Smoking Cessation

45 Million americans smoke35 Million want to quit smoking

Smoking Cessation

“It's not hard to quit smoking, I've quit thousands of times.”

Mark Twain

Smoking Cessation

Why are people addicted to cigarettes?

Nicotine Nicotine is a naturally occurring chemical in tobacco. It

is a stimulant, insecticide, it not a food, it is an accident Nicotine is a poisonous alkaloid, C10H14N2

NICOTINE DOES NOT CAUSE CANCER

Nicotine binds the nAcetylcholine receptor and triggers dopamine and other neurotransmitter release, identified as pleasure and calm feeling. Rats will press a button for more nicotine, choosing it over food in a lab setting.

SMOKING CESSATION

Smoking causes cancer Radon causes cancer Inhaling asbestos and other particles causes

cancer Cigarette smoke has 4,000 different

chemicals, 69 carcinogens such as Nitrosamine and benzopyrene

Combining cigarettes with other inhalants increases the chances of cancer.

Smoking cigarettes increases the chances of lung cancer, and cancers of the pancreas, bladder, kidney, stomach and colon.

Smoking Cessation

Smoking cigarettes started in the the 1500s 1610 “Smoking may be dangerous” 1632 Illegal to smoke in Massachusetts 1760 First Tobacco Company in New York 1826 Pure form of Nicotine refined 1836 Samuel Green Discovers “Nicotine

can kill a man if too much is taken” It causes rapid heart rate and constriction of the arteries.

1847 Phillip Morris established 1902 Marlboro brand 1913 Camel brand

Smoking Cessation

The link to cancer first noted by a German Doctor Fritz Lickint. Prior to 1900 the diagnosis of lung cancer at autopsy was rare. Dr. Lickint noted an increase in lung cancers and noted the association with smoking.

During WWII cigarettes were given out in soldiers rations.

1952-1956 Kent brand contains asbestos in the filters

1953 Study proves that tar from cigarettes causes cancer in mice

1960 Warnings about the hazards of smoking

Smoking Cessation

What methods are available Will power---- long term success 3% Nicotine replacement products over the counter

6% Physicians counseling and NRT –10% Bupropion (Wellbutrin/Zyban-- 13% Bupropion 150mg twice a day and Transdermal

Nicotine patch 21mg/day had a 35% success

Smoking Cessation

What methods are available Varenicline (Chantix) a new partial agonist of

nicotinic acetylcholine receptor at one milligram twice a day had a 44% continuous abstinence rate

Hypnotherapy in hospitalized patients 50% quit rate at 6 months.

Smoking cessation clinic combining all methods, 6 one hour sessions 65% quit rate at completion

Smoking Cessation

Nicotine Replacement Products Nicotine Patch dose varies, 21mg/day to 7mg/day

Easy to use, helps with morning cravings, no rx FREE from New York State 1-866 NY QUIT Calculating the dose, #of cigarettes/day closest to

multiple of 7,14 or 21 OK to use 2 patches, rotate sites, cannot smoke while on patch

NICOTINE GUM 2mg and 4mg Easy to control dose, prevents over

eating, no prescription Nicotine spray/inhaler—Fast relief

for cravings, easy to adjust dose. Disadvantage requires prescription

Smoking Cessation

Buproprion (Zyban and Wellbutrin Blocks reuptake of dopamine and norepinephrine and

has a direct competitive inhibitory effect on the nicotine Ach receptor

Anti-depressant that boosts chemicals that elevate mood. It also decreases cravings for food and alcohol

Requires a Doctor visit and prescription Contraindications include history of seizure disorder,

head trauma, eating disorder, side effects, insomnia “Dr Pillsbury, I don't know if I was depressed

and therefore I smoked, or if I smoked and was so angry at myself I was depressed-- but taking Wellbutrin I am so happy—I don't smoke!”

Smoking Cessation

Varenicline (Chantix) New type of medication that partially blocks the

action of nicotine and partially stimulates the nicotine receptor in the brain so there are not severe nicotine withdrawal symptoms

Blocks the euphoria associated with smoking Causes mild nausea Minimal weight gain Does not interact with Digoxin,

warfarin(coumadin), or metformin (glucophage)

Cons Requires a prescription and office visit, there are

reports of stable psychiatric patients having severe mood changes, use with caution if there is a history of a mood disorder.

Smoking Cessation

The Future There will be more partial agonists drugs similar to

Varenicline. The rate of smoking in the world is increasing, there is an explosion is basic research on selective receptor modulators involved in mood/addiction

Nicotine Vaccine (NicVax) Nicotine is bound to a protein and injected to produce

an antibody response. The antibody binds to Nicotine and prevents it from crossing the blood vessels into the brain. It is a 5 shot series over one year. Not yet available

Quit rate after one year of study 16% Long term safety not known Groups that should not have this done, not known Has not been combined with other stop smoking

techniques

Smoking Cessation

Social Factors

Its very important that teenagers do not start smoking. 18 year olds have a 80% chance of continuing to

smoke once they start and almost all recently surveyed (20+yrs) wished they did not smoke

Explaining the money saved to younger patients is very effective. Two effective behavior techniques that work well in the young:

deposit $4 into a jar every day that they do not smoke.

Exercise vigorously for 10 minutes before smoking, the urge to smoke will often pass after exercise.

Smoking Cessation

Social Factors

The lowest rates of smoking in the country are in the state of Utah. Many counties there have a smoking rate less than 10%. The main factor is religious.

Hawaii has a very low smoking rate 12% in some surveys, Asians have a very low rate of smoking. The state of Hawaii also spends significantly on stop smoking education

The State of New York sponsors free patches, web site, and selected stop smoking clinics including a very successful program on Long Island at the Center for Smoking Cessation at Long Island Jewish Hospital in Great Neck, New York

Smoking Cessation

Research Clinicaltrials.gov

There are many trials combining new drugs and comparing different methods to help people become non-smokers

There are several new types of drugs being studied that modulate the subsets of nicotine receptors in the research phase.

If you smoke, talk to your Doctor and keep trying to quit. Try hypnotherapy, try Chantix

Smoking Cessation

In the 1950s close to 45% of American adults smoked cigarettes.

In 2005 the percent has dropped to close to 20%

Smoking Cessation

Smoking is an Addiction The 5 A’s

Ask, at every visit Advise, age based advise Assess, are they ready to quit Assist, websites, quit lines, programs Arrange, follow up visit discuss more option

Smoking Cessation

Behavioral Advice The 5 D’s, Cravings will pass

Delay Drink Water Do something else, distraction Deep Breath Discuss

Smoking Cessation

Relapse, The 5 R’s Relapsing x 5 is not unusual

There has never been any program with >50% success at one year. The programs that have combined all techniques including Chantix have less than 40% success at the one year mark.

Addressing the “Why?” The other 5 R’s Patients will tell you if you ask.

Relevance Risks Rewards Roadblocks Repetition, teachable moments

The MKMG/NWHC Smoking Cessation Program “Break the habit” 666-1182 MKMG.com, NWHC.com Four consecutive one hour sessions from 7-8pm Goal is to combine all techniques, support group, peer

group enrollment, behavior modification, education, nutrition, hypnotherapy, aroma therapy, exercise instruction, nicotine replacement and information on Zyban and Chantix, RXs must come from primary MD. The program is seeking MD volunteers, 2 hours during weeks 1 and 2

Week 1, support group, behavior and MD information Week 2 , Nutrition information, discussion, support Week 3, Intro to hypnotherapy Week 4, Alternative approaches, aroma therapy, etc