Nicotine Addiction

Tobacco usage

2002 20060

10

20

30

40

50

60

total 18-25total>25male 18-25male>male>25female 8-25female >25

Highest smoking prevalance in 2007: Kentucky-28.3%, West Virginia 27% Oklahoma25.8%, Missouri 24.6%Lowest prevalence: Utah 11.7% and California 14.3%

Smoking prevalence

1 in 5 Americans smoke 21% of adults > 18 years

(23.9%men, 18% women) AND

22% high school students (The prevalence decreases as education levels Increase)

More than 400,000 people in the United States die annually as a result of smoking and exposure to second hand smoke. For each person who dies from a smoking related disease, it

is estimated 20 more people are living with a smoking related illness

Cancers caused by smoking

LungEsophagealPancreaticBladderMouthPharyngealStomachKidneyCervicalAcute myeloid leukemia

Lung CancerLeading cause of cancer deaths

Smoking results in: 90% of lung cancer deaths in men

And 80% in women

Cessation readinessIn the United States:

70% of smokers want to quit 45% attempt to quit 5% are successful without

assistance

Variables associated with higher abstinence rates

VARIABLES EXAMPLES

High motivation Tobacco user reports a strong motivation to quit.

Ready to change Tobacco user is ready to quit within a 1-month period.

Moderate to high self-efficacy Tobacco user is confident in his or her ability to quit.

Supportive social network A smoke-free workplace and home; friends who do not smoke in the quitter's presence

Variables associated with lower abstinence rates

VARIABLE EXAMPLES

High nicotine dependence Tobacco user smokes heavily ( ≥ 20 cigarettes/day), and/or has first cigarette of the day within 30 minutes after waking in the morning.

Psychiatric comorbidity and substance use

Tobacco user currently has elevated depressive symptoms, active alcohol abuse, or schizophrenia.

High stress level Stressful life circumstances and/or recent or anticipated major life changes (e.g., divorce, job change).

Exposure to other smokers Other smokers in the household.

How to assist with successful nicotine

cessation

PUBLIC POLICYBecome aware of your community anti-

tobacco activismBecome a vocal member within your

communityGrowing body of evidence for 3

approaches:1)increased taxation on tobacco2)restrictive smoking policies3)anti-tobacco advertising

Framework for health promotion strategies

Hopkins et al 2001

PRIMARY PREVENTIONBegin with preadolescentsTeach skills to resist pressure and adsInstructions and rehearsals with peersCommunity health leaders support1)bans on tobacco use in public2)enforce prohibitions on sales to

minors3)increase price of tobacco4) restrict advertising that glamourizes

smoking to youth

Primary prevention should also be implemented for all adolescents and abstinence reinforced for all

non-tobacco users

HEALTH CARE OFFICE APPROACH

Brief directed smoking interventions delivered during routine care are cost effective and have potential for impact

Smoking cessation assessments and interventions included in each assessment like checking BP

Essential that each provider adopt assessment as standard of practice

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

Expand the vital signs to include tobacco use, or use an alternative universal identification system

VITAL SIGNS Weight: ___Blood Pressure: ____Pulse: ____ Temperature:______ Respiratory Rate: ______

Tobacco Use (circle one): Current Former Never

1. Ask: Systematically identify all tobacco users at every visit

2. Advise: Strongly urge all tobacco users to quit

3. Assess: Determine willingness to make a quit attempt

4. Assist: Aid the patient in quitting (provide counseling and medication)

5. Arrange: Ensure follow-up contact

Management of the patient addicted to nicotine

The 5 A’s

Suggested Interview questions

"Do You smoke?" Label Chart "SMOKER" (or sticker) Make Smoking a Vital Sign

How Much do you smoke? Greater nicotine dependence if >1 pack per day

How soon after waking do you have first cigarette? Greater nicotine dependence if under 30 minutes

Have you tried to quit before? Successful cessation requires 3-6 attempts

(average)

(http://www.fpnotebook.com/Psych/CD/TbcCstn.htm)

ScriptingDo you smoke or use any tobacco

products?I probably don’t have to tell you how bad

tobacco is for your health. I strongly encourage all of my patients to quit smoking/chewing/dipping.

Do you ever think about quitting?What kind of help or support can I

provide for you to help your efforts?

