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Tobacco & Nicotine: Addiction and Treatment

Tim McAfee, MD, MPH Chief Medical Officer - Free & Clear

206-876-2551 - tim.mcafee@freeclear.com

Affiliate Assistant Professor, University of Washington, School of Public Health

Vital Statistics •  47 million US smokers

•  440,000 deaths/year

•  >8 million disabled

•  Smokers die ~ 8-13 years earlier

•  5 million smoking deaths/year in world

More than 440,000 Annual Deaths Attributable to Cigarette Smoking—United States

Lung Cancer

125,000

Other Cancers

31,000

Chronic Lung

Disease

82,000

Stroke

17,000

Ischemic Heart

Disease

82,000

Other

Diagnoses

105,000

Source: MMWR, 2005

19+ % of Americans smoke tobacco 70+% want to quit

Of those making a quit attempt: ~20% use a medication ~2% use behavioral support

Quitting Stats

One in 20 quit attempts succeed

Year

s of

life

gai

ned

Age at cessation (years)

•  Prospective study of 34,439 male British MDs •  Mortality monitored for 50 years (1951–2001)

Impact of Quitting Smoking

Doll et al. (2004). BMJ 328(7455):1519–1527

Sir Richard Doll 1912 – 2005

Addiction

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Nicotine •  Tertiary amine

– pyridine and pyrrolidine ring – strongly alkaline

•  Evolved as insecticide in tobacco •  Binds to nicotinic-cholinergic

receptors –  stimulus effect in locus ceruleus –  reward effect in limbic system –  releases acetylcholine, norepinephrine, dopamine,

serotonin, vasopressin, beta-endorphin, growth hormone & ACTH

The Masters Speak… •  “We are in the business of

selling nicotine, an addictive drug effective in the release of stress mechanisms”

Brown & Williamson, VP Addison Yeaman, 1963

Your turn…

•  Is nicotine addictive? •  How is it different and the same as

other substances classically thought of as addictive?

Drug Dependence Criteria

•  Tolerance •  Psychoactive effects •  Withdrawal •  Use despite harm to self or others •  Cravings with compulsive use

How is nicotine the same/different from other addictive

drugs? •  85+% who use nicotine, use daily

– 10% of cocaine/etoh users •  Withdrawal not life-threatening

– Can be for alcohol •  Most severe consequences

delayed •  ?

The Opportunity •  Most tobacco users want to quit

•  Half make a serious attempt each year

•  5-7% who quit on their own succeed

•  Assistance increases absolute success 15-40%

•  Only one in 5 use meds

•  one in 50 get counseling

•  80% see a HCP each year

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MPH MD/HCP

Raising taxes

Clean indoor air regulation

Product regulation

Denormalization

Population prevalence

Greatest good from available resources

Compare costs to:

Individual treatment

Maximize the probability of success

Compare costs to:

Lung cancer treatment

Cancer screening

Substance abuse treatment

Road repair

Treatment Perspective

MPH: How do we increase quit success in a population (total quitters) ??

Increase use of evidence-based support during quit attempts

Increase effectiveness of evidence-based support

Increase quit attempts

Sweet Spot

Task Force on Community Preventive Services

•  Independent, nonfederal Task Force – evidence-based – focus on non-clinical interventions

•  Reviewed 14 interventions to:* – reduce ETS exposure – reduce tobacco use initiation – increase tobacco use cessation

*Am J Prev Med February 2001

Strategies to increase tobacco use cessation

•  Increasing unit price: strongly recommend •  Mass media campaigns (combine w other)

- strongly recommend •  Health Care System-level interventions

–  provider reminders: recommended –  provider education: insuff evidence –  provider remind + education: strong rec –  reduce patient out-of-pocket costs: rec –  multicomponent phone support: str. rec

WHO recommends 3 treatment services for all countries

•  Primary-care advice to quit •  Low-cost pharmacotherapy •  Easily accessible and free quitlines

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Case Study: Mr G

•  53 y.o male with gradually increasing trouble breathing

Past History: •  High blood pressure •  Smokes 1 pack/day Social: •  Married, 2 children,

non-smokers Insured Through Work: •  No cessation benefit

•  A long-term condition •  Stakes are high •  Relapse is part of nicotine dependence

