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Dartmouth Hitchcock Medical Center

Elizabeth Maislen, APRN, CTTSCTOP Retreat May 22, 2014

Tobacco Treatment Update 2014

Disclosures

None. I do not intend to discuss off label use of

any products. I don’t smoke and I don’t vape or

hookah. When patients ask, “Did YOU ever

smoke?” I tell them “It’s not about me today, it’s all about YOU.”

Thank you to Susanne Tanski, MD

Key Points Review 7 first line medications and dosing

What’s new from the FDA, changes in NRT

package labeling

Insurance coverage under ACA

An array of tobacco/nicotine delivery products

Electronic cigarettes

Tobacco dependence, a chronic disease

Cessation Treatments are Underused!

The treatments recommended in the PHS guideline are underused by smokers and health care providers.

About 70% of smokers want to quit smoking, and about half try to quit each year.

However, less than 10% succeed, in part because less than one-third of smokers who try to quit use proven cessation treatments.

In 2010, less than half of smokers (48.3%) who saw a health professional in the past year reported receiving advice to quit

The Surgeon General’s Report

Cigarettes and other tobacco products have evolved into highly engineered, addictive and deadly products, containing thousands of harmful chemicals causing a wide range of diseases, cancers and premature deaths.9 of 10 smokers regret ever having started.60% of current smokers perceive themselves at “very addicted.”

Health Consequenses Smoking-50 years of Progress, UHDHHS, Report of Surgeon General 2014

What’s Different?

Today’s cigarette smokers, especially women, have much higher risk for lung cancer, COPD and CVD, despite smoking fewer cigarettes.

The design of the cigarette is different.

More nicotine is absorbed when smoked.

Combinations of products in cigarettes.

International Tobacco Control Study S. Glantz et al, 2-8-14; 2002-2011 longitudinal study

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is the chief, single, avoidable cause of death

in our society and the most important public health issue of our time.”

C. Everett Koop, M.D., former U.S. Surgeon General

“CIGARETTE SMOKING…

All forms of tobacco are harmful.

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MedicationsSeven first-line medications shown to be effective and recommended for use by the USPHS Guidelines Panel:

– Nicotine Patch– Nicotine Gum– Nicotine Lozenge– Nicotine Inhaler– Nicotine Nasal Spray– Bupropion SR – Varenicline

Nicotine Patches1mg /1cigarette

21 mg14 mg 7 mg

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Nicotine Inhaler

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FDA Labeling Update

NO significant safety concerns associated with using more than one form of NRT

NO significant safety concerns associated with using NRT at the same time as a cigarette

Use longer than 12 weeks is safe!

April 2013 www.fda.gov/ForConsumers/ConsumerUpdate/ucm345087.htm

FDA Changes to NRT Labels

Previous labels Current labels

Bupropion

Monocyclic antidepressantUnknown mechanism in

tobacco cessationDose Bupropion SR 150 mg a

day x 3 days then 150 mg bidMay cause dry mouth,

insomnia

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VareniclineEffectiveness and abstinence rates for various medications and medication combinations compared to placebo at 6-months post-quit (n = 86 studies)

MedicationNumber of arms

Estimated odds ratio (95% C. I.)

Estimated abstinence rate

(95% C. I.)

Placebo 80 1.0 13.8

Varenicline(2 mg/day)

53.1

(2.5, 3.8)33.2

(28.9, 37.8)

Varenicline=Chantix

Starter dose packStart with 0.5 mg a day x 3 days

then increase to 0.5 mg bid x 4 days

Then 1 mg bid1 course of treatment is 3 months2 courses of treatment is 6 months

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Ask about tobacco use. Identify and document tobacco use status for every patient at every visit.

Advise to quit. In a clear, strong and personalized manner urge every tobacco user to quit.

Assess willingness to make a quit attempt. Is the tobacco user willing to make a quit attempt at this time?

Assist in quit attempt. For the patient willing to make a quit attempt, use counseling or pharmacotherapy to help him or her quit.

Arrange followup. Schedule followup contact, preferably within the first week after the quit date.

The "5 A's" Model for Treating Tobacco Use and Dependence - 2000

Brief interventions have been shown to be

effective

In the absence of time or expertise:

– Ask, advise, and refer to other resources, such as local group programs or the toll-free quitline1-800-QUIT-NOW

BRIEF COUNSELING: ASK, ADVISE, REFER (cont’d)

This brief intervention can be

achieved in less than 3 minutes.

0

10

20

30

No clinician Self-helpmaterial

Nonphysicianclinician

Physicianclinician

Type of Clinician

Est

imate

d a

bst

inence

at

5+

month

s

1.0 1.11.7

2.2

n = 29 studies

Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.

