Tobacco Use Disorder

A Patient-Centered, Evidence-Based Diagnostic and Treatment Process1

A Presentation for SOMC Medical Education

Kendall L. Stewart, MD, MBA, DFAPASeptember 21, 2012

1 This presentation is designed as a problem-based learning module.

Why is this important?

• Scioto County has the highest smoking rate in the United States! (36%!)

• Tobacco kills more people each year than anything else.

• Secondhand smoke causes 10% of the tobacco-related deaths.

• Nonsmokers live more than a dozen years longer than smokers.

• Nicotine is highly addictive.• About 20% of us smoke.• Many more are affected by that

smoke.• Our progress in decreasing

smoking has stalled.1

• After listening to this presentation, you will be able to answer the following questions:

– Why is this important?– What are the diagnostic criteria?– How many people does smoking

kill each year?– What are some of the

demographics of tobacco use disorder?

– What counseling techniques are helpful?

– What medications are helpful?– What excuses do we physicians

make for not engaging these patients more?

1 Young people often start smoking because they still view smoking as cool.

What current diagnoses are included in this category?

• Nicotine Dependence• Nicotine Withdrawal• Nicotine-Related Disorder NOS• In DSM-5, these will likely be replaced

with Tobacco Use Disorder and included in the Substance Use Disorders category.

What are the diagnostic criteria?1

• Problematic pattern of tobacco use causing significant impairment or distress– Tobacco used longer than intended– Unsuccessful efforts to cut down usage– A great deal of time consumed by tobacco-related activities

and complications– A tobacco-related failure to fulfill obligations at school, work

or home– Continued tobacco use in spite of the problems it causes– Tobacco use negatively impacts social, occupational or

recreational activities– Recurrent use when physically hazardous– Continued use in spite of tobacco-related complications– Tolerance– Withdrawal– Craving

1 These are the proposed DSM-5 criteria.

How many people does smoking kill each year?1

Lung Cancer 128,900

Heart Disease 126,000

COPD 92,900

Other Diseases 44,000

Stroke 15,900

Other Cancers 35,300

1 Adapted from Rakel and Rakel, Textbook of Family Medicine and the CDC, Average Annual Number of Deaths, 2000-2004.

What are some of the key demographics of tobacco use?1

• Few people start smoking after age 18.• About 4000 children smoke for the first time every

day; 2/3 will become addicted.• 70% of smokers would like to stop.• 50% try to stop.• Less than 5% will succeed.• College graduates are more likely to succeed.• Only about 6% of people with graduate degrees

smoke.• People with mental illness smoke 70% of the

cigarettes in the United States.• Smoking is a pestilence mostly embraced by the

poor, uneducated and mentally ill.11 Rakel and Rakel, Textbook of Family Medicine

What about filtered cigarettes?1

• These varieties, 97% of those sold here, are not safer.

• Those who smoke “low nicotine, low tar” cigarettes just smoke more of them to get the same nicotine hit.

• Likewise, “natural” and “organic” cigarettes are just marketing ploys.

1 Rakel and Rakel, Textbook of Family Medicine

What about cigars?1

• These carry the same risks as cigarettes.• The risk varies with the number

smoked and the degree on inhalation.• More than 9% of men and 2% of women

smoke cigars.• The higher pH of cigar smoke permits

nicotine absorption across the oral mucosa.

• Cigar smokers do tend to inhale less.• The use of alcohol multiplies the risks.

1 Rakel and Rakel, Textbook of Family Medicine

What about electronic cigarettes?1

• These were developed in China in 2003.• They contain a battery, atomizer and cartridge

with liquid nicotine, and propylene glycol (used in antifreeze and cosmetics)

• Flavors such as chocolate and bubblegum are included to entice children.

• The FDA regulates them, but testing has not yet been completed.

• Internet sales are growing.• The price is dropping.• These may become “harm reduction” tools

and play some helpful role.1 Rakel and Rakel, Textbook of Family Medicine

What about smokeless tobacco?1

• Snuff greatly increases the odds of cancer of the gums and cheeks.

• About 9% of high school students use smokeless tobacco products; it is more popular with boys than girls

• Spitting tobacco is popular in organized sports.• Carcinogens are more concentrated in smokeless

tobacco than in cigarette smoke.• Nitrosamine levels are 10,000 times greater than in

bacon and beer.• Tobacco companies are marketing snus as an

alternative to spitting and smoking.• Smokeless tobacco users are less successful at

quitting.1 Rakel and Rakel, Textbook of Family Medicine

What about secondhand smoke?1

• 1/3 of lung cancers are caused by living with a smoker.

