practical smoking cessation allan prochazka, m.d., m.sc. denver vamc
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Practical Smoking CessationPractical Smoking Cessation
Allan Prochazka, M.D., M.Sc.Allan Prochazka, M.D., M.Sc.
Denver VAMCDenver VAMC
OutlineOutline
5 A’s Approach5 A’s Approach– AskAsk– AdviseAdvise– AssessAssess– AssistAssist– ArrangeArrange
AHQR GuidelinesAHQR Guidelines
Released 6/00Released 6/00 Based on review of > 3,000 studiesBased on review of > 3,000 studies Nearly all are RCT’sNearly all are RCT’s Probably the most evidence-based guideline Probably the most evidence-based guideline
in medicinein medicine Resulted in the 5A’s approachResulted in the 5A’s approach
AskAsk
Ask all patients at each visit whether they Ask all patients at each visit whether they smokesmoke
Why every visit?Why every visit?– Relapse among ex-smokers occurs even years Relapse among ex-smokers occurs even years
after quittingafter quitting Makes smoking salient for patients and Makes smoking salient for patients and
providersproviders Triggers quit attempts by patients and Triggers quit attempts by patients and
advice/interventions by providersadvice/interventions by providers
ImplementationImplementation
Electronic recordsElectronic records– VA is all electronic, reminders are VA is all electronic, reminders are
automatically triggered, documentation of automatically triggered, documentation of smoking status and advice is a performance smoking status and advice is a performance measure for the hospital directormeasure for the hospital director
Paper SystemPaper System» Decide who will be responsible and how one will Decide who will be responsible and how one will
track compliancetrack compliance
AdviseAdvise
Strongest data are for physician adviceStrongest data are for physician advice– Other clinicians also likely to be effectiveOther clinicians also likely to be effective
Ideal to have a consistent approach across Ideal to have a consistent approach across providers to reinforce the messageproviders to reinforce the message– Patients will receive advice from multiple Patients will receive advice from multiple
sourcessources
Simple, direct messageSimple, direct message– ‘‘I’m your (doctor, nurse, therapist, health I’m your (doctor, nurse, therapist, health
educator…) and the best thing you can do for educator…) and the best thing you can do for your health is to quit smoking’your health is to quit smoking’
Avoid equivocationAvoid equivocation– ‘‘You might want to think about someday You might want to think about someday
perhaps considering quitting smoking’perhaps considering quitting smoking’
Increasing Advice EffectivenessIncreasing Advice Effectiveness
Link to patient’s healthLink to patient’s health– Make the connection to other health problemsMake the connection to other health problems
» Asthma/Bronchitis/EmphysemaAsthma/Bronchitis/Emphysema» Heart diseaseHeart disease» Reflux, ulcersReflux, ulcers» Skin changesSkin changes» Vision—macular degenerationVision—macular degeneration» Diabetes—accelerating effect of smoking on renal Diabetes—accelerating effect of smoking on renal
dysfunction, cardiovascular effectsdysfunction, cardiovascular effects» Peripheral Vascular DiseasePeripheral Vascular Disease
Use Ancillary Testing to Enhance Use Ancillary Testing to Enhance Motivation to QuitMotivation to Quit
– Pulmonary function testing and lung agePulmonary function testing and lung age» Portable units have greatly increased test qualityPortable units have greatly increased test quality
» $500 - $1500, can be billed$500 - $1500, can be billed
– Expired carbon monoxide testingExpired carbon monoxide testing» Instant feedbackInstant feedback
» No teaching required on meaning of CONo teaching required on meaning of CO
» Low initial costs ($500-800)Low initial costs ($500-800)
AssessAssess
Identify willingness to quitIdentify willingness to quit– Do you want to quit smoking?Do you want to quit smoking?– If yes, when do you want to quit?If yes, when do you want to quit?
» If ready now, then provide assistance on quitting at If ready now, then provide assistance on quitting at this visit and deal with other problems at the next this visit and deal with other problems at the next visitvisit
» If not ready, then work on motivation and on If not ready, then work on motivation and on barriersbarriers
AssessAssess
Identify Tobacco DependenceIdentify Tobacco Dependence– DSM IV R criteriaDSM IV R criteria
» Withdrawal with cessationWithdrawal with cessation
» Smoking in the face of medical illnessSmoking in the face of medical illness
– FagerstromFagerstrom» How soon after awakening do you smoke your first How soon after awakening do you smoke your first
cigarette?cigarette?
» If < 5 minutes, then highly dependentIf < 5 minutes, then highly dependent
Why bother with dependence?Why bother with dependence?– Reminder to providersReminder to providers– Identifies those who surely need more than Identifies those who surely need more than
adviceadvice– Reminder to patients when the diagnosis is Reminder to patients when the diagnosis is
shared with themshared with them
Increasing MotivationIncreasing Motivation
RelevanceRelevance RisksRisks Rewards Rewards RoadblocksRoadblocks RepetitionRepetition
RelevanceRelevance– Personalize the effects of smokingPersonalize the effects of smoking
– Consider influence on family members (e.g. parents Consider influence on family members (e.g. parents smoking aggravating child’s asthma)smoking aggravating child’s asthma)
RisksRisks– Generic risks are not as influential as personal riskGeneric risks are not as influential as personal risk
– Short term risks are more salient than long term risks, Short term risks are more salient than long term risks, especially for young peopleespecially for young people
– Risks without benefits, sometimes lead to paralysis, so Risks without benefits, sometimes lead to paralysis, so emphasize the improvements that are possibleemphasize the improvements that are possible
RewardsRewards
PersonalPersonal– Taste/smell improveTaste/smell improve– Clothes, home, breath smell betterClothes, home, breath smell better
HealthHealth– Improvement in current medical conditionsImprovement in current medical conditions– Avoidance of complicationsAvoidance of complications
EconomicEconomic– Out of pocket costs of smoking can be significant expense for Out of pocket costs of smoking can be significant expense for
those on fixed incomethose on fixed income SocialSocial
– Example for childrenExample for children– Self-control, masterySelf-control, mastery
RoadblocksRoadblocks
Weight gainWeight gain Fear of failureFear of failure Withdrawal symptomsWithdrawal symptoms Lack of support from family/friendsLack of support from family/friends ‘‘The only thing I have left is smoking’The only thing I have left is smoking’
RepetitionRepetition
Key point is that messages need to be Key point is that messages need to be repeated over timerepeated over time
A person may not be ready to take action A person may not be ready to take action today, that doesn’t mean he/she won’t be today, that doesn’t mean he/she won’t be ready next week, next month or next yearready next week, next month or next year
Smokers also need to know that relapse Smokers also need to know that relapse after a quit attempt is normal, most will after a quit attempt is normal, most will need several solid efforts to be successfulneed several solid efforts to be successful
AssistAssist
Behavioral Behavioral Drug TherapyDrug Therapy Smokers wanting to quit need bothSmokers wanting to quit need both Dose of each one can be tailored to the Dose of each one can be tailored to the
patient’s needspatient’s needs
BehavioralBehavioral
Key element is time with patient and empathic Key element is time with patient and empathic counselorcounselor
More time, more benefit, but get results even with More time, more benefit, but get results even with small investmentssmall investments
GoalsGoals– Set a quit dateSet a quit date– Tell family, friends, coworkersTell family, friends, coworkers– Make the home smoke free, start acting like a non-Make the home smoke free, start acting like a non-
smokersmoker– Identify barriers to cessationIdentify barriers to cessation
