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Copyright Alcohol Medical Scholars Program1 Assessment and Pharmacological Treatment of Tobacco Dependence Jill Williams, M.D. Associate Professor of Psychiatry.

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Presentation on theme: "Copyright Alcohol Medical Scholars Program1 Assessment and Pharmacological Treatment of Tobacco Dependence Jill Williams, M.D. Associate Professor of Psychiatry."— Presentation transcript:

1 Copyright Alcohol Medical Scholars Program1 Assessment and Pharmacological Treatment of Tobacco Dependence Jill Williams, M.D. Associate Professor of Psychiatry UMDNJ-Robert Wood Johnson Medical School, UMDNJ-School of Public Health

2 Copyright Alcohol Medical Scholars Program2 Smoking = Big Health Problem ~50% of smokers try to quit/ year Advice from MD ↑ quitting Double success with treatment But….Treatment Improves Outcomes #1 preventable cause morbidity/ mortality 1 in 5 deaths in US

3 Copyright Alcohol Medical Scholars Program3 This Lecture will Cover Epidemiology /consequences Nicotine pharmacology Assessment Pharmacological treatments

4 Copyright Alcohol Medical Scholars Program4 Epidemiology of Tobacco Use Cigarettes > 95% of all tobacco use >1 billion tobacco users worldwide Stable or ↓ in US/ developed nations Increasing in developing countries Higher rates in ↓ SES

5 Copyright Alcohol Medical Scholars Program5 Smoking Prevalence Rates

6 Copyright Alcohol Medical Scholars Program6 Women and Smoking Rates men ~ women Highest in those living below the poverty level Lung cancer # 1 cancer death MMWR 1993 Cancer Death Rates in Women after 1950

7 Copyright Alcohol Medical Scholars Program7 Smoking A Pediatric Epidemic > 5 million children will die prematurely from cigarettes Most adults started < age 18 During grades 6-9 If start age  1.6x more dependence

8 Copyright Alcohol Medical Scholars Program8 Tobacco-Caused Illness ~90% of all lung cancers ~100% COPD 2X death from stroke/ CAD Half of all smokers die from a tobacco-caused disease Surgeon General’s Report 2004

9 Copyright Alcohol Medical Scholars Program9 Other Consequences Other Cancers Oral Esophagus (cigars/ chew) Cervix Bladder Pancreas (cigars) Costs > $100 billion annually Primary cause of fatal house fires

10 Copyright Alcohol Medical Scholars Program10 It’s the Smoke that Kills Cigarette smoke > 4000 compounds Acetone, Cyanide, Carbon Monoxide, Formaldehyde > 60 Carcinogens Benzene, Nitrosamines ( CDC 2003)

11 Copyright Alcohol Medical Scholars Program11 Environmental Tobacco Smoke ETS is a known human carcinogen (Class1A), in the same class as asbestos 50,000 additional deaths/ year in non-smokers ~3000 from lung cancer

12 Copyright Alcohol Medical Scholars Program12 This Lecture will Cover Epidemiology /consequences Nicotine pharmacology Assessment Pharmacological treatments

13 Copyright Alcohol Medical Scholars Program13 Nicotine Pharmacology Pharmacology depends on delivery route Reaches brain in 10 sec Arterial levels 6-10x higher than venous Half-life 2 hours Metabolized to cotinine in liver

14 Copyright Alcohol Medical Scholars Program14 Russell et al., BMJ, 1983

15 Copyright Alcohol Medical Scholars Program15 Nicotine Possible therapeutic effects: Alzheimer's Attention deficit disorder Autism Schizophrenia Ulcerative colitis

16 Copyright Alcohol Medical Scholars Program16 Nicotine Safety Smokers misinformed about safety/efficacy of nicotine Not a carcinogen Not a significant risk factor for cardiovascular events Risk-benefit ratio supports nicotine medications over using tobacco

17 Copyright Alcohol Medical Scholars Program17 This Lecture will Cover Epidemiology /consequences Nicotine pharmacology Assessment Pharmacological treatments

18 Copyright Alcohol Medical Scholars Program18 Nicotine Dependence –withdrawal –tolerance –desire or efforts to cut down/ control use –great time spent in obtaining/using –reduced occupational, recreational activities –use despite problems –larger amounts consumed than intended ≥ 90% smokers meet dependence criteria

19 Copyright Alcohol Medical Scholars Program19 Nicotine Withdrawal Depressed mood Insomnia Irritability, frustration or anger Anxiety Difficulty concentrating Restlessness Decreased heart rate Increased appetite or weight gain

