Smoking Cessation: the pharmacotherapeutic and non-pharmacotherapeutic approaches to addictive behavior Andrea C. McKean February 22, 2007

Smoking Facts Cigarette smoking is the #1 cause of preventable disease and death in the United States Smoking causes an estimated 440,000 premature deaths annually in the United States (1 in every 5 deaths) The highest state estimates for cigarette smoking include: Men Women Kentucky (30.6%) Kentucky (26.9%) Indiana (29.7%) West Virginia (26%) Alabama (29.5%) Indiana (25.1%) The lowest state estimates include: California (11.3%), Utah (13.7%), and Massachusetts (18.1%) One half of all lifetime smokers will die early because of their decisions to smoke, shortening their own life span by an average of 13.2 years in men and 14.5 years in women 

The Health Consequences of Smoking Diseases/Conditions caused by Smoking  Cardiovascular Dz: stroke, HTN, CAD, Aortic aneurysms, and peripheral vascular disease Cancer: larynx, oral cavity, esophagus, lung, stomach, cervix, pancreas, kidneys, and bladder Respiratory Dz: chronic bronchitis, COPD, Emphysema, Pneumonia Other: osteoporosis, cataracts, gum disease, gastric and duodenal ulcers

The Benefits of Quitting Compared to smokers … Stroke risk is reduced to that of a person who never smoked after 5 to 15 years of not smoking. Cancers of the mouth, throat, and esophagus risks are halved 5 years after quitting. Cancer of the larynx risk is reduced after quitting. Coronary heart disease risk is cut by half 1 year after quitting and is nearly the same as someone who never smoked 15 years after quitting. Chronic obstructive pulmonary disease risk of death is reduced after you quit. Lung cancer risk drops by as much as half 10 years after quitting. Ulcer risk drops after quitting. Bladder cancer risk is halved a few years after quitting. Peripheral artery disease goes down after quitting. Cervical cancer risk is reduced a few years after quitting. Low birthweight baby risk drops to normal if you quit before pregnancy or during your first trimester

Goals The U.S. Public Health Service has set goals to reduce smoking in our country by the year First goal: –cut smoking rates among high school aged youth from 22% to 16%. –cut smoking rates among all adults from 23% to 12%. Another goal: –increase the number of 1° care providers who routinely provide smoking cessation counseling for their patients who smoke by 75% If these goals are met ~ 7.1 million early deaths will be prevented after 2010 !!!

Addictive Nature of Nicotine Addictive characteristics of nicotine are a result of its action on the nicotinic acetylcholine receptors –nicotine reaches the brain within 10 seconds upon inhalation Nicotine is known for its ability to both stimulate and depress the CNS –small rapid doses produce alertness and arousal –long drawn out doses induce relaxation and sedation Tobacco use is more likely to lead to dependence than any other drug –Among those who ever tried one cigarette, approximately 1/3 rd develop nicotine dependence Similar to addiction associated with cocaine, amphetamines and opiates, nicotine addiction is a “chronic relapsing medical condition” that warrants clinical intervention.

Clinical Intervention for Smoking Cessation Smoking cessation is the most important, cost effective preventive clinical intervention that healthcare providers can offer to their patients that smoke. At least 70% of smokers see their primary care clinician annually  which means that many practitioners are missing a prime opportunity to improve the health of their smoking patients Primary care providers play a KEY role in the identification, assessment and treatment of smokers. It is essential for smoking cessation to be implemented into the clinical setting during each patient visit!

Treatment Options Non-Pharmacotherapies (Behavioral Therapies) –Brief counseling (< 3 min) –5 A’s –5 R’s –Other: Support groups Web Sites Quit-lines Pharmacotherapies –NRT: polacrilex gum polacrilex lozenge transdermal patch nasal spray inhaler –Non-NRT Bupropion Hydrochloride Varenicline Tartrate

Types of Behavioral Therapy “5A” Model –Ask (about smoking) –Advise (to stop) –Assess (will to stop) –Assist (will to stop) –Arrange (f/u visits) “5R” Model –Relevance (personally) –Risks (of tobacco use) –Rewards (of quitting) –Roadblocks (to cessation) –Repetition (every visit) Other – social support groups, group/individual counseling, pamphlets, books, U.S Dept Health and Human Services telephone quit line QUIT NOW, websites: also many pharmacotherapies now offer support plans with purchase of their product.

Nicotine Transdermal Patch Nicoderm CQ (remove after hrs) NicotineOTC21mg/24 hr 14mg/24hr 7mg/24 hr 21mg per day 6wks,14mg per day 2wks, then 7mg per day for 2 wks Apply- clean, dry, nonhairy site on trunk or upper outer arm. Rotate Nicotrol Step- Down patch (remove after 16 hrs) NicotineOTC15mg/16 hr 10mg/16 hr 5mg/16 hr 15mg for 6 wks, 10mg for 2 wks, then 5mg for 2 wks. Apply to clean, dry, nonhairy site on hip or upper outer arm. Rotate Nicotine Polacrilex Gum/ Lozenge Nicorette Gum Commit Lozenge NicotineOTC2mg 4mg 1 piece q 1-2hr 6wks, 1q 2- 4hrs 3 wks, then 1q 4-8hrs 3 wks Avoid food/ acidic drinks for 15min before and after use. Nicotine Nasal Spray NicotrolNicotineRx.5mg/spray1-2 doses/hr. Max 5/hr& 40/day (2 sprays is one dose) (Tx up to 3 months) No sniff, inhale, swallow spray Nicotine Inhaler NicotrolNicotine (inhalation) Rx10mg/ cartridge  4mg del ~6-16 cartridges/ day up to 12wks, then reduce over 12wks (Tx up to 6 months) 20min puffing releases 4mg c 2mg nicotine abs. (2 cigs)