• Passive smoking is the third most common preventable cause of death–after smoking and drinking.

• Passive smoking increases SIDS, respiratory infections, ear infections, asthma and slows lung growth.

• There is no risk-free level of exposure.• Only eliminating smoking indoors completely

protects nonsmokers.• Cleaning rooms after smokers pollute them is

not entirely possible.1 Rakel and Rakel, Textbook of Family Medicine

What about third hand smoke?1

• Tobacco smoke reacts with nitrous acid to produce tobacco-specific nitrosamines—a carcinogen that becomes more potent over time.

• It is concentrated in dust and carpeting and is thus more harmful to children.

• Worse still, this stuff is essentially impossible to remove.

• This danger is regularly overlooked by parents who mistakenly think not smoking indoors when kids are present is safe.

1 Rakel and Rakel, Textbook of Family Medicine

What counseling techniques are helpful?1

• Assess the patient’s readiness for change and respond accordingly:– Pre-contemplation (not interested)– Contemplation (thinking about quitting)– Preparation (planning to quit in next 30 days)– Action (in process of quitting)– Maintenance (tobacco free for 3 months or more)

• Use motivational interviewing to build patient’s self motivation.

• Brief counseling (<3 minutes) = 13% quit rate.• Intensive counseling = 22% quit rate• Prenatal care, non fatal MIs and hospitalizations for

tobacco-use complications are the best teachable moments. Seize them!

• Study Treating Tobacco Use and Dependence: 2008 Update, a critical clinical practice guideline.

1 Rakel and Rakel, Textbook of Family Medicine

What medications are helpful?1

• Nicotine Patch (Nicoderm, Habitrol, Nicotrol, ProStep)– Start 2 weeks before the

patient plans to quit.– This first-line treatment is

often combined with counseling and other medications.

– Avoid insomnia by removing the patch before going to bed.

– Adding gum, the lozenge or nasal spay for “breakthrough” symptoms increases the odds of success.

• Nicotine Gum (Nicorette)– Chew slowly, intermittently

and park between the gum and cheek for a half hour.

– Avoid eating or drinking anything but water for 5 minutes and during administration.

– Use enough!– Use the 4 mg strength for

those who smoke more than 1 pack per day.

– Continue the trial for at least 6 weeks.

1 Rakel and Rakel, Textbook of Family Medicine

What medications are helpful?1

• Nicotine Lozenge (Commit)– The effect lasts 20-30

minutes– Do not eat or drink 15

minutes before or during use.

– Use up to 20/day for up to 12 weeks.

– The side effects are similar to those with nicotine gum (sore teeth, throat, gums, indigestion)

• Nicotine Inhaler (Nicotrol Inhaler)– Use up to 16

cartridges/day for 12 weeks, then taper and discontinue over the next 12 weeks.

– Each cartridge is equivalent to 2 cigarettes.

– Nicotine delivery declines in cold temperatures.

1 Rakel and Rakel, Textbook of Family Medicine

What medications are helpful?1

• Nicotine Nasal Spray (Nicotrol NS)– Do not use if you have

severe restrictive airway disease.

– Do not sniff, inhale or swallow when you spray.

– Tilt your head slightly back when spraying.

– Spray once in each nostril up to 40 times/day for 12 weeks.

• Bupropion SR– Start 2 weeks before

quitting.– Take 150 mg every

morning for 3 days, then BID for 12 weeks.

– Do not use if you have a history of head trauma, seizures or if you have used a MAOI in the past 14 days.

– Side effects include nausea, bad dreams, insomnia, headache and flatulence.

1 Rakel and Rakel, Textbook of Family Medicine

What medications are helpful?1

• Varenicline(Chantix)– Start 1 week before

you plan to quit.– Take 0.5 mg daily for 3

days, then BID for 4 days, then 1.0 mg daily for total of 12 weeks.

– The side effects are similar to bupropion SR.

• Combination Therapy– This may be the best

approach.– Think of bupropion SR or

the patch as maintenance and short-acting NRT agents breakthrough drugs.

– Triple therapy (patch, bupropion SR and the inhaler) for up to 6 months has produced the best documented results.

1 Rakel and Rakel, Textbook of Family Medicine

What public health interventions actually work?1

• Enforce tobacco advertising bans.• Raise the price of tobacco products.• Provide smokers who want to quit with the

help they need.• Prevent unwanted exposure to secondhand

smoke.• Publicize the health hazards of tobacco use.• Decrease the impact of the marketers of death.• Increase the influence of anti-smoking forces.• Use attention-getting warning labels.• Read more about this problem here.

