smoking cessation and chronic mental illness csam may 15, 2009 david kan, m.d. e-mail:...
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Smoking Cessation and Chronic
Mental Illness
CSAM
May 15, 2009
David Kan, M.D.
E-mail: [email protected] Francisco VA Medical CenterAsst. Clinical Professor, UCSF
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Overview
Epidemiology Nicotine & Tobacco
Aka: Dr. Jekyll & Mr. Hyde Smoking Cessation
Psychosocial Pharmacological
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Epidemiology Total
47.2 million adults (24.1%) were current smokers
24.8 million men and 22.4 million women. 82.4% of all smokers were everyday smokers
Age The highest rate of smoking was in 18-24 year olds: 27.9% and 25-44 year olds: 27.5%.
Smoking rates drop with Age
Source: CDC 1998 Survey
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Epidemiology Ethnicity
Native Americans/Alaska Natives: 40%,
25% of Caucasians and 24.7% of African Americans smoke.
Hispanics: 19.1% and Asians/Pacific Islanders:13.7%.
Education and income More Education = Less Smoking More Income = Less Smoking
Source: CDC Survey 1998
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Smoking Rates
22.50%
34.80%41%39.10%
55.30%59%
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
No Mental Illness Lifetime MentalIllness
Past-Month MentalIllness
Current Smoking
Lifetime Smoking
Smoking and Mental Illness, Lasser, et al. JAMA. 2000;284:2606-2610.
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Smoking Rates & Mental Illness In general 2x Non-Mentally Ill
Diagnosis In Past Month
US Population, %
Current Smokers, %
Lifetime Smokers, %
Quit Rate, %
Major Depression 4.9 44.7 60.4 26
Non Affective Psychosis 0.2 45.3 45.3 0
Drug Abuse or Dependence 1 67.9 87.5 22.4
Bipolar Disorder 0.9 60.6 81.8 25.9
National Comorbidity Study – 1989 US NHIS
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Nicotine vs. Tobacco
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Nicotine
Ideal CNS DrugVery EffectiveVery Safe
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Neurochemical Effects
Slide Courtesy: David Sachs, M.D.
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Why Cigarettes?Ideal Drug Delivery SystemVery Rapid DeliveryHigh DoseHighly Concentrated
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What is the Problem with Cigarettes?
Toxic Delivery System
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SMOKE is the PROBLEMNOT NICOTINE!!!
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Smoking Related Illness
1/3rd of Smokers will die prematurely of tobacco-related illness
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Tobacco – Drug Interactions Pharmacokinetic
Polycyclic aromatic hydrocarbons (PAHs) are some of the major lung carcinogens found in tobacco smoke
PAHs - potent inducers of the hepatic cytochrome P-450 (CYP) isoenzymes 1A1, 1A2, and, possibly, 2E1
CYP 1A2 – largest effect
Kroon, L “Drug interactions with smoking.” Am J Health Syst Pharm. 2007 Sep 15;64(18):1917-21
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Tobacco – Drug Interactions
Drugs Affected Clozapine Fluvoxamine Olanzapine Caffeine Tacrine
UP TO 50% REDUCTION IN BLOOD LEVELS
Kroon, L “Drug interactions with smoking.” Am J Health Syst Pharm. 2007 Sep 15;64(18):1917-21
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Tobacco – Drug Interactions
Hormone Contraceptives Increased risk of Stroke and Heart Attack
Inhaled Corticosteroids Decreased Efficacy
Kroon, L “Drug interactions with smoking.” Am J Health Syst Pharm. 2007 Sep 15;64(18):1917-21
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What About Quitting?
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Tobacco Dependence In Perspective Approximately 35% try to quit each year 70% to 80% try to quit “cold turkey”
Most Relapse — 95%
Cold turkey quit rates at 1 year are 5%
Physician-assisted quit rates (short-term counseling + medications) at 1 year are 10% to 30%
Fiore MC, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: US Dept of Health & Human Services. Public Health Service. June 2000. (www.surgeongeneral.gov/tobacco/default.htm)
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Disease Model of Tobacco Dependence
Acute Disease Short-Term Disorder Severe Sudden in Onset Single, Time-limited intervention
Examples: Common Cold Broken Bone
Chronic Disease Long-Term Disorder Periods of relapse and remission
Requires ongoing rather than acute care
Examples: Diabetes Hypertension Addiction
Smoking!
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Psychiatric Conditions Psychiatric Conditions
2x as likely to smoke
Depressed Smokers More Depression less likely to quit
Psychiatric Conditions Data mixed or lacking as to long-term outcomes
Many studies show interventions work as well as with those not mentally ill
Ranny, et al: Systematic review: smoking cessation intervention strategies for adults and adults in special populations. Ann Intern Med. 2006 Dec 5;145(11):845-56. Epub 2006 Sep 5. Review.
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Substance Abuse
Alcohol & Tobacco Alcohol Use Triggers / exacerbates tobacco use
Quitting both led to higher quit rates for both
Joseph, AM et al A randomized trial of concurrent versus delayed smoking intervention for patients in alcohol dependence treatment. Stud Alcohol. 2004 Nov;65(6):681-91
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Indications for Longer/More Intensive Treatment High Nicotine Dependence
FTQ >5
High Serum Cotinine >250ng/ml
Depression Beck Depression Inventory > 9
Smoker in Household Decreases chances by 50%
Sachs DPL. “Tobacco Dependence: Pathophysiology & Treatment” Pulmonary Rehabilitation Guidelines to Success, 3rd Edition 2000:261-301
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Indications for Longer/More Intensive Treatment Smoking Initiation at Younger Age
<17 years old
Heavy Smoker >1 Pack Per Day
# of Prior quit attempts
Alcohol or Drug Abuse
Psychotic Spectrum Illness
Sachs DPL. “Tobacco Dependence: Pathophysiology & Treatment” Pulmonary Rehabilitation Guidelines to Success, 3rd Edition 2000:261-301
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Treatment Recommendations
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Psychosocial Interventions Counseling
Behavioral Therapy
Quit Line (1-800-NO-BUTTS)
Motivational Enhancement
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FDA Approved Medications CONTROLLER MEDICATIONS
Bupropion SR (Zyban, Wellbutrin SR, Wellbutrin XL)
Nicotine Patch Varenicline (Chantix)
RESCUE MEDICATIONS Nicotine Inhaler Nicotine Nasal Spray - Fastest Nicotine Polacrilex Gum (Nicorette) – pH dependent
Nicotine Polacrilex Lozenge (Commit) – pH dependent
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Slide Courtesy: David Sachs, MD
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Success Strategies
Combined Strategies Behavioral + Medication
Always at least 1 controller
Almost always need Rescue
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Nicotine Replacement“Clean vs. Dirty”1
Start with Patch
Add lozenge, gum, nasal spray, inhaler
Target 30-60 days smoke free prior to tapering Taper short acting first
Weeks to YEARS!1. Peter Banys, MD – Personal Communication
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Nicotine Replacement Dosing?
80% of 1-PPD smokers not adequately replaced with 21mg nicotine patch
Clear Dose-Response Curve1
Serum Cotinine 24-Hour half-life of nicotine metabolism Dose to level
No absolute maximum
10-15% smoke free at one year
1. Sachs DPL. J Smoking-Related Dis 1994;5: 183-193
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Bupropion(Wellbutrin/Zyban) Mechanism
Affects dopaminergic projections
Dosing Start 1 week before quit date 150mg SR x 3-6 days then 150mg BID Psychosocial treatment recommended
Contraindications Seizure Disorder Eating Disorder
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Bupropion(Wellbutrin/Zyban) Common SE
Insomnia – 28-35% vs. 22%* Headache – 30% vs. 28% Dry Mouth – 15% vs. 5%* Dizziness – 8-9% vs. 8% Nausea – 5-7% vs. 5%
Uncommon SE Seizures (1/1000 patients) Psychosis Hypertension Suicidal Ideation
* Statistically significant
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Varenicline(Chantix) Mechanism
Α4β2 - Nicotinic Receptor Partial Agonist
Dosing 0.5mg PO qd x 3 days 0.5mg PO BID x 4 days 1mg BID thereafter Quit date is day #8
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Varenicline(Chantix)
Duration3 months initial6 months total (if pt. can get 10 days smoke-free in first 3 months
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Varenicline Warnings Common SE:
Nausea Abnormal Sleep / Dreams Dizziness Fatigue
Uncommon AE but reported: Aggressive and erratic behavior Suicidal thoughts Possible suicide attempts
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Varenicline vs. BupropionWeeks 9-52 Abstinence
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Varenicline Maintenance
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Conclusions & Recommendations
1. Tobacco Use is the #1 preventable cause of death
2. Psychiatric Patients carry a large disease burden both medical and physical
3. Tobacco is the problem - NOT Nicotine
4. Tobacco Use Disorder is a Chronic Illness needing repeated intervention
5. Smoking Cessation Works6. Combine your treatments