Successfully Addressing Tobacco Use in our Patients – 2016

F.S.A.C.O.F.P.Friday July 29 , 2016

Dennis H. Penzell, D.O., M.S., F.A.C.P

Associate Professor of Medicine

Nova Southeastern University

Health Professions Division

College of Osteopathic Medicine

NO DISCLOSURES

There may be off label info.

IQuit with AHEC1-877-848-6696

ahectobacco.com

• Free In-person Tobacco Cessation Groups• Receive tools/strategies to quit and stay tob-free• Programs in English and Spanish• Friendly, respectful, supportive group setting• Free nicotine replacement therapy

FLORIDA QUIT LINE 1-877-U-CAN-NOW

• Counseling via phone or on-line services available.

• Quitline services in English, Spanish, Haitian Creole.

• Translation services for all other languages.

• Free starter kit of nicotine replacement therapy.

HOW CAN AHEC HELP YOU?

• The Florida Area Health Education Centers (AHEC) Network is an extensive,

statewide system for health professional education and support .

• Each AHEC is supported by an AHEC program at one of the state's five medical

schools.

• The Florida AHEC Network has, over this past decade, addressed the

primary health care needs of Florida's most vulnerable populations

through a series of innovative strategies designed to:

-Extend academic health resources.

-Provide information and support for community providers.

-Influence health professions education.

-Influence the future health professional workforce.

AUDIENCE

-Educating and training health professions students.

-Offering cme to practicing health professionals.

-Providing cessation services for tobacco users.

- Clin. Prac. Guidelines into Practice: Tobacco.

Use the Fax Referral Form!

Why make referrals to AHEC?

• Provides opportunity to engage smoking pts.

• Discussion and signature promote commitment .

• Involve family members for ongoing support.

• Trained Tobacco Specialist calls patient.

• Curricula are evidence-based.

• Follow-up is provided at regular intervals.

WHAT IS ADDICTION?

”Compulsive drug use, without

medical purpose, in the face of

negative consequences”

Alan I. Leshner, Ph.D.Former Director, National Institute on Drug Abuse

National Institutes of Health

Power of Intervention

• Cold turkey: yields 2% - 4% x

• Brief:1- 3 min. intervention= 3% - 6% quit

• Behavioral counseling: -dose related - quit rate increases with time spent

-yields 10% - 15% quit rate

• Meds and counseling yields: 20% - 30%

©2004 Seton Health System

NICOTINE

• Nicotine is psychoactive, producing transient dose-related changes in mood and feeling.

• It is a euphoriant that produces dose-related increases in scores on standard measures of euphoria.

• It is a reinforcer (or reward, in both human and animal intravenous self-administration paradigms, functioning as do other drugs of abuse. Nicotine activates the receptors which lead to an increase in “dopamine” release.

PHARMACOTHERAPY

Why Pharmacotherapy?

Alleviates withdrawal

Eliminates reinforcing effect of nicotine

Gives time to break habits/routines

Nicotine Patch

•Pros: All are available over the counter; administered qd.

•Cons: Slow-acting; doesn't respond instantly; possibility of rash; may require daily

change of patch location; may require patch be removed at bedtime to avoid vivid

dreams or nightmares.

•Comments: May need to use adhesive tape .

•Sources: Grocery store, pharmacy, drugstore

Nicotine Patch

24 hr (21, 14, 7mg) Nicoderm/generic

The first time, use at bedtime

A new patch is applied each morning

Nicotine Patch

wean – 8-12 weeks

rashes, abnormal dreams

no euphoria - no stimulant effect

no increased risk of MI

May combine w gum/losenge/Zyban

What about combining long acting NRT and short

acting?

