Rx for CHANGE
Clinician-Assisted Tobacco Cessation for Surgical Patients
Developed through a collaboration of the American Society for Anesthesiologists and the Rx for Change: Clinician-Assisted Tobacco Cessation program.
Funded by the National Cancer Institute and the Robert Wood Johnson Foundation.
TRAINING OVERVIEW
Epidemiology of Tobacco Use
Benefits of Quitting for Surgical Patients
Tobacco Dependence and Medications for Quitting
Changing Behavior – How You Can Help
EPIDEMIOLOGY
of TOBACCO USE
is the chief, single,
avoidable cause of death in our society and the most
important public health issue of our time.”
C. Everett Koop, M.D., former U.S. Surgeon General
“CIGARETTE
SMOKING…
Adapted from NCI Smoking and Tobacco Control Monograph 8, 1997, p. 13. Data from U.S. Department of Agriculture.
Reprinted with permission. Thun et al. 2002. Oncogene 21:7307–7325.
ADULT PER-CAPITA CONSUMPTION of TOBACCO, 1880–2005
All forms of
tobacco harmful. are
Year
TRENDS in ADULT SMOKING, by SEX—U.S., 1955–2006
Trends in cigarette current smoking among persons aged 18 or older
Graph provided by the Centers for Disease Control and Prevention. 1955 Current Population Survey; 1965–2005 NHIS. Estimates since 1992 include some-day smoking.
Percent
70% want to quit 70% want to quit
Male
Female 23.9%
18.0%
20.8% of adults are current
smokers
Year
TRENDS in TEEN SMOKING, by ETHNICITY—U.S., 1977–2007
Trends in cigarette smoking among 12th graders: 30-day prevalence of use
Institute for Social Research, University of Michigan, Monitoring the Future Project www.monitoringthefuture.org
P er ce n t
White
Hispanic Black
PUBLIC HEALTH versus
“BIG TOBACCO”
The biggest opponent to tobacco control efforts is the tobacco
industry itself.
Nationally, the tobacco industry is outspending our state tobacco control funding.
For every $1 spent by the states, the tobacco industry
spends $18 to market its products.
TOBACCO INDUSTRY ADVERTISING
$13.11 billion spent in the U.S. in 2005
$35.9 million a day
95% increase over 1998 figures
B il li o n s o f d o ll ar s sp en t
Year
Federal Trade Commission. (2007). Cigarette Report for 2004 and 2005.
New marketing
restrictions
The TOBACCO INDUSTRY
For decades, the tobacco industry publicly denied the addictive nature of nicotine and the negative health effects of tobacco.
April 14, 1994: Seven top executives of major tobacco
companies state, under oath, that they believe nicotine is not addictive: http://www.jeffreywigand.com/7ceos.php (video)
Tobