SMOKING CESSATION – The #1 Health Priority for our smoking patients

Mike Murchie

Health Risks

• Early DEATH!!!

• On average smokers die 10 years earlier than nonsmokers

Health Risks

• Pulmonary – COPD / Emphysema• Vascular – CVA, CAD, AAA, PVD, Buerger’s• Other - catarcts, chronic cough, skin damage,

poor oral health, low bone density, gerd, fire-related injury, pregnancy related, second-hand smoke, female infertility, cataracts, macular degeneration

• Cancer– lung, mouth, esophagus, stomach, pancreas, bladder,

kidney, cervix, AML, +/- colon

Smoking Related Deaths

CV disease37%

Lung Cancer

31%

Respiratory causes

24%

Other Cancers

8%

Public Health Consequences of Smoking

• #1 preventable cause of death in the US

• 440,000 deaths per year in US

• 5 million deaths per year worldwide

• 8.6 million in US are disabled from smoking-related diseases.

• 2x as many deaths as HIV/AIDS, alcohol abuse, MVA’s and suicide COMBINED!!!

Benefits of Quitting

• Longer life– If quit before 50yo, ½ risk for dying within next 15years– 2 Large Studies – Smokers aged 65 and up who continue to

smoke have higher mortality and cv, neoplasia at 5 yr f/u than those who quit.

– Patients >65yo who quit add 4 years to their life on average• Chronic cough –

– 94-100% resolves or decreases. – 50% resolve within a few weeks

• Lung function – improves within 3 months• Shortness of Breath improves within 1-9 months• Skin, breath, teeth, gum effects reverse• Smell, taste improve

Source - “In the Clinic: Smoking Cessation”, Laine et al, Annals of Internal Medicine, Volume 146(3), 2/6/2007, pgs ITC2-1-ITC2-16

Benefits of QuittingPublic Health

• Reduction of Second Hand Smoking’s Effects– ~3000 lung ca related deaths a year– Assoc w/ nasal sinus, cervix, breast, bladder CA– Assoc w/ chronic cough, decr lung funct– 60,000 annual heart disease deaths in adult

nonsmokers attributable to 2nd hand smoking– In Kids, increased risk of sids, severe asthma,

pneumonia, ear infections

• Cost of smoking cessation efforts per life-year saved = $2000(Mammogram = $50,000)

Benefits of QuittingFinancial

• Cost Savings

• Doesn’t include: Health care savings• Doesn’t adjust for inflation or increasing taxes

Cost of a Pack of Cigarettes in Indiana = $ 3.81

1month 6months 1year 5 years 10 years 20 years 30 years 40 years

.5ppd $57.15 $342.90 $685.80 $3,429.00 $6,858.00 $13,716.00

$20,574.00 $27,432.00

1 ppd $114.30 $685.80

$1,371.60 $6,858.00

$13,716.00

$27,432.00

$41,148.00 $54,864.00

1.5ppd $171.45 $1,028.70

$2,057.40

$10,287.00

$20,574.00

$41,148.00

$61,722.00 $82,296.00

2 ppd $228.60

$1,371.60

$2,743.20

$13,716.00

$27,432.00

$54,864.00

$82,296.00 $109,728

Benefits of QuittingFinancial

• Duke Health Economists estimated the cost of smoking (including all factors) to be $40 per pack– $33 of the $40 paid for by the individual– Costs to society in general pretty much

neutral due to early death of smokers

“The Price of Smoking”, Sloan et al, December 2004.

Benefits of QuittingFinancial

• Health and life insurance rates decrease

• Employment options may increase

• Worker productivity may increase– 20 cigarettes in a pack, about 10 minutes to

smoke each cigarette = 3 hours and 20 minutes of smoking a day

Why is it so difficult to quit?

• Nicotine is Highly addictive– 1/3 of people exposed to

nicotine become addicted

• Mood-elevating response• Withdrawal syndrome, weight

gain, etc• Habit• Smokers claim it provides

short term “Stress relief”

Why aren’t physicians better at helping their patients to quit?