Combination TherapiesKEY POINT

• 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

• European Heart Journal (2000) 21, 438–445

NICOTINE PATCH THERAPYINITIAL DOSING GUIDELINES

(Off Label)

Based on Baseline Cigarettes/Day

• <10 CPD 7-14 mg/d

• 10-20 CP 14-21 mg/d

• 21-40 CP 22-42 mg/d

• >40 CPD 42+ mg/dHughes et al:Nicotine and Tobacco Research (1999)I.169-174

Dale et al: Mayo Clinic Proceedings: 2000;75:1311-1316

HIGHER DOSE NICOTINE PATCH

There is a dose-response effect

*Cochrane Database of Systematic Reviews 2005

Nicotine Gum(nicotine polacrilex, Nicorette®)

2 mg (<25 cigs) vs. 4 mg (>24 cigs) –max 24/day

1-2 per hour for first 6 weeks-taper

“chew, park, chew, park”-30 minutes

Absorbed in a basic environment, avoid acidic

beverages 15 minutes pre and during dose.

Side effects: dyspepsia, mouth soreness

NICOTINE LOZENGE

• Efficacy: Doubles to triples 12 month cessation

• Dosage (max 20/day)– 2 mg-for those smoking >30 min after waking

– 4 mg-for those smoking <30 min after waking

• First 6 weeks- 1 lozenge every 1-2 hrs

• Weeks 7-10- 1 lozenge every 2-4 hrs

• Weeks 11-12- 1 lozenge every 4-8 hrs

• Avoid eating or drinking for 15 minutes before

Smoking Cessation Methods: Nicotine Inhaler

Pros: Self-administered dosing satisfies

the hand-to-mouth component of

cigarette smoking.

Cons: Requires a prescription; looks and is used much like a

cigarette, so may be conducive to overuse; can cause throat

irritation and coughing.

Nicotine Inhaler

Rx---2 mg absorbed per insert.

Continuous 20 minutes/dose

(80 puffs = 4 mg)/ 80 puffs in 20 minutes

6-16 cartridges per day for 12 weeks.

Use 3 months then wean over 3 months

40% throat irritation

20% quit at 6 months, 13% at 1 year

Nicotine Nasal Spray (NS)

•Pros: Gets nicotine into bloodstream much faster than the patch

or gum; relieves acute cravings instantly.

•Cons: Requires a prescription; nasal irritation, throat irritation,

runny nose, lightheadedness, odd taste.

•Comments: Use in public is not attractive.

Bupropion/Wellbutrin

• Bupropion, Wellbutrin/ Bupropion SR(Zyban®)

• Pros: Can be used with the patch; can alleviate symptoms of

depression during withdrawal.

• Cons: Requires a prescription; should not be used for those

who suffer from epilepsy, have histories of eating disorders,

dry mouth, insomnia; can cause tremors.

Bupropion , Wellbutrin

Blocks neural reuptake: dopamine norepinephrine

ZYBAN®Wellbutrin/Bupropion

• Side effects– Dry mouth

– Insomnia

– NEJM 2002 – seizure induced by bupropion – case report of adolescent who crushed six 150mg tablets and snorted them

.5

VARENICLINE

CHANTIX®

Varenicline

• Pros: Provides nicotine effects to ease withdrawal symptoms,

and blocks effects of nicotine.

• Cons: Nausea, headache, vomiting, insomnia, abnormal

dreams, change in taste perception

Varenicline• Rx. For one or two 12 wk. blocks

• Day 1-3: You will take one 0.5 mg tablet;

• Day 4-7: You will take a 0.5 mg tablet twice daily

May smoke for the first week

QUIT SMOKING ON DAY 8

• Day 8-28: you will take a 1 mg tablet twice daily

• Continuing Months: Wk. 2 to end of treatment: 1 mg tablet twice daily.

Side Effects…

• Side effects with VARENICLINE– Headaches

– Nausea

– Vomiting

– Trouble sleeping/unusual dreams

Chantix (Varenicline)

• Behavior, mood changes, drowsiness

• Contraindicated with CrCl<30

• Still have about 60% dopamine produced.

PRACTICAL QUESTIONS

Should I Recommend Stopping Tobacco before surgery?