Goal: total abstinence after quit dayGoal: total abstinence after quit day Review prior quit attempts, learn from themReview prior quit attempts, learn from them Anticipate triggers and challenges Anticipate triggers and challenges Encourage others in the home to quitEncourage others in the home to quit Provide optionsProvide options
– ReferralReferral– QuitlineQuitline– Self-help materialsSelf-help materials
Drug TherapyDrug Therapy
Nicotine Replacement Therapy (NRT)Nicotine Replacement Therapy (NRT)– Nicotine GumNicotine Gum– Nicotine PatchNicotine Patch– Nicotine Nasal SprayNicotine Nasal Spray– Nicotine InhalerNicotine Inhaler– Nicotine LozengeNicotine Lozenge
Non-Nicotine TherapyNon-Nicotine Therapy– Bupropion (Zyban)Bupropion (Zyban)
NRTNRT
Overall success rate comparable among the Overall success rate comparable among the productsproducts
Doubles the quit rate over advice aloneDoubles the quit rate over advice alone– (e.g. 5-8% to 10-15%)(e.g. 5-8% to 10-15%)
Selection based on side effects, patient Selection based on side effects, patient preference, insurance coveragepreference, insurance coverage
PDR duration of therapy 8-12 weeksPDR duration of therapy 8-12 weeks Selected patients need longer therapy or Selected patients need longer therapy or
higher doseshigher doses
Nicotine GumNicotine Gum
2 forms (2 mg and 4mg), 4 mg best for most 2 forms (2 mg and 4mg), 4 mg best for most smokerssmokers
Available OTC and in Generic formsAvailable OTC and in Generic forms Absorption is buccal, so park and chewAbsorption is buccal, so park and chew Regular dosing better than ad libRegular dosing better than ad lib Typical patient will use 5-8 pieces per dayTypical patient will use 5-8 pieces per day Cost $35-50 for 108 piecesCost $35-50 for 108 pieces
Side EffectsSide Effects– Dental trauma, jaw pain, nausea, upset stomachDental trauma, jaw pain, nausea, upset stomach
Duration of UseDuration of Use– 8-12 weeks8-12 weeks– 2-5% have trouble quitting gum2-5% have trouble quitting gum– Long term use combined with behavioral Long term use combined with behavioral
therapy (up to 5 years) safe and effective, 25% therapy (up to 5 years) safe and effective, 25% validated quit rate in Lung Health Studyvalidated quit rate in Lung Health Study
Transdermal NicotineTransdermal Nicotine
3 strengths (21, 14, 7 mg/24hr)3 strengths (21, 14, 7 mg/24hr) Some patients require higher doses (e.g. Some patients require higher doses (e.g.
very heavy smokers), but for typical pack a very heavy smokers), but for typical pack a day smoker 21mg is the starting doseday smoker 21mg is the starting dose
4-6 weeks on 21 mg, 2-4 weeks on 14 mg, 4-6 weeks on 21 mg, 2-4 weeks on 14 mg, then 2-4 weeks on 7 mgthen 2-4 weeks on 7 mg
Costs $35-50 per 14 day supplyCosts $35-50 per 14 day supply
Side EffectsSide Effects– Skin irritation (30%)Skin irritation (30%)– Skin allergy (1-4%)Skin allergy (1-4%)– Poor sleep/nightmares (10%)Poor sleep/nightmares (10%)– Arm pain (2-4%)Arm pain (2-4%)
Nasal Nicotine SprayNasal Nicotine Spray
Very rapid absorption of nicotineVery rapid absorption of nicotine Dosing 0.5 mg per spray, one spray in each Dosing 0.5 mg per spray, one spray in each
nostril is one dose (about the amount of nostril is one dose (about the amount of nicotine in one cigarette)nicotine in one cigarette)
Typical patient uses 3-6 doses per dayTypical patient uses 3-6 doses per day Side Effects: mostly irritation, face pain, Side Effects: mostly irritation, face pain,
perhaps more likely to result in difficulty perhaps more likely to result in difficulty stopping use due to fast absorptionstopping use due to fast absorption
Costs $46.99 per 10 ml vial (100 doses)Costs $46.99 per 10 ml vial (100 doses)
Nicotine InhalerNicotine Inhaler
Each cartridge 10 mg nicotine, 4 mg Each cartridge 10 mg nicotine, 4 mg released, 2 mg absorbedreleased, 2 mg absorbed
Best with continuous puffing (80 deep Best with continuous puffing (80 deep inhalations over 20 minutes give 2 mg inhalations over 20 minutes give 2 mg nicotine)nicotine)
Dosage 6-16 cartridges per dayDosage 6-16 cartridges per day Side Effects: mouth/nose irritationSide Effects: mouth/nose irritation Costs $51.69 per 42 cartridgesCosts $51.69 per 42 cartridges
Nicotine LozengeNicotine Lozenge
Approved 11/02Approved 11/02 Available OTC, 2 mg and 4 mgAvailable OTC, 2 mg and 4 mg Allow lozenge to slowly dissolve, no chewing or Allow lozenge to slowly dissolve, no chewing or
swallowing of the lozenge—need to be careful not swallowing of the lozenge—need to be careful not to develop too much salivato develop too much saliva
20-30 minutes per lozenge20-30 minutes per lozenge Dose 20 max per dayDose 20 max per day Side effects: hiccups, nausea, stomach upset, Side effects: hiccups, nausea, stomach upset,
palpitationspalpitations Cost $42.00 for box of 72 lozengesCost $42.00 for box of 72 lozenges
Non-Nicotine TherapyNon-Nicotine Therapy
Bupropion (Zyban)Bupropion (Zyban) Antidepressant, works in normal, non-Antidepressant, works in normal, non-
depressed smokersdepressed smokers Slower onset of action (7-10 days)Slower onset of action (7-10 days) Dosage: 150 mg a day for 3 days, then 150 Dosage: 150 mg a day for 3 days, then 150
mg bid, but not much difference in mg bid, but not much difference in effectiveness between 150 and 300 mg /dayeffectiveness between 150 and 300 mg /day
Duration: 3 months, but longer term therapy Duration: 3 months, but longer term therapy is safe and effectiveis safe and effective
Costs VA $53 for one monthCosts VA $53 for one month Side EffectsSide Effects
– CommonCommon» Shaky,tremorShaky,tremor
» HeadacheHeadache
» Dry mouthDry mouth
– Rare but seriousRare but serious» SeizuresSeizures
» Avoid in those with epilepsy, active drug use, concomitant Avoid in those with epilepsy, active drug use, concomitant psychiatric medications, bulemia, MAOI usepsychiatric medications, bulemia, MAOI use
Combined with NRTCombined with NRT– Borderline significance, but 9% better with patch Borderline significance, but 9% better with patch
combined with bupropioncombined with bupropion Very useful in healthy populations (e.g. worksite) Very useful in healthy populations (e.g. worksite)
and in those with active cardiac diseaseand in those with active cardiac disease Hard to use in populations with lots of psychiatric Hard to use in populations with lots of psychiatric
comorbidity/substance abuse due to risk of comorbidity/substance abuse due to risk of seizures, precipitation of mania and need to add to seizures, precipitation of mania and need to add to already complex drug regimensalready complex drug regimens
May be better in those with a depressive tendencyMay be better in those with a depressive tendency Less weight gain than with patchLess weight gain than with patch
Has been tested in several populations Has been tested in several populations including patients with COPD, African including patients with COPD, African Americans; effect appears to be robustAmericans; effect appears to be robust
Bottom Line: very useful agent for many Bottom Line: very useful agent for many populationspopulations
ArrangeArrange
Followup greatly enhances cessation resultsFollowup greatly enhances cessation results Can be in person or on the telephoneCan be in person or on the telephone Linkage to Quitline in Colorado and other Linkage to Quitline in Colorado and other
states may allow more intensive followup states may allow more intensive followup that would usually be available in primary that would usually be available in primary care settingscare settings
Congratulate on successCongratulate on success Review lapsesReview lapses Emphasize total abstinenceEmphasize total abstinence Review drug therapyReview drug therapy Consider referral if neededConsider referral if needed
Cost EffectivenessCost Effectiveness$ per QALY$ per QALY
No NRTNo NRT NRTNRT
BriefBrief 31813181 21202120
Individual Individual IntensiveIntensive
18221822 14551455
Group IntensiveGroup Intensive 11081108 11711171
ConclusionsConclusions
Implement the 5A’sImplement the 5A’s Use combined drug and behavioral Use combined drug and behavioral
approachesapproaches Select drugs based on patient preference Select drugs based on patient preference
and associated medical conditionsand associated medical conditions Followup and allow patients to recycleFollowup and allow patients to recycle Make a long term commitmentMake a long term commitment