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Tobacco Cessation:
Old Myths & New Methods
Linda Hancock, FNP, PhDVCU Student Health Services
Director, Office of Health Promotion
(804) 828-7815 or [email protected]
Who is this woman and why is she talking with us?
• FNP• Funny Nurse Practitioner• College health for 20 years• Have a decade of experience being the
Tobacco Cessation Guru at VCU• PhD in education…
– “Scientist and Seeker of the Truth “• Clicker Addict• Daughter of a 3 ppd smoker who died of lung
cancer and mother of 3 sons
I don’t look like a college student, but…
I talk like a college student…
Clicker lessons• Immediate Audience
Response Device• Anonymous• Radio Frequency- you don’t
have to point it at anything• Just hit the number you
choose• You can change your
response by just hitting a different number…but only one response will record per person!
Have you ever used clickers before? (TV remotes don’t count)
No, I’
m a cli
cker
virgin
Yes, ju
st on
ce but I
di... Yes
, I’m a
click
er gu
ru
0% 0%0%
1. No, I’m a clicker virgin
2. Yes, just once but I didn’t inhale
3. Yes, I’m a clicker guru
10
0 of 5
Gender?
Male
Female
0%0%
1. Male2. Female
0 of 5
10
Who are you?
Prescri
ber (
MD, NP, P
A)
Hea
lth Educa
tor
PhD Res
earch
er
Community
organ
iz...
Hea
lth D
ept s
taff
Other
0% 0% 0%0%0%0%
1. Prescriber (MD, NP, PA)
2. Health Educator3. PhD Researcher4. Community
organization5. Health Dept staff6. Other
0 of 5
10
Goals for today• Share some strategies for
cessation• Increase attempts• Meds give patients another reason
to make another quit attempt• Meds offer hope- “It might be
different this time”• Meds WORK! • Then we do relapse prevention• Even if you aren’t a prescriber…
you need to know what’s available and how to give hope
Summer Reading Book
Change or Die
Friday afternoon clinic 12- 5pm11 appointments scheduled• 1 Urinary tract infection• 1 Bronchitis• 1 Mono recheck• 1 Asthma• 1 STI check
• AND…. The front desk has scheduled 6 smoking cessation appointments
CASE STUDIES – names and details have been changed, but the ISSUES are real
Find a discussion buddy – focus on a #1-6What more do you want to know???
1 Mark: 25 year old store manager
1ppd smoker for 8 years. Quit smoking using bupropion in 2001 but after 2 years of not smoking he relapsed. He has a history of depression in his teens. He disliked the side effects on Paxil and Zoloft.
2 Chen: 26 year old MD PhD student. He dips 2 cans/wk for 6 years. Uses it to study. Has tried both gum and patch without success. He wants to quit before 3rd
year rotations start next fall. He is the class president.
CASE STUDIES
3. Staci: 19 year old voice major
½ ppd smoker x 3 yearsHas tried to quit cold turkey twice with no success.She has a new boyfriend who is a non-smoker. He suggested she come to clinic and get some help.
4. Tonya: 30 year old waitress.
Married with two children ages 2 and 5. She was a 1ppd smoker, now 5 cigs/day. Wants to quit for her children. Her husband is a non- smoker. Allergic to patch. Gum didn’t help.
5. Ron: 23 yr old Iraq war veteran. Smokes 1 ppd. Was honorably discharged now a Criminal Justice major. “Drinks alcohol to forget… then forgets why he drank”. Used Zyban in Iraq to quit but it didn’t help that much, would like something different.
6. Paul: 21 year old computer major from Kenya. 1 ½ -2ppd for 2 years. Just started smoking when he came to the US. No one in his family smokes. He dislikes the time he wastes and wants to quit. This is his first quit attempt.
Prochaska & DiClemente’s Transtheoretical Model of Change Which stage was your case study patient in?
• A. Pre-contemplation• B. Contemplation• C. Preparation• D. Action• E. Maintenance &
Relapse Prevention
I love smokers! And I want you to learn to love them too!
Tobacco users are good people with TOUGH ADDICTIONS
Remember, smoking doesn’t kill people.
People who are quitting smoking kill people.
What percent of adult Marylanders are daily smokers? CDC 2007 BRFSS data
12%
15%
20%
25%
30%
35%
40%
0% 0% 0% 0%0%0%0%
11.5%1. 12%2. 15%3. 20%4. 25%5. 30%6. 35%7. 40%
23% former smokers
59% never smokers
10
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Most VCU students (7 of 10)
didn’t smoke at all in the past month.