• Recent Smoking Cessation: No Increase Pulmonary Complics. (1)

• Smoking status does not affect changes in perceived stress. ---

perceived stress measured from before surgery up to one week

postoperatively (2)

1.. Barrera et al, Chest 127:1977, 2005

2.. Warner et al, Anesthesiology 199:1125, 2004

3.. Shi Y, Warner DO: Anesth Analg. 2011 Dec;113(6):1348-51.

Epub 2011 Sep 29.

Cigarettes and Surgery

Pts should be advised to stop smoking as early as possible.

No evidence not to advise quitting prior to surgery.

•ARCH INTERN MED: ONLINE MARCH 14, 2011-Katie Myers, MSc, CPsychol; Peter Hajek, PhD; Charles Hinds, FRCP, FRCA; Hayden

McRobbie, MBChB, PhD

CIGARETTES AND SURGERY

• Available evidence does not support a detrimental effect of

NRT in surgical patients.

• Especially when compared with the consequences of

continued smoking.(1, 2)

(1) Forrest CR, Xu N, Pang CY:. Can J Physiol Pharmacol 1994;72:30–8.

(2) Warner, D.O. :Anesth Analg 2005;101:481–7

Effect of smoking, smoking cessation, and nicotine patch on wound dimension,

vitamin C, and systemic markers of collagen metabolism.

Anecdotal evidence suggests that some surgeons believe that providing cancer

patients with NRT will diminish the effect of surgery because of vasoconstriction.

Found that smoking abstinence using NRT had no effect on collagen synthesis or

wound size after seven days of healing, when compared to smoking abstinence with a

placebo patch.

Sorensen LT, et al. Surgery. 2010; 148:982–990.

Can I get a CAT Scan?

Patients should be asked about their smoking history. Patients who meet ALL of the

following criteria may be candidates for lung cancer screening:

55 to 74 years old (ACS), 80(CDC)

Have at least a 30 pack-year smoking history

Are either still smoking or have quit within the last 15 years

“I have not been successful with a patch”

RECOMMENDED PRACTICE IS TO USE

A NICOTINE PATCH AND A PRN NICOTINE.

CURRENT RECOMMENDED PRACTICE :

A NICOTINE PATCH AND A PRN NICOTINE.

“But I smoke Lights”

• A concern with reducing cigarette nicotine

content is that smokers may compensate, or

increase their smoking frequency/intensity

(e.g., increased daily consumption and/or

puffing).

“Will I go crazy on these meds?”

Neuropsych Safety of Smoking Cess Meds

Lancet; ePub 2016 Apr 22; Anthenelli, Benowitz, et al

• There was no significant increase in

neuropsychiatric adverse events

associated with varenicline or bupropion

relative to patch or placebo.

How many attempts needed to quit?

A recent study estimated 6-142!

30 was most reasonable answer.

• (BMJ 2016, 6, )

My friends say pick yourself up and do it!

Reluctance to seek treatment is that quitting is all about willpower.

This is how people thought about depression and alcoholism.

ITS AN ADDICTION!!!

Can I Still Drink?

Smoking is associated with ETOH use.

I am quitting what about my meds?May Decrease Effectiveness

• Beta Blockers

• Furosemide

• Nifedipine

• Warfarin

• H2 Blockers

• Anticonvulsants

NRT and Cardiovascular Ds.

Effect of Nicotine Replacement Therapy on Cardiovascular Outcomes After Acute Coronary

SyndromesOctober 2012-Volume 110, Issue 7, Pages 968–970

Wolfe MD et al.

The aim of the study was to determine the relationship between NRT use and adverse cardiovascular outcomes after ACS.

NRT use was not associated with an increased risk of

adverse cardiovascular events in the first year after

ACS.

Nicotine Replacement Therapy for Patients With Coronary Artery

Disease

• Transdermal nicotine did not affect angina frequency,

overall cardiac symptom status, nocturnal events,

arrhythmias, or episodes of ischemic ST segment

depression.

• Arch Intern Med. 1994;154(9):989-995.