– 19/20 relapse without treatment

– 2/3 relapse even with best treatment

– not an indication of personal failure

The 5 A’s •  ASK about tobacco use

•  ADVISE to quit

•  ASSESS willingness to make quit attempt

•  ASSIST in quit attempt

•  ARRANGE follow-up

Treatment Methods In Use

Counseling Group Counseling

Telephone-based counseling

1:1 counseling

Pharmacotherapy OTC Pharmacotherapy

Rx Pharmacotherapy

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25

Washington State Quit Line

Available to all ― Half-hour coaching ― Triage

Available to some ― Intensive Benefit: 4

calls & patches

Pharmacotherapy •  Increases cessation

rates

•  Can increase use of behavioral therapies

Pharmacologic Methods First-line Therapies

Three classes of FDA-approved drugs for smoking cessation •  Nicotine replacement therapy (NRT)

–  Nicotine gum, patch, lozenge, nasal spray, inhaler

•  Psychotropics –  Sustained-release bupropion

•  Partial nicotinic receptor agonist –  Varenicline

Nicotine Patch

• Available in 7mg, 14mg, 21mg doses

• Easy to use, conceal

• Provides consistent nicotine levels

• Not recommended in patients with serious skin conditions

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Nicotine Gum

• Available in 2mg, 4mg doses

• Patients can titrate nicotine levels

• Requires correct technique

• Not recommended in patients with dentures

Nicotine Lozenge • Available in 2mg, 4mg doses

• Patients can titrate nicotine levels

• A bit easier to use than nicotine gum

• Can have GI side effects

What is Currently Approved?

Front Line Treatments available with Rx only:

•  Nicotine Inhaler

•  Nicotine Spray

•  bupropion

•  varenicline

Nicotine Inhaler

• Mimics hand to mouth action of smoking

• Patient can titrate nicotine levels

• Possible initial throat and mouth irritation

Nicotine Spray • Patient can titrate nicotine levels

• Quick onset of action

• May be more effective than other forms of NRT

• Can result in dependence

• Side effects can be significant

bupropion • Easy to use

• As effective as patch

• Might be useful in patients with depression

• Slight risk of seizure

• Contraindicated in a number of conditions

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varenicline

•  Reduces craving and withdrawal

•  High efficacy

•  Different mechanism than NRT

•  Can cause nausea

varenicline – FDA Advisory

•  Use with caution in patients with a history of psychiatric illness (includes depression).

•  May cause changes in behavior or mood.

•  May impair ability to drive or operate heavy machinery.

NRT: Can you use in combination?

•  Patch in combination with short acting (gum or spray) more effective than either alone

•  Bupropion can be used with patch

+ =Increased Success

Common Misconceptions

•  I should use as little NRT as possible.

•  Medications are a “Magic Bullet”.

•  Nicotine will give me a heart attack.

NRT for Pregnancy and Youth

•  Evidence is inconclusive

•  Determine if benefits outweigh the risks.

Maximizing Treatment Success

2008 US PHS Guidelines

Medication plus counseling is the most effective treatment.

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What Should I Recommend?

•  Patient preference is important.

•  Side-effect profiles vary.

•  Past experience may predict future experience.

•  Combination therapy is effective.

Treatment Access: Convenient for us

Inconvenient for smokers

Model for treating tobacco dependence

Why variation in reach? •  Size of service and promotion budget

•  Efforts to markedly increase reach use via revenue from tobacco taxes, health insurance or other sources have worked (up to 5-12%)

•  Editorial comment: Taxing tobacco users on tobacco products and for healthcare while not providing treatment is a human rights and policy issue!

Treatment Challenges •  Who does it? •  Who pays? •  Mainstreaming •  Overcoming Tobacco Control anti-

treatment biases •  Avoiding hyper-medicalization •  What the H*** are those 5 As again?

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In Conclusion •  Effective treatments for tobacco

dependence exist

•  When made available without barriers and publicized, treatments are used

•  Gap between effectiveness and use is a social justice issue