Only about 8-12% smoke daily.
FREE Quit Kits at
OHP smoking cessation
pills Chantix
“Genetic Snowflakes” & tobacco• Research on genes such as CYP 2A6
• About 1 in 4 are missing genetic ability make enzymes to break down nicotine
• 3 in 4 people can metabolize nicotine and if used are at high risk for addiction
• Research by Ken Kendler, PhD: two sets of factors, one predicts “trying” another predicts “abuse &/or addiction”
Understanding a smokers struggle -adapted from Mayo Clinic Nicotine Dependency Center publication 2005
= Withdrawal - empty receptors
= Craving chemicals – triggered by environment
How many medications are currently considered “first-line” in the treatment of nicotine addiction?
3 5 7
0% 0%0%
1. 32. 53. 7
Clonidine and nortriptyline are second-line pharmacotherapy
0 of 5
10
There are currently 7 MEDICATIONS for first line use
Bupropion HCL( Wellbutrin or Zyban)
PatchGumNasal SprayPuffersLozenges
Varenicline(Chantix or Champix)
Blocks Nicotinic receptors, not advised to
use with NRT
2 Smoking Cessation PILLS5 NRT products
(nicotine replacement therapy)
Combination Therapy
Shoes Analogy
You know how you try on shoes? Some fit and some don’t…
but you don’t give up wearing shoes!
That’s they way it is with medications.You try them on. Some fit. Some don’t.
But you don’t give up trying to quit.
Did you ever smoke cigarettes?
No
Yes
I smoke
d someth
ing b..
0% 0%0%
1. No2. Yes3. I smoked
something but I’m not sure it was tobacco.
10
0 of 5
The tobacco epidemic, like the “flu” is always mutating.
-Jack Henningfield, PhD
Tobacco Companies and others out to make money on nicotine are always changing-
•What they market •How they market•To whom they market
What is this?
Not..
Hookah
Water Pipes
also called “Hookah”
Which type of smoke has more cancer causing chemicals?
Cigare
tte
Hooka
h
0%0%
1. Cigarette2. Hookah
10
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Maassel or mu’essel(assal means honey in Arabic)
Moist paste like mixture with 30% crude cut tobacco
Fermented with approximately 70% honey, molasses and pulp of different fruits.
Hookah Materials
Toxin Content of smoke (single hookah session compared to a single cigarette)
Chemical HOOKAH CIGARETTE COMPARISON
“Tar” 802mg 22.3 mg 36 times the tar
Nicotine 2.96 mg 1.74 mg 1.7 times the nicotine
Carbon Monoxide
145 mg 17.3 mg 8.4 times the carbon monoxide
Please post this poster!
www.lgbtsmokefree.org
A high-risk population for smoking!
LGBTs smoke at rates 40% to almost 200%
higher than the general population
Have you ever heard of Snus?
Yes No
0%0%
1. Yes2. No
0 of 5
10
What is Snus?
• Rhymes with "goose" • Cynics might say "noose“• Swedish type of “spitless-smokeless” tobacco • Comes in teabag-like pouches • User sticks between the upper lip and gum • Use 30 minutes • Then discard without spitting
Is Snus safer?
• Snus is subjected to a heating treatment process that sharply reduces microorganism content; no fermentation has been used in its production
•• This processing method and refrigerated
storage reduce the formation of nitrates and nitrosamines, resulting in a product low in TSNAs.
The verdict is out about the safety of snus
• The long-term health effects of snus use starting early in life are also unclear. This has become a concern
• New types of smokeless snus are introduced to North America (e.g., Camel Snus, Marlboro Snus)
• Some of these products are clearly aimed at youth (e.g., Marlboro snus packaging resembles a cell phone).
SNUS PRODUCTS
Look for them at a convenience store
near your office!
My personal biases…
• We need to be prepared to get smokers at “reachable moments”
• Smokers get sick frequently!• ALL STAFF who can prescribe must be
intervene with tobacco users.– Every clinic needs a
“smoking cessation guru”
Everyone should know as much as possible about tools/meds to help people quit!
Neurobiology of nicotine addiction
• Nicotine ACh Receptors are all over the body• There are several subtypes
– Alpha4Beta2 receptors predominate in the brain • (site of action for Varenicline)
– Alpha 7 receptors (link to schizophrenia?)