20 Copyright Alcohol Medical Scholars Program20 Heaviness of Smoking Index= Measure of Dependence Number of cigarettes per day (cpd) AM Time to first cigarette (TTFC ) ≤ 30 minutes = moderate ≤ 5 minutes = severe (Heatherton 1989)

21 Copyright Alcohol Medical Scholars Program21 Hard to Quit Without Treatment 70% of smokers want to quit Few quit without treatment < 1/3 remain abstinent for 2 days < 5% ultimately successful per quit attempt

22 Copyright Alcohol Medical Scholars Program22 Role of Physician 5As Ask, Advise, Assess, Assist, Arrange Brief physician advice ↑ quitting 10% quit rates with < 3 minutes 20% quit rates >10 minutes Tobacco dependence = chronic condition < 25% successful on first attempt > 8 quit attempts before successful

23 Copyright Alcohol Medical Scholars Program23 This Lecture will Cover Epidemiology /consequences Nicotine pharmacology Assessment Pharmacological treatments

24 Copyright Alcohol Medical Scholars Program24 Pharmacological Treatment Rationale Reduce or eliminate withdrawal Block reinforcing effects of nicotine Manage negative mood states Unlearn smoking behaviors Cost-effective treatment

25 Copyright Alcohol Medical Scholars Program25 Pharmacological Treatment Nicotine Replacement Patch Gum Lozenge Inhaler Nasal Spray Bupropion Varenicline

26 Copyright Alcohol Medical Scholars Program26 Nicotine Replacement Therapy (NRT) Nicotine absorption poorer than cigs Lower dose delivered Poorly orally absorbed; ↑ first pass metabolism Less rewarding than smoking Under dosing common Worsened by poor compliance

27 Copyright Alcohol Medical Scholars Program27 Few Contraindications to NRT With caution if: Recent MI Smokes < 10 cpd Pregnant/breastfeeding Adolescents (Not FDA approved) Mild side effects Mostly local Systemic, less common

28 Copyright Alcohol Medical Scholars Program28 Nicotine Patch Slow onset Continuous delivery 24 or 16 hour dosing Easy, good compliance Gradual taper Side effects- skin, insomnia OTC

29 Copyright Alcohol Medical Scholars Program29 Nicotine Gum Use every 1 hour Bite and “park” Slow, buccal absorption Acidic foods ↓ absorption Slight mouth, throat burning Dose: 2mg < 25 cpd 4mg > 25 cpd OTC

30 Copyright Alcohol Medical Scholars Program30 Nicotine Lozenge Don’t chew 2 and 4mg dose Up to 20 lozenges/ daily Dose based on TTFC 2mg if > 30 mins 4 mg< 30 mins OTC; No generics

31 Copyright Alcohol Medical Scholars Program31 Nicotine Inhaler 6-16 cartridges/day Puff for minutes Misnomer (Oral puffer) Acidic foods ↓ absorption Slight throat irritation, cough Rx needed

32 Copyright Alcohol Medical Scholars Program32 Nicotine Nasal Spray Rapid delivery Most side effects (nasal irritation, rhinitis, coughing, watering eyes) 2 sprays= 1 dose Up to 40 doses/day Some dependence liability Rx needed

33 Copyright Alcohol Medical Scholars Program33 Bupropion SR Nonsedating/ activating Affects NE and DA, nicotine receptor Side effects- headache, insomnia Don’t use: seizures/ eating disorder Start days prior to quit date 300mg dose has least weight gain Rx needed

34 Copyright Alcohol Medical Scholars Program34 Efficacy of Medications NRT 2x success vs. placebo 25-30% Efficacy Efficacy NRT ≃ bupropion Patient preference, cost, tolerability Combinations Improve Outcomes

35 Copyright Alcohol Medical Scholars Program35 Varenicline Nicotinic partial agonist 1mg BID dose superior to placebo or bupropion in 12 week trials Additional 12 weeks prevented relapse Nausea, headache, insomnia and abnormal dreams- most common side effects Discontinuation rate similar to placebo Gonzales et al., 2006; Tonstad et al., 2006; Jorenby et al., 2006

36 Copyright Alcohol Medical Scholars Program36 Conclusions It’s the smoke that kills – not the nicotine All practitioners should treat tobacco Treatments ↑success Six FDA approved treatments: effective and well tolerated

37 Copyright Alcohol Medical Scholars Program37 Free Resources 1. PHS Guidelines tobacco_use.pdf/ 2. Surgeon General Report (2004) smokingconsequences/


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