With help from a clinician, the odds of quitting approximately doubles.

Compared to patients who receive no assistance from a clinician, patients who receive assistance are 1.7–2.2 times as likely to quit successfully for 5 or more months.

CLINICIANS CAN MAKE a DIFFERENCE

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Type: PNG

                     Website for this imageFirst iPad App on Quit Smoking. Welcome visit Our WebSite:

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Insurance Coverage of Cessation Treatments is Cost Effective

Cessation treatments are both clinically effective and highly cost-effective relative to interventions for other clinical disorders.

Cost-effectiveness analyses have shown that tobacco dependence treatment compares favorably with routinely reimbursed medical interventions such as the treatment of hypertension and high cholesterol, as well as preventive screening interventions such as periodic mammography and PAP tests.

Current Status of Cessation Coverage

Nine states have laws or regulations in place requiring at least some private insurance plans to cover certain cessation treatments.

(Colorado, Illinois, Maryland, New Jersey, New Mexico, North Dakota, Oregon, Rhode Island, and Vermont)

Medicaid Coverage and the ACA

Section 4107 of the Affordable Care Act requires all state Medicaid programs to provide a comprehensive tobacco cessation benefit as defined by the USPHS guidelines to pregnant women who are enrolled in Medicaid, effective October 2010

As of January 2014, Section 2502 of the law bars state Medicaid programs from excluding cessation medications, including over-the-counter medications, from coverage.

Medicare Coverage Medicare recipients have access to individual

cessation counseling and prescription cessation medications.

The benefit covers two quit attempts a year and four counseling sessions per quit attempt.

Medicare copayment, coinsurance, and deductibles for cessation treatments are waived under the Affordable Care Act, effective January 1, 2011.

Other forms of Tobacco Cigars Blunts Hookah or Water Pipe Vaping products Smokeless tobacco

Chewing tobacco Snuff- moist and dry, sachel or Snus “Dip” Dissolvables

From Cigarette to Vapor Pen, an evolution in technology

Roll Your Own Cigarettes

Roll in rolling machine or by hand “rollies” Use increases when branded cigarette prices go

up Pipe tobacco Greater tar and nicotine yields/cigarette Likely inhale differently or more deeply,

depositing smoke, nicotine and toxins in lungs Greater urinary concentrations of toxins Increases risks for lung and oral cancers Low cost=more affordable

Addict Biol, 14, 2009, page 315 Tobacco Control, June 1998, Darrall & Figgins, page 168.

Dual Tobacco Use

Combustible plus non combustible tobacco types

Convenient packaging facilitates availability and ease of using both types of products.

Snus package can fit just about anywhere, can be used in places where you cannot smoke.

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Electronic CigaretteA SMOKING CESSATION DEVICE?

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ELECTRONIC CIGARETTES Battery operated devices that deliver vaporized nicotine

– Cartridges contain nicotine, flavoring agents, and other chemicals

Battery warms cartridge; user inhales nicotine vapor or

‘smoke’

Available on-line and in shopping malls

– Not labeled with health warnings Preliminary FDA testing found some

cartridges contain carcinogens and impurities (e.g., diethylene glycol)

No data to support claims that these products are a safe alternative to smoking

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PHS-Sponsored Clinical Practice Guideline Treating Tobacco Use and Dependence: 2008 Update

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PHS-Sponsored Clinical Practice Guideline Treating Tobacco Use and Dependence: 2008 Update

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PHS-Sponsored Clinical Practice Guideline Treating Tobacco Use and Dependence: 2008 Update

Cloud Vape Pen

The Electronic Cigarette

http://www.ispot.tv/ad/7fnS/njoy-e-cigarette-return-the-favor-song-by-avicii

What are the public health harms?

Re-normalizing the image of smoking Allowed in places where smoking is not

allowed Advertising is completely unrestricted, with

TV ads for the first time since 1971 Largely indistinguishable from cigarettes

Second-hand vapor is NOT just water vapor Emit variable levels of nicotine

So what to do?

Research is imperative to assess second hand vapor effects (of all kinds), addiction potential and dual-use maintenance

Must have a regulated product for an informed consumer, with fully disclosed labeling

Until we know more about “e-anything” and cessation, we can still recommend medicinal NRT, quit lines and support while people are becoming non-tobacco users

Tobacco Dependence Tobacco dependence is a chronic disease,

with most smokers making multiple quit attempts before succeeding.

Many of these smokers require repeated intervention.

THANK YOU!(For not smoking)