Quitting Tobacco: Why is it so hard? What works?

Harry A. Lando

University of Minnesota

March 16, 2015

I have no disclosures or conflicts of interest with the material presented in this talk

Nicotine Addiction

https://www.youtube.com/watch?v=yd46Hs7pTow

Those who have tried to give up smoking usually know the meaning of being hooked

Even those who initially succeed in quitting suffer the same relapse rate as recovering alcoholics and heroin addicts

1988 U.S. Surgeon General Report: cigarettes and other forms of tobacco are addicting

• Recommended warning labels about addiction

• Power of desire for cigarettes

• Physiological need that is more than mere urge

• Like many drugs that stimulate the nervous system, nicotine at the same time stimulates and relaxes the body

• Because it is inhaled, it only takes seven to ten seconds to reach the brain—twice as fast as heroin

• Mimics some of the effects of adrenaline, a hormone, and acetylcholine, a powerful neurotransmitter

• After a few puffs, the level of nicotine in the blood increases dramatically

• Heart beats faster and blood pressure increases

• Result: smokers become more alert and may react faster

• In addition, nicotine may produce a calming effect by triggering the release of natural opiates called beta-endorphins

• Because nicotine cannot be stored in the body, smokers maintain a relatively constant level in the blood by continuing to smoke

• Because a smoker takes 200 to 400 puffs per day, there is a lot of reinforcement

• Nicotine is self administered, and it affects mood and performance

• That makes it powerfully addicting

• New research shows that addiction can occur very quickly

• Even limited exposure to nicotine can change the brain, modifying neurons in a way that stimulates the craving to smoke

• Studies have indicated that some smokers experience withdrawal symptoms after smoking as few as one to four cigarettes

• Functional magnetic resonance imaging (fMRI) was used to measure levels of metabolic activity in brains of rats given a dose of nicotine on five consecutive days

• Response to the first dose was relatively limited

• Brain activity was much more intense and widespread after the fifth dose

• These findings indicate that the brain quickly becomes sensitized to nicotine, enabling addiction to occur after just a few doses

Reference: DiFranza, J. Hooked from the first cigarette,

Scientific American May 2008, 82-87.

Tobacco Industry Secrets

• The industry acknowledged nicotine’s addictive properties internally by 1963

• Law firm advised that entire matter of addiction is the most potent weapon a prosecuting attorney can have in a lung cancer cigarette case

• Cannot defend continued smoking as “free choice” if the person was addicted

• Sir Charles Ellis, scientific advisor to British American Tobacco: “As a result of these various researches, we now possess a knowledge of the effects of nicotine far more extensive than exists in the published literature.”

• Addictive potential of a drug is enhanced by delivery systems that cause it to reach the brain more quickly

• This concept was fully appreciated by tobacco industry scientists

• Denial, rationalization, and reinforcement are key elements in the addictive process

• Clearly the smoker is concerned about smoking and health

• This factor can be used to advantage in marketing Kent and True brands

• Consumer faith in safer smoking or denial of anti-smoking information

• For cigarettes as with all drug delivery devices critical to ensure that the drug is delivered within an acceptable dose range

• Proposal to reduce absolute level of nicotine in cigarettes below addicting levels

• For decades, industry scientists, executives, and lawyers have known that nicotine is addicting and that they are in the business of selling a drug delivery device

• The cigarette is a sophisticated drug delivery device

• The smoker can control the nicotine dose by altering smoking behavior

• This makes the cigarette one of the most technologically sophisticated drug delivery devices available

W.L. Dunn: Think of a cigarette as a dispenser for a dose unit of nicotine…smoke is …the most optimized vehicle of nicotine and the cigarette is the most optimized dispenser of smoke

The Scam: Low-Tar Low-Nicotine Cigarettes

• Industry implied reduction in health consequences

• Smokers compensate to maintain desired blood nicotine concentrations

• Ventilation holes often blocked by smoker

• Smoking with greater intensity, deeper inhalation, larger puff volume

• Industry recognized that those who smoke low tar and nicotine cigarettes generally believe that such cigarettes pose less risk

Freebasing Nicotine• Ammonia and pH manipulation, the higher the

pH the more extractable nicotine

• Perhaps most surprising finding in document review was evidence of industry-wide efforts spanning three decades to increase freebase nicotine delivered to smokers

• Outside the industry little was known of this

• A 1966 BAT report noted: It would appear that the increased smoker response is associated with nicotine reaching the brain more quickly

From Hurt, R. Prying open the door to the tobacco

industry’s secrets JAMA October 7, 1998

Quitting: What Works?