Screening for current or past tobacco use will result in four possible responses:

1. The patient uses tobacco but is not willing to make a quit attempt at this time

2. The patient uses tobacco and is willing to make a quit attempt at this time

3. The patient once used tobacco but has since quit

4. The patient never regularly used tobacco.

The Clinical Practice Guideline from Agency for Healthcare Research and Quality (AHRQ) provides the clinician with simple but effective interventions for all of these patient groups

Pharmaceutical Management

1. Nicotine Replacement 2. Smoking cessation aids 3. Off label medications

How the pharmaceuticals work Nicotine Replacement

Therapy Mechanism of Action

1. Smoking stimulates the ventral tegmental area of the brain which results in the release of dopamine into the nucleus accumbens.

2. NRT activates the dopamine reward pathway with a lower dose of nicotine.

3. This slower steady state of plasma nicotine allows for reduction of withdrawal symptoms and promotion of better behavior control.

Fagerstrom Test for Nicotine Dependence

Assessment of tobacco addiction for nicotine replacement dosing (short version) How soon after waking do you smoke first

cigarette? Time less than 5 minutes: 3 points Time 5 to 30 minutes: 2 points Time 31 to 60 minutes: 1 point

How many cigarettes do you smoke per day?

more than 30 per day: 3 points 21 to 30 per day: 2 points 11 to 20 per day: 1 point

Suggested dosing for Nicotine Patch

Heavy nicotine dependence: 5-6 points Consider 21 mg Nicotine patch

Moderate nicotine dependence: 3-4 points Consider 14 mg Nicotine Patch

Light nicotine dependence: 0-2 points Consider 7 mg Nicotine patch or no patch

Heatherton (1991) Br J Addict 86:1119

Smoking Cessation Drugs

Mechanism of Action1. Bupropion-decreases withdrawal and

cravings for nicotine by blocking dopamine and norepinephrine uptake in the CNS.

2. Varenicline- targets the neurobiology of nicotine addiction by blocking nicotine from binding to nicotinic receptors in the brain.

Off Label Medications

1. Clonidine2. Naltrexone3. Mecamylamine4. Nortriptyline5. Wellbutrin6. Selegiline

Non-Pharmaceutical Management

1. Behavioral Therapy 2. Self help materials 3. Alternative methods 4. Quit lines 5. Internet resources

Additional Management1. Symptoms of Withdrawal2. Medication side effects3. Avoiding weight gain

Remember:Tobacco use affects everyone

References AHCPR Supported Clinical Practice Guidelines/Treating Tobacco Use and Dependence: 2008

Update. (2008). Retrieved April 10, 2009, from HSTAT/ Health Services Technology Assessment Text: http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.chapter.28163

American Lung Association. (2008). Trends in tobacco use 2008. Retrieved April 22, 2009, from American Lung Association Web Site: http://lungusa.org/site/pp.asp?c=dvLUK9O0E&b=33347

Barker, L., Burton, J. & Zieve, P. (2007). Principles of ambulatory medicine (7th ed.). Baltimore: Williams and Wilkins

Barone, C. P. Heath, J . (2007 ). Evidence-based strategies for tobacco cessation . American Association of Critical Care Nurses News, 4(1), 16-19.

Centers For Disease Control And Prevention Smoking and tobacco use)Centers For Disease Control And Prevention. (n.d.). Smoking and tobacco use. Retrieved April 22, 2009, from http://www.cdc.gov/tobacco/

Heath, J., Barone, C. P., & Andrews, J. O. (2007). Pharmacotherapy advances for evidence-based tobacco cessation strategies. American Association of Critical Care Nurses News, 11(1), 12-14.

Loughlin, K., & Generali, J. (2006). The guide to off label prescription drugs. : simon and schuster.

Mundey, K. (2009). An appraisal of smoking cessation aids. Current Opinion in Pulmonary Medicine, 15, 105-112.

Potts, L. A., & Garwood, C. L. (2007). American Journal of Health System Pharmacy, 64(13), 1381-1384.

Ranney, L., et al. (2006). Tobacco Use: Prevention, Cessation, & Control. No. 06-E015. Research Triangle Park: RTI International.

Steele-Moses, S. K. (2008). Smoking cessation: what is the evidence? Clinical Journal of Oncology Nursing, 12(5), 813-815.