• These receptors affect brain reward, mood, cognition, etc.
• SMOKERS have UPREGULATED but poorly functioning receptors.
Cochrane Reviews for Nicotine receptor partial agonists
Date of last substantive update: November 15. 2006
• Included varenicline and cytisine• Found six randomized controlled trials of
varenicline, covering nearly 5000 participants. • Varenicline increased the odds of successful long-
term smoking cessation approximately threefold compared with pharmacologically unassisted quit attempts.
• The evidence on cytisine is limited at present, and no firm conclusions can yet be drawn
Varenicline research – 2 key studies (Gonzales, JAMA, 2006 & Jorenby JAMA, 2006)
• In two large randomized placebo controlled trials of varenicline for 12 weeks vs. bupropion SR or placebo, varenicline significantly outperformed placebo with 44% of the subjects abstinent from smoking at the end of medication vs. 18% for placebo (OR 3.85, P<0.001).
• Varenicline also outperformed bupropion SR which produced a smoking abstinence rate of approximately 30% at the end of treatment (OR 1.9-1.93, P<0.001).
• At week 52, varenicline was nearly three times more effective than placebo (OR 2.66-3.09, P<0.001) while the difference in smoking abstinence between varenicline and bupropion SR was no longer significant (OR 1.46, 95% CI 0.99-2.17) in one study but was significant in the other (OR 1.77, 95% CI 1.19- 2.63).
• Both varenicline and bupropion SR significantly reduced the urge to smoke, craving for cigarettes and negative affect compared with placebo.
Recommendations: Dr. Richard Hurt, Director,
Mayo Clinic Nicotine Dependency Center
• Varenicline should be considered a first line medication for the treatment of tobacco dependence.
• It has not been tested in adolescent, pregnant or breastfeeding smokers.
• Varenicline is cleared almost entirely by the kidneys and dose adjustments are necessary in the presence of severe renal failure (creatinine clearance < 30 ml/min.) and patients receiving hemodialysis.
• Nausea can be minimized by taking the medication with a large glass of water after eating.
• If patients are intolerant of 1.0 mg twice a day, a trial of 0.5 mg twice a day should be encouraged.
0.5 mg and 1mg pills and ways to and adjust the dosing
The QUESTION in your minds…
Does varenicline (Chantix) make people suicidal or
homicidal?None of the 5000 patients involved in the clinical trials
experienced this problem.
Do talk share this issue with your patients and simply have them agree to contact you if they have any
problems.
Bupropion• On the market for cessation since 1997• Found by accident• Originally an antidepressant• Generic 100 mg tab, SR 150 mg tab = Zyban• Category B in pregnancy (safer than the patch- D)• CONTRAINDICATIONS- don’t prescribe if…
– History of Seizure Disorder– Head Trauma with LOC > 30min in past 5 years– History of an Eating Disorder – On other meds that lower seizure potential– Heavy drinkers (a hangover is a seizure prone state)
Main Side effects on bupropion
• You’re not depressed• You have extra energy• Seems to limit weight gain with cessation• Treatment for ADHD• May improve ability to orgasm• Cigarettes may taste different
True or False Patients should never smoke when
they have on a nicotine patch.
True
False
0%0%
1. True2. False
0 of 5
10
Nicotine Patch BEFORE cessation doubles success rates
Jed Rose, PhD, Feb 1, 2006 issue of Nicotine and Tobacco Research
• Duke University Center for Nicotine Research & Smoking Cessation– 96 smokers attempting to quit
• Half wore patch 2 weeks before quitting• Half wore a placebo patch• AFTER 4 weeks
– NO adverse effects from smoking & using patch– 23% with placebo patch had quit– 50% with real patch had quit
“Cigarettes are less rewarding and satisfying when there is already a level of nicotine in the system provided by the patch.”
- Jed Rose, PhD
NRT is safer than tobacco use…
• No carbon monoxide exposure• No effect on coagulation
– (Ex: Second-hand smoke in bars – strokes/MIs)• Pharmacokinetics of NRT different than Tobacco• NRT harder to get high levels
New ways to use Nicotine Replacement Therapy
(NRT)
1. Starting NRT before stopping tobacco 2. Matching dose to daily use3. Combination Therapy
Nicotine Patch Therapy Initial Dosing Guidelines
suggested by Mayo Clinic NDC
• Based on Baseline Cigarettes/Day–<10 cig/d 7-14 mg patch–10-20 cig/d 14-21 mg patch–21-40 cig/d 21-42 mg patch–>40 cigs/d 42+ mg
PICK
3
How combination therapy can help
What you do is important!
