1. SMOKING CESSATION Leading Preventable Cause of Death 400,000 to 500,000 deaths per year in USA 3 Million deaths world wide 1 of every 6 deaths in USA Directly attributable to smoking Yet — 46 Million continue to smoke

3. SMOKING “A cigarette is a finely tuned drug delivery system” Katherine E. Hartman, MD

4. SMOKING “ Smoking is not a bad habit --- It is a chronic medical condition” Michael C. Fiore, MD

5. SMOKING CESSATION Why do we smoke? Why should we stop/benefits? How do we stop?

6. Nicotine Dependence slide “As an addictive substance, nicotine, on a milligram for milligram basis, is 10 times more potent than heroin…” Sachs DPL. Advances in Smoking Cessation Treatment In: Simmons, ed. Current Pulmonology, Chicago; Year Book Medical Publishers, 1991, 12:139-198

9. SMOKING CESSATION Why Do We Smoke? 3-Pronged Dependency Physiological Psychological Behavioral

10. Why Do We Smoke? Physiological Nicotine to brain – 7 seconds Binds to nicotine receptors resulting in secretion of Dopamine Causes a pleasurable sensation and cognitive arousal

11. Physiological Increased Levels of: Norepinephrine Beta-Endorphin Acetylcholine Serotonin Glutamate Vasopressin

12. Physiological Enhance: –Concentration –Alertness –Memory Decrease: –Tension –Anxiety Promotes feeling of well being

13. SMOKING CESSATION Why should we stop smoking? Benefits: General Cardio-cerebrovascular Cancer Pulmonary

14. SMOKING CESSATION Long term tobacco use raises the risk of premature death by 50% * Quitting at any age increases longevity Those who quit smoking by age 50 decrease their risk of dying over the next 15 years by 50% compared with those who do not stop ** * W.H.O. Tobacco Dependency Fact Sheet #222 1999 ** U.S. Dept of Health & Human Services publication #90-8416

15. SMOKING CESSATION Why should we stop smoking? Benefits: General Cardio-cerebrovascular Cancer Pulmonary

16. Why should we stop smoking? 30% of all Cancer Deaths related to Smoking 4000 Chemicals in Tar –43 Carcinogenic

17. Why should we stop smoking? Lung Cancer – Most Common in Cancer –Oral9 fold increase –Throat9 fold increase –Esophagus75% in smokers –Bladder7 fold increase –Kidney5 fold increase –Pancreas2 fold increase –Stomach1.5 fold increase

18. Why should we stop smoking? Lung Cancer Life Long risk in Non-Smoker – 1% 15-25% risk in heavy smokers Each Cigarette cuts 6 minutes off of life

19. SMOKING CESSATION Why should we stop smoking? Benefits: General Cardio-cerebrovascular Cancer Pulmonary

20. How Do We Stop Smoking? Problems Patient Motivation Physician Interest Medications Support Systems

21. SMOKING CESSATION Patient Motivation 70% want to quit 2 large studies Appropriate moment

22. SMOKING CESSATION The Right Moment Acute MI InterventionMinimal 55% 34% Dornelas, E.A. Prev Med 2000; 30, 216-228

23. The Negatives Physicians advising patients to stop 1975 – 38% 1983 – 42% 1991 – 48% 1672 Ex-Smokers –3.6% Physician Helped 70% smokers see physician yearly

24. SMOKING 38 Family Practices 2963 Smokers - Addressed in 21% Increased to 58% if Doctor used standard forms for recording smoking status When smokers identified –smoking cessation therapy started in only 38% 68% of the offices had smoking cessation material J. Fam. Pract. 2001; 50: 688-9

25. Physicians Role in Smoking Cessation The Positives Admit Nicotine is an Addiction Provide information Show an interest Train office personnel Select the opportunity

26. SMOKING CESSATION The 5 A’s Ask Advise Assess Assist Arrange

27. Planning a Program Establish degree of nicotine dependency –Serum Cotinine Level –Fagerstrom Test Quit Date Support Group Behavioral Modification Discuss Relapses & Weight Gain

28. Pharmacologic Nicotine Replacement Bupropion

29. Planning A Program Low Dependency –Nicotine Replacement High Dependency –Bupropion + –Nicotine Replacement x 2

30. Nicotine Replacement N=504 Patch 21% Gum20% Spray24% Inhaler24% Arch. Int. Med. September 27, 1999

31. Nicotine Replacement Gum – 1984 Advantages Neutral PH More Rapid Adjunct Disadvantages Heartburn and Indigestion Throat and Mouth Irritation Sore Jaw Flatulence

32. Nicotine Replacement Patch – 1991 Advantages Convenient Best Compliance 30-40% while on patch 10% at 1 year Disadvantages Skin Irritation Over the counter

33. Nicotine Replacement Nasal Spray Advantages Alone or Combination Fast Acting - Urge Disadvantages Irritation Low Compliance

34. Nicotine Replacement Inhaler Advantages Hand-Mouth Disadvantages Low Compliance Less Nicotine Delivery

35. Nicotine Replacement Lozenge – 2002

36. Bupropion Placebo23% Nicotine Replacement36% Bupropion 300 MA49% Bupropion + Nicotine58% Long Term25-35%

37. SMOKING CESSATION N12 MOKG Placebo16015.6%2.1 Nicotine Patch24416.4%1.6 Bupropion24430.3%1.7 Bupropion + patch24535.5%1.1 JORENBY - N.E.J.M. 3/4/99

38. SMOKING CESSATION BUPROPION 450 Smokers (Failed Treatment) AgainPlacebo 27% 5% Gonzales DH, Clin. Pharm Therapy 2001; 69

39. SMOKING CESSATION BUPROPION Duration 784 PATIENTS 7 WEEKS TREATMENTPLACEBO 12 MONTHS 55% 42% Hays, JT. Ann Intern Med. 2001 135

40. SUMMARY Smoking KILLS Physicians can and should play a role in helping patients stop smoking Effective tools are available and they work

42. SUMMARY Include Smoking as a Vital Sign Use the 5 A’s Use multiple modalities Use them long enough Be Persistent