1 Rakel and Rakel, Textbook of Family Medicine

What excuses do physicians make?1

• “My patients are not motivated.”• “My patients don’t have the necessary

insurance coverage.”• “I am not reimbursed enough for my time

when treating these people.”• “I don’t have enough time to do this.”• “There are not enough resources to refer my

patients to.”• “Nothing works anyway.”• “I’m not trained to do this; this is not my

specialty.”• “I don’t like this kind of work.”

1 Rakel and Rakel, Textbook of Family Medicine

What should you do?1

• You must be the change you want to see in the world. Mahatma Gandhi

• Become a wellness champion and continue that lifestyle as long as you live.

• If you smoke or use any tobacco product, stop now.

• Support prevention efforts for kids.• Ask every new patient about tobacco use.• If they use, ask them to please stop.• Inquire whether patients who are using

tobacco are ready to stop—at every visit.1 Rakel and Rakel, Textbook of Family Medicine

What else should you do?1

• Seize every teachable moment to urge quitting.

• Make sure your users know 1-800-QUITNOW (1-800-784-8669)

• Remember, the first two weeks are critical; arrange daily phone or text follow up contacts.

• View this as a chronic disease.• Focus on what you can do instead of fretting

about what you can’t do.• Never, never, ever give up.

1 Rakel and Rakel, Textbook of Family Medicine

The Psychiatric InterviewA Patient-Centered, Evidence-Based Diagnostic and Therapeutic Process

• Introduce yourself using AIDET1.• Sit down.• Make me comfortable by asking some

routine demographic questions.• Ask me to list all of problems and concerns.• Using my problem list as a guide, ask me

clarifying questions about my current illness(es).

• Using evidence-based diagnostic criteria, make accurate preliminary diagnoses.

• Ask about my past psychiatric history.• Ask about my family and social histories.• Clarify my pertinent medical history.• Perform an appropriate mental status

examination.

• Review my laboratory data and other available records.

• Tell me what diagnoses you have made.• Reassure me.• Outline your recommended treatment

plan while making sure that I understand.

• Repeatedly invite my clarifying questions.

• Be patient with me.• Provide me with the appropriate

educational resources.• Invite me to call you with any

additional questions I may have.• Make a follow up appointment.• Communicate with my other

physicians.1Acknowledge the patient. Introduce yourself. Inform the patient about the Duration of tests or treatment. Explain what is going to happen next. Thank your patients for the opportunity to serve them.

Where can you learn more?

• American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000

• Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 2008

• Stern, et. al., Massachusetts General Hospital Comprehensive Clinical Psychiatry, 2008. You can read this text online here.

• Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 2007• Stead, L, Stead, SM and Kaufman, M,

First Aid© for the Psychiatry Clerkship, Second Edition, March 2005• Klamen, D, and Pan, P,

Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition, March 20093

• Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007• Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, January

2008• Medina, John,

Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, February 2008

• Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000• Order the Kindle version of the Rakel and Rakel Textbook of Family Medicine here.

Where can you find evidence-based information about mental disorders?

• Explore the site maintained by the organization where evidence-based medicine began at McMaster University here.

• Sign up for the Medscape Best Evidence Newsletters in the specialties of your choice here.

• Subscribe to Evidence-Based Mental Health and search a database at the National Registry of Evidence-Based Programs and Practices maintained by the Substance Abuse and Mental Health Services Administration here.

• Explore a limited but useful database of mental health practices that have been "blessed" as evidence-based by various academic, administrative and advocacy groups collected by the Iowa Consortium for Mental Health here.

• Download this presentation and related presentations and white papers at www.KendallLStewartMD.com.

• Learn more about Southern Ohio Medical Center and the job opportunities there at www.SOMC.org.

• Review the exceptional medical education training opportunities at Southern Ohio Medical Center here.

How can you contact me?1

Kendall L. Stewart, M.D.VPMA and Chief Medical OfficerSouthern Ohio Medical Center

Chairman & CEOThe SOMC Medical Care Foundation, Inc.

1805 27th StreetWaller Building

Suite B01Portsmouth, Ohio 45662

740.356.8153

StewartK@somc.org KendallLStewartMD@yahoo.com

www.somc.orgwww.KendallLStewartMD.com

1Speaking and consultation fees benefit the SOMC Endowment Fund.

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Are there other questions?

Thomas Carter, DO

Justin Greenlee, DO