Never push AMBIVALENT patients…
Guess which way they will tip?
Motivational Interviewing
(MI)
William Miller, PhD
Have you heard of Motivational Interviewing (MI)?
Nope,
never
heard
of it,
Yes, h
eard
of it
but n...
Yes, I’
ve bee
n train
ed i..
.
0% 0%0%
10
0 of 5
1. Nope, never heard of it,
2. Yes, heard of it but never officially taught or trained
3. Yes, I’ve been trained in it
How you ask the questions influences how the patient will answer…
• NOT EFFECTIVE “Do you want to quit smoking?”
• Not very effective because often they have tried quitting and they haven’t succeded.
• MORE EFFECTIVE“Where are you in your love/hate
relationship with your tobacco?”
3-Fold Relapse Prevention Plan for Life OFF the medications
1. SYMBOL– of what you want more than tobacco
2. PARAGRAPH– about what you hate about tobacco
3. KEEP SOME PILLS/MEDS– for several years, use for a few days if needed
QUIT KITS -5 A’s in a bagAskAssessAdviseAssistArrange follow-upEmail me at [email protected] for quit ki contents in electronic format
Mark: 35 year old store manager 1ppd smoker for 16 years.
Quit smoking on bupropion in 2001 but after 2 years of not smoking he relapsed.
He has a history of depression in his teens. He disliked the side effects on Paxil & Zoloft.
• Reason he relapsed was that his girlfriend died in an MVA
• Impotence issues from Paxil and Zoloft still affect his current relationship.
Chen: 26 year old MD PhD student Dips 2 cans/wk for 6 years. Uses dip to study. Has tried both gum and patch without success. He wants to quit before 3rd year rotations which
start next fall.
• Drinks every other weekend
• 8 – 10 beers on Friday & Saturday nights
• Did NOT prescribe bupropion
• Ysed patch & lozenges
Staci: 19 year old voice major ½ ppd smoker x 3 years
Has tried to quit cold turkey twice with no success. She has a new boyfriend who is a non-
smoker. She wants to quit for him.
• Suicidal depression over an abortion she had 6 months ago.
• She feels like a total failure in life.
• I walked her over to the counseling center.
Tonya: 30 year old waitress. Was a 1ppd smoker, now 5 cigs/day. Married with
two children ages 3 and 5. Allergic to patch. Gum didn’t help.
• “Guts it out” to only use 5 cigs/day & only allows herself to smoke in backyard where the dog poops.
• Last Period: 12 weeks ago• Patch – Category D• Bupropion – Category B
Ron: 23 yr old Iraq war veteran. Smokes 1 ppd. Was honorably discharged now
a Criminal Justice major. Drinks alcohol “to forget… then forgets why he drank”. Used
Zyban in Iraq to quit but it didn’t help that much, would like something different.
• Thank goodness for Chantix• Did extremely well… quit
smoking (still drinking)• Brought “friend” by• Couldn’t believe I didn’t
lecture him
Paul: 21 year old computer major from Kenya 1 ½ -2ppd smoker for 2 years.
Just started smoking when he came to US. No one in his family smokes. He dislikes the time he wastes and wants to quit. This is his first attempt.
• Psych Hospitalization October 2004 for hearing voices and being combative.
• Diagnosed Schizophrenic• Did not stay on meds.• Not currently delusional.
SMOKING CESSATION ASSEMENT
& MANAGEMENT
FORM
I’ll send you an electronic version you can adapt for your clinical use
Email [email protected] and ask for it.
The bottom line
Be methodical about assessing BEFORE recommending meds.
BUT…remember medications greatly increase quitting success.
Please support patients with prescriptions where appropriate.
Implementing an Effective Smoking Cessation Strategy in Medical Practice
RESOURCES FOR PATIENTS
℡QUITLINES – trained phone counselors provide practical counseling, support, materials, relapse prevention, etc:
Quit Now Virginia 1-800-QUIT NOW(1-800-784-8669, English or Spanish speaking.8AM-Midnight, seven days a week)
Great Start Quitline 1-866-66-START(For pregnant women, English or Spanish speaking)