US Clinical Practice Guideline 2008

10 Key recommendations:

1.Tobacco dependence is a chronic disease that often requires repeated intervention

2. It is essential that clinicians and health care delivery systems consistently identify and document tobacco use status and treat every tobacco user

3. Tobacco dependence treatments are effective across a broad range of populations

4. Brief tobacco dependence treatment is effective

5. Individual, group, and telephone counseling are effective and their effectiveness increases with treatment intensity. Two components of counseling that are especially effective are practical counseling (problem solving/skills training) and social support delivered as part of treatment

6. Numerous medications are available for nicotine dependence: Bupropion SR, Varenicline, nicotine gum, nicotine inhaler, nicotine lozenge, nicotine nasal spray, nicotine patch (Also more recent evidence for cytisine)

7. Counseling and medication are effective when used by themselves, but combination of counseling and medication is more effective than either alone

8.

8. Telephone quitline counseling is effective with diverse populations and has broad reach

9. If a tobacco user currently is unwilling to make a quit attempt, clinicians should use motivational treatments

10. Tobacco dependence treatments are both clinically effective and highly cost-effective

• Even after long periods of abstinence, cues in the environment may promote cravings

• If long time abstinent smoker surrenders to an urge to smoke, addiction can be quickly reestablished

• The US Clinical Practice Guidelines describe nicotine dependence as a chronic relapsing condition

FCTC Article 14• Each party shall develop and disseminate

appropriate, comprehensive and integrated guidelines based on scientific evidence and best practices, taking into account national circumstances and priorities, and shall take effective measures to promote cessation of tobacco use and adequate treatments for tobacco dependence

• Challenges to implementing Article 14 in low-resource settings

• Importance of primary care

• Tobacco dependence is a chronic disease that often requires repeated intervention

• It is essential that clinicians and healthcare delivery systems identify and treat tobacco users

• Brief tobacco dependence treatment is effective

• Numerous medications have been demonstrated to be effective for tobacco dependence

• However, cost is a barrier

• Clinicians often do not treat smokers

• Too busy

• Lack of expertise

• No financial incentive

• Believe smokers cannot or will not quit

• Do not wish to scare patients away

Opportunity: Most smokers want to quit• Without assistance only 5 percent of quit

attempts are successful

• Most try to quit on their own—95% relapse

• Using evidenced-based methods can greatly increase success

• Repeated advice and support for quitting are important

Brief advice can significantly increase quitting

“As your doctor, I believe the most important thing you can do for your health is to quit smoking”

• All tobacco users should be offered at least minimal intervention

• Even when patients are not ready to quit, brief motivational messages can increase likelihood of future quit attempts

• Brief treatment is effective

• Telephone counseling is effective

• Lay people can be trained to provide support

• Individual and group counseling

• Problem solving/skills training

• Social support as part of intervention

• May be readily available and low-cost

• Can provide practical counseling and social support

• Can also support appropriate use of medications

Lay Interventionists

• We successfully trained lay facilitators to lead multi-session group programs

• Cost kept low through use of lay facilitators and donated sites

• Lay facilitators often are highly motivated

• Studies have supported effectiveness of using trained lay health influencers and peer interveners

• Teaching lay people knowledge and skills for tobacco intervention is both feasible and practical

• Project Reach in Arizona

• Nurse-managed, lay-led tobacco cessation intervention for poor Ohio women

World Health Organization recommends three types of treatment:

• Tobacco cessation advice incorporated into primary healthcare services

• Easily accessible and free quitlines

• Access to low-cost pharmacological therapy

Quitlines (where available)

• Can refer patient to tobacco cessation quitlines

• Quitlines often staffed by trained cessation experts

• Calling a quitline can significantly increase a smoker’s chance of successfully quitting

Ask: “Do you, or does anyone in your household, ever smoke or use any type of tobacco?”

Advise: “I realize quitting is difficult, but it is the most important thing you can do to protect your health now and in the future.”

Refer: To other clinicians for additional counseling, local group program, or quitline

Tips from former smokersUS Centers for Disease Control and

Prevention

http://www.cdc.gov/tobacco/campaign/tips/resources/videos/beatrice-videos.html#cessation

treatobacco.net (efficacy, policy, health effects, resources)

“If we do not act decisively, a hundred years from now our grandchildren and their children will look back and seriously question how people claiming to be committed to public health and social justice allowed the tobacco epidemic to unfold unchecked.”

Dr. Gro Harlem Bruntland

Former Director-General of the World Health Organization