NRT and The Heart

• No increase in CV events using NRT

• NRT plus smoking equivalent to smoking

Benowitz NL, Gourlay SG J Am Coll Cardiol 1997;29:1422-31

Benowitz-Progs in Cardiovascular Diseases, V. 46, No. 1, (July/August) 2003: pp 91-111

Tzivoni-Cardiovascular Drugs and Therapy 1998;12:239–244

Doc, I know about lung cancer and heart

attacks but what else?

STROKE

Est. incr. in risk for stroke from exposure to SHS is 20–30%.

• The Health Consequences of Smoking – 50 years of progress: a report of the Surgeon General. – Atlanta, GA. : U.S. Department of Health and Human

Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health,

2014. p. 944

COLORECTAL CANCER

Causal relationship between smoking and

colorectal adenomatous polyps/colorectal

cancer.

DIABETES

• The risk of developing dm is 30–40% higher for smokers.

• There is a positive dose-response relationship between the

number of cigarettes smoked and the risk of developing DM.

CAN I USE THESE MEDS LONGER?

Extended Use of Medications

NRTs do not contain nicotine toxic substances (e.g., “tar,”

carbon monoxide, formaldehyde, benzene).

They do not produce sharp surges in blood nicotine levels;

and/or produce strong dependence.

Doc, are E Cigs better than smoking?

AEROSOL

VAPOR??? AEROSOL???

E-CIG “SMOKE’

is a suspension of fine particles of liquid, solid or

both in a gas. gaseous state of a substance.

Electronic Cigarette

No data on delivery of nicotine .

No data on the blood nicotine levels achieved.

FDA shown that e-cigs contain carcinogens.

Benzaldehyde is found in E Cig vapors

Thorax. January 28, 2016. Kosmider L, Sobczak A, Prokopowicz A, et al.

E Cigs: What We Need to Know

• If you don't smoke, don't start vaping.

• You're better off with an FDA-approved method of quitting, like the

nicotine patch or gum. There's good evidence that they help.

• E-cigarettes may turn out to be an effective way to quit, but we don't

have the proof yet.

• If you're not planning to quit, would it be healthier to switch from

tobacco products to e-cigarettes? Maybe. Talk to your doctor about the

risks and benefits.

JOURNAL OF CIRCULATIONBENOWITZ

Circulation. 2014;129:1972-1986

Health claims and claims of efficacy for quitting smoking are unsupported

by the scientific evidence to date.

How can I talk to pts in a short time?

USPHS TASK FORCE Guidelines

•Ask –Identify tobacco users at every visit

•Advise - Strongly urge all smokers to quit

•Refer- to AHEC etc.

Treating Tobacco Use and Dependence:USPHS Taskforce: 2008 Update

Health Benefits After Quitting

cough, DOE resolve in weeks

exercise tolerance improves rapidly

bladder cancer: 50% reduction in 5 years

lung cancer: 50% reduction in 10 years

heart disease: 50% reduction in 1 year!

No increased risk of heart disease by 10-15 yrs

vascular disease: 50% reduction in 5 years

mortality rates =as never smoked by 10-15 yrs

Little or No Efficacy:

– Hypnosis

– Acupuncture

– Nicotine water/lollypops/lip balm/hand gel

– Cigarette-like devices

– Unassisted tapering/nicotine fading

– Laser

– Herbal remedies

Typical Trigger Situations

• Morning

• Coffee

• After meals

• In the car

• On the phone

• Stress

• Anger

• Anxiety

• Celebration

• Alcohol

“The most important thing you can do for your

health is to quit smoking. If you need help or

feel you cannot quit on your own, there are

programs staffed by qualified professionals

who can help you.”

SUMMARY

1. Its an addiction2. It’s a chronic disease!3. QUIT LINE, Referral lines.4. Meds help- withdrawal: Double NRT.5. Long term meds might be indicated.6. Remind them, "Quitting smoking is the most important

action they can take to improve their health now and in the future."

THE END!!!