicotine inhaler Nicotine nasal spray Nicotine lozenge Caution with dentures Don t drink acidic beverages during use May irritate mouth/throat at first (but improves with use) Don t drink acidic beverages during use Not for patients with asthma May irritate nose (improves over time) May cause dependence Do not eat or drink 15 minutes before or during use 1 lozenge at a time Limit 20 in 24 hours Mouth soreness Stomachache Local irritation of mouth and throat Nasal irritation Hiccups Cough Heartburn Nicotine patch Do not use if you have severe eczema or psoriasis Local skin reaction Insomnia 14

Nicotine Replacement Therapy and Cardiovascular Disease Nicotine replacement therapy is not an independent risk factor for acute myocardial events Nicotine replacement therapy should be used with caution among the following cardiovascular patient groups Those in the immediate (within 2 weeks) postmyocardial infarction period Those with serious arrhythmias Those with unstable angina pectoris 43 Most Common Side Effects Associated With Bupropion and Varenicline Medication Cautions Side Effects Bupropion SR 150 Varenicline Not for use if your patients: Currently use a monoamine oxidase (MAO) inhibitor Use bupropion in any other form Have a history of seizures Have a history of eating disorders Use with caution in patients: With significant renal impairment With serious psychiatric illness Insomnia Dry mouth Nausea Insomnia Abnormal dreams Neuropsychiatric symptoms Medication 2 second-line medications shown to be effective Clonidine (strength of evidence=a) Nortriptyline (strength of evidence=a) This information concerns a use that has not been approved by the US Food and Drug Administration. 45 15

Most Common Side Effects, Contraindications, and Warnings Associated With Second-Line Medications Medication Cautions Side Effects Monitor blood pressure Dry mouth Drowsiness Clonidine Taper dose gradually over 2-4 days Dizziness to avoid rebound hypertension, agitation, confusion and/or tremor Sedation Constipation Sedation Nortriptyline Patients should avoid operating machinery or driving car Use with caution in patients with cardiovascular disease Use with caution in patients who use an MAO inhibitor Dry mouth Blurred vision Urinary retention Light-headedness Shaky hands This information concerns a use that has not been approved by the US Food and Drug Administration. Obtaining the 2008 Guideline The full text of the 2008 guideline, the general references, and the references for the randomized control trials used in the meta-analyses can be reviewed and downloaded by visiting the Surgeon General s Web site at www.ahrq.gov/path/tobacco.htm#clinic qg You can order the 2008 guideline and the various supplemental materials, go to www.ahrq.gov/clinic/tobacco/order.htm 47 Key Guideline Web Links Guideline materials http://www.surgeongeneral.gov/tobacco List of over 50 endorsing organizations at http://www.ctri.wisc.edu/researchers/researchers_cpgupdate2008_endorse.htm May 7th Web Cast http://www.ctri.wisc.edu UW-CTRI www.ctri.wisc.edu CS2day www.ceasesmoking2day.org 48 16

Helpful Web Sites: Government-sponsored organizations and nonprofit foundations Addressing Tobacco in Healthcare (formerly Addressing Tobacco in Managed Care) www.atmc.wisc.edu Agency for Healthcare Research and Quality www.ahrq.gov Alliance for the Prevention and Treatment of Nicotine Addiction www.aptna.org American Academy of Family Physicians www.aafp.org American Cancer Society www.cancer.org American College of Chest Physicians www.chestnet.org American Legacy Foundation www.americanlegacy.org 49 Important Information Please complete the evaluation form provided in your handout materials and hand it to the meeting staff as you exit Your evaluation will assist us in determining the effectiveness of this specific educational activity and the quality of the instructional process Thank you 50 17