july 2006 treating tobacco use and dependence. learning objectives at the end of this session you...
TRANSCRIPT
July 2006
Treating Tobacco Use and Dependence
Learning Objectives
At the end of this session you should understand:
The impact of tobacco dependence
Tobacco dependence as a chronic disease
Clinical interventions for tobacco users willing to quit
Clinical interventions for tobacco users not willing to make a quit attempt
Why should I treat tobacco dependence?
Tobacco causes premature death of almost half a million Americans each year
1/3 of all tobacco users in this country will die prematurely from tobacco dependence losing an average of 14 years
70% of smokers see a physician each year
70% of smokers want to quit
Are physicians intervening in tobacco use?
In 38 primary care practices:
Tobacco was discussed in 21% of encounters.
Discussion was:
− more common in the 58% of practices with standard forms for recording smoking status
− more common during new patient visits
− less common with older patients
− less common with physicians in practice more than 10 years.
Ellerbeck, Ahluwalia, et al. Direct observation of smoking cessation activities in primary care practice. J Fam Pract. 2001;50:688-693
Barriers to treating tobacco dependence
“Not enough time.”
“Patients don’t want to hear about it.”
“I can’t help patients stop.”
“Not enough time”
“Minimal interventions lasting
less than 3 minutes increase overall tobacco abstinence rates.”
The PHS Guideline
(Strength of Evidence = A)
“Patients don’t want to hear about it”
“Smoking cessation interventions during physician visits were associated with increased patient satisfaction with their care among those who smoke.”
1,898 patients in a study who reported that they had been asked about tobacco use or advised to quit during the latest visit had 10%greater satisfaction rating and 5% less dissatisfaction than those not reporting such discussions
Mayo Clin Proc. 2001;76:138-143.
“I can’t help patients stop”
Effective clinical interventions exist:
The Public Health Service Clinical Practice Guideline Treating Tobacco Use and Dependence was published in June, 2000 and offers effective treatments for tobacco dependence.
Tobacco dependence is achronic disease
Tobacco dependence requires ongoing rather than acute care
Relapse is a component of the chronic nature of the nicotine dependence — not an indication of personal failure by the patient or the clinician
Tobacco results in a true drug dependence
Tobacco dependence exhibits classic characteristics of drug dependence
Nicotine is:– Causes physical dependence characterized by
withdrawal symptoms upon cessation
– Psychoactive
– Tolerance producing
How do I treat tobacco users who are willing to quit?
The 5 A’sFor Patients Willing To Quit
ASK about tobacco use.
ADVISE to quit.
ASSESS willingness to make a quit attempt.
ASSIST in quit attempt.
ARRANGE for follow-up.
ASK
VITAL SIGNS Blood Pressure: _______________________________ Pulse: ________________ Weight: _______________ Temperature: ________________________________ Respiratory Rate: _____________________________ Tobacco Use: Current Former Never (circle one)
EVERY patient at EVERY visit
ADVISE
Once tobacco use status has been identified and documented, advise all tobacco users to quit
Even brief advice to quit results in greater quit rates
Advice should be:- clear - strong- personalized
“As your health care provider, I must tell you that the most important thing you
can do to improve your health is to stop smoking.”
ASSESS
After providing a clear, strong, and personalized message to quit, you must determine whether the patient is willing to quit at this time.
“Are you willing to try to quit at this time? I can
help you.”
ASSIST
Help develop a quit plan
Provide practical counseling
Provide intra-treatment social support
Help your patient obtain extra-treatment social support
Recommend pharmacotherapy except in special circumstances
Provide supplementary materials
Developing a quit plan
Set a quit date Review past quit attempts Anticipate challenges Remove tobacco products Avoid
– Alcohol use
– Exposure to tobacco
How do I counsel patients to quit?
Counsel your patients to quit
“Minimal interventions lasting less than 3 minutes increase overall tobacco abstinence rates”
The PHS Guideline
(Strength of Evidence = A)
“There is a strong dose-response relation between the session length of person-to- person contact and successful treatment outcomes. Intensive interventions are more effective than less intensive interventions and should be used whenever possible.”
The PHS Guideline
(Strength of Evidence = A)
What pharmacotherapies are available to ASSIST in the quit attempt?
By using the pharmacotherapies found to be effective in the PHS Guideline, you can double or triple your patients’ chances of abstinence.
First-line pharmacotherapies
Bupropion SR (Zyban, Welbutrin)
Nicotine gum
Nicotine inhaler
Nicotine nasal spray
Nicotine lozenge
Nicotine patch
Varenicline (Chantix)
Bupropion SR
One of two non-nicotine medications approved by the FDA as an aid to smoking cessation treatment
Available by prescription only (USA)
Mechanism of action: presumably blocks neural reuptake of dopamine
Bupropion SR
Contraindications:− Seizure disorder− MAO inhibitor used within previous 2 weeks− Hx of anorexia nervosa or bulimia− Current use of Wellbutrin
Side effects:− Insomnia− Dry mouth
Bupropion SR
Dosing: − start 1-2 weeks before quit date− 150 mg orally once daily x 3 day− 150 mg orally twice daily x 7-12 weeks− no taper necessary at end of treatment
Maintenance:− efficacious as maintenance medication for <6
months post-cessation
Varenicline (Chantix)
New medication was FDA-approved in May 2006and on the market July 2006
Varenicline, a pill, is available by prescription only
Varenicline is neither a nicotine replacement therapy nor an anti-depressant drug
Unique: Varenicline acts on nicotine receptors with two types of action: It blocks some of the rewarding effects of nicotine (acts as an antagonist) and at the same time stimulates the receptors in a way that reduces withdrawal (acts as an agonist).
Varenicline (Chantix)
Side Effects: Generally well tolerated The most common side effects are nausea, headache, trouble sleeping and abnormal dreams
Dosage: Start varenicline one week before the quit date for maximum
effectiveness. Recommended treatment is 12 weeks: – ⇒ Days 1-3: …………….1 pill (0.5 mg) per day; – ⇒ Days 4-7: …………….1 pill (0.5 mg) twice a day (a.m. and p.m.) – ⇒ Day 8 to the end: ……1 pill (1 mg) twice a day (a.m. and p.m.)
For best results, quit smoking on Day 8
An additional course of 12 weeks for maintenance can be considered. Pfizer pre-packages Chantix so the pills are laid out day-by-day, in a “Starting Month” package (four weeks) and “Continuing Month” packages thereafter.
Varenicline (Chantix)
Precautions: Use with caution and consider dose reduction in
patients:– With significant renal impairment– Undergoing dialysis
Cost Varies: Cost varies, but it is approximately $120 per month
($4 per day). Varenicline is covered by many health care plans.
Nicotine Replacement Therapy (NRT)
Nicotine is active ingredient
Supplied as steady dose (patch) or self-administered (gum, inhaler, nasal spray)
Self-administered products should be used on scheduled basis initially before tapered to ad lib use and eventual discontinuation
Nicotine Replacement Therapy (NRT)
No evidence of increased cardiovascular risk with NRT
Medical contraindications:− immediate myocardial infarction (< 2 weeks)− serious arrhythmia− serious or worsening angina pectoris− accelerated hypertension
Nicotine Replacement Therapy (NRT)
Nicotine gum
Nicotine patch
Nicotine inhaler
Nicotine nasal spray
Nicotine lozenge
Nicotine gum
2 mg vs. 4 mg
Chew and park
Absorbed in a basic environment
Use enough pieces each day
Nicotine patch
Available as both prescription and OTC
A new patch is applied each morning
Rotating placement site can reduce irritation
Nicotine inhaler
Available by prescription
Frequent puffing is required
Eating or drinking before and during administration should be avoided
Nicotine nasal spray
Available by prescription
Patient should not sniff, swallow, or inhale the medication
Initial dosing should be 1 to 2 doses per hour, increasing as needed
Dosing should not exceed 40 per day
Nicotine lozenge
Available over the counter
− Treatment period is up to 12 weeks
− Lozenges should not be chewed or swallowed, but should slowly dissolve in the mouth
− Dosage: 2mg or 4 mg (if smoke less than 30 minutes after waking)
− Use lozenges on a regular schedule, using at least 9 lozenges per day during the first 6 weeks
Combination Pharmacotherapy
Combination NRT
− Patch + gum or patch + nasal spray are more effective than a single NRT
− Encourage use in patients unable to quit using single agent
− Caution patients on risk of nicotine overdose
− Currently, not an FDA-approved treatment option
ARRANGE
Schedule a follow-up contact within one week after the quit date− Telephone contact− Quit lines
The majority of relapse occurs in the first two weeks after quitting
The Quit Line and the 5 A’s
ASK about tobacco use.
ADVISE to quit.
ASSESS willingness to make a quit attempt.
ASSIST in quit attempt.
ARRANGE follow-up.
Preventing Relapse– Congratulate success– Encourage continued abstinence– Discuss with your patient:
benefits of quitting barriers
If your patient has used tobacco, remind him or her that the relapse should be viewed as a learning experience
Relapse is consistent with the chronic nature of tobacco dependence; not a sign of failure
Relapse
“How has stopping tobacco use helped
you?”
How do I treat tobacco users who are not willing to make a quit attempt?
Treating patients who are not ready to make a quit attempt
RELEVANCE: Tailor advice and discussion to each patient.
RISKS: Outline risks of continued smoking.
REWARDS: Outline the benefits of quitting.
ROADBLOCKS: Identify barriers to quitting.
REPETITION: Reinforce the motivational message at every visit.
Encourage continuedabstinence
Prevent relapse
Promote motivation
to quit(5 Rs)
Provide appropriate treatments
(5 As)
Assessment of Tobacco Use
Patient presents to a health care provider
Does patient currently use tobacco?
Is the patient currently willing to quit?
Did the patient previously
use tobacco?
YES
YES YES
NO
NO NO
Web Sites
USPHS Guideline and materials: www.surgeongeneral.gov/tobacco
Wisconsin Tobacco Control: www.tobwis.org
UW-Center for Tobacco Research & Intervention: www.ctri.wisc.edu
www.ctri.wisc.edu
“Not since the polio vaccine has this nation had a better opportunity to make a significant impact in public health.”
David Satcher, MD, PhD,Former U.S. Surgeon General