• We’re “too busy” taking care of the other problems their smoking has contributed too

• Rx given without much behavioral counseling or before patients motivated to quit

• Myths– Fatalism, i.e. “he’ll never quit”– “She’s too old to quit, it wouldn’t make any difference

at this point”• Smoking Cessation counseling reimbursement is

sporadic– Medicare part B covers only for patients with

diseases/health effects related to smoking

Smoking Cessation Game PlanBe nonjudgemental and truthful

• Ask

• Advise

• Assess

• Assist

• Arrange

• Anticipate

Techniques

• Cold Turkey

• Behavioral Interventions

• Medications

Cold Turkey

• No difference between gradual versus abrupt cessation

• Quit rates are better with intervention, but clearly there is a subset that this works for

Behavioral Interventions

• Brief Physician Advice

• Self-Help Therapy (websites, leaflets, etc)– Not useful alone

• Individual Therapy– More time and more sessions better than less but

even a small amount is effective– Consider an entire appointment for smoking

cessation strategies

Behavioral Interventions

• Quitlines– Best are those with call-back counseling

• Group Therapy / Smoking Cessation Classes

• Exercise, acupuncture, hypnosis, aversive smoking– Reviews don’t show benefit, but certain

individuals may benefit

Medications

• Nicotine Replacement

• Wellbutrin

• Varenicline

MedicationsCost Per Day Cost at PCC

Pharmacy (before discount)

Nicotine Replacement (patch)

$3.75 $1.65

Wellbutrin $3.33 $1.56

Varenicline $4.00 $2.92

MedicationsNicotine Replacement

• Alleviates symptoms of withdrawl– Gum/patch/lozenge/inhaler/nasal spray/sublingual tablet– 1.5-2.5x increased quit rate over placebo at 6months for

motivated patients– Start using on the person’s quit date (not before)– Duration

• Usual Length Tx is 12-16 weeks• Can step down gradually or abruptly withdraw when patient is ready.

No proven benefit to either approach• Safety, efficacy of long term tx unknown

– Patch, gum cheapest out of pocket– SE- skin irritation, throat irritation– CI- MI within last month, severe angina, life-threatening

arrhythmia, pregnancy (category D). – Safe for stable ischemic heart disease patients

MedicationsNicotine Replacement

Adapted from “Interventions to Facilitate Smoking Cessation”, American Family Physician

Pro’s Con’s QuitRate@6mo Cost per day

Patch (16 hours or 24 hour preparations available)

Less Potential for addiction

Can use 24hr patch overnight to decr am cravings

Cheapest

Compliance

Skin irritation

Sleep disruption

Lower quit rate

8-21% $3.60 – $4

Spray Fastest delivery Highest potential for addiction

Frequent dosing needed

Nose/eye irritation

Need rx

30% $16.00 ??

Inhaler Hand to Mouth

Few side effects

Need rx

Mouth/throat irritation

23% $9.50 ??

Lozenge Frequent dosing

No food/drink 15 min before use

Dyspepsia

24% $8.88

Gum Fast nicotine delivery Higher potential for addiction

No food/drink 15 minutes before use

Jaw pain, dyspepsia, hiccups

24% $9.33 - $10.33

MedicationsBupropion

• Inhibits serotonin, NE, DA • Mechanism: Inhibits cravings, decreases withdrawal• One study showed bupropion 30% 1year quit rate vs 15% for nicotine

replacement• It’s NOT magical. Must be used in a motivated patient and with a specific

quit date to be effective!• May delay post-cessation weight gain• Start 1-2 weeks before quit date • Duration - continue for 8-12 weeks or longer• SE- nausea, dry mouth• CI- Seizures (rate is 1/1000 persons treated), eating d/o, MAO or MAO-like

agents within the past 14 days, antipsychotics, cocaine, psychostimulants, sodium phosphate, theophylline, tramadol, systemic corticosteroids

• Monitor BP• Category B in pregnancy

MedicationsVarenicline

• Binds nicotine receptor, blunting the relaxing effect of nicotine leading to reduced cravings

• 2 rct’s Varenicline vs Bupropion vs Placebo– Abstinence at 4 weeks – 44% vs 30% vs 18%– Abstinence at 9-52 weeks – 23% vs 16% vs 9%

• Another trial showed benefit of 12 additional weeks (total 24weeks) for maintaining abstinence

• Start taking 1 week before quit date• Duration- 12weeks with consideration of an additional 12weeks• SE- Nausea (in 28.1% of patients in the above study) and Vomiting,

abnormal dreams, constipation, flatulence• CI/Caution – Caution in renal impairment w/dose adjustments for

CrCl <50, Category C in pregnancy, probably excreted in breast milk

**Quit line available for varenicline users at no additional charge**

MedicationsOthers

• Approved - Clonidine, Nortryptiline

• Off-label- Naltrexone, Alprazolam, silver acetate, mecamylamine, lobeline

MedicationsCombination Therapy

• Effective for the most part– Patch + Gum, Inhaler, or Spray increases

success by up to 50% over patch alone– Veterans study showed no benefit for combo

NRT + Bupropion over Bupropion alone

• Consider for:– A) those who have failed monotherapy, or– B) initial treatment for those who have multiple

pack-years

Picking the right therapy for your Patient

• Contraindications

• Financial considerations

• H/o Depression

• Compliance

• Combination Therapy

• Patient Preference

Multi-Pronged ApproachKnow and Use All Available Resources

• Quitlines

• Smoking Cessation Classes

• Medicine

Prepare Patients for Side Effects of Quiting

• Withdrawal Syndrome– Most intense sx in first 72 hours after quitting. Syndrome lasts 2-8 weeks– Mild depression, anxiety– Headache– Nausea– “The shakes”– Hunger– Fatigue or insomnia.

• Weight gain (Men averaged 4.4kg gain, Women 5.0kg) – Naltrexone may be more weight neutral– Nicotine gum and bupropion have been shown to delay, but not prevent weight

gain

• Depression– Especially patients with prior MDD

Care After Quitting

• Continue to ask about abstinence after they have “quit”

• Don’t give up when relapse occurs. Most people that eventually quit permanently do so after multiple attempts (on average, 8 attempts!)

• Set a new quit date when relapse occurs and consider a new approach

• Urine cotinine testing in some

SUMMARY

• Smoking cessation is:

– The greatest thing smokers can do for their health– The greatest piece of assistance a doctor can offer for their

patients who smoke– Extremely cost effective– Important for smokers of ANY # pack-years– An achievable goal (with perseverance from patient and doctor)– Best achieved with an individualized, multi-pronged approach– Encouraged effectively through brief interventions, but better

success is seen with longer, more intensive measures– Accompanied by withdrawal symptoms that patients should be

prepared for in advance

Resources

• Quit Lines– 1-800-QUIT-NOW

• Local Resources– Marion County HD free smoking cessation

classes schedule: http://www.mchd.com/tobcess.htm

• Calculator - Personal cost of smoking– http://www.cancer.org/docroot/PED/ped_10_C

igCostCalc.asp?sitearea=PED

References• “Interventions to Facilitate Smoking Cessation”, Kolawole et al, American

Family Physician, Vol 74(2), 7/15/2006, pgs 262-271• “What to Do With a Patient Who Smokes”, Schroeder, JAMA, Vol 294(4),

7/27/2005, pgs 482-487• “In the Clinic: Smoking Cessation”, Laine et al, Annals of Internal Medicine,

Volume 146(3), 2/6/2007, pgs ITC2-1-ITC2-16• “Randomized Comparative Trial of Nicotine Polacrilex, a Transdermal

Patch, Nasal Spray, and an Inhaler”, Hajek et al., Annals of Internal Medicine, Volume 159(17), 27 September 1999, pp 2033-2038

• “Overview of Smoking Cessation”, Rennard et al, Up To Date Online• “A controlled trial of sustained-release bupropion, a nicotine patch, or both

for smoking cessation,” Jorenby et al., New England Journal of Medicine, 340(9):685-91, 3/4/1999.

• http://www.quitsmokingsupport.com• “The Price of Smoking”, Sloan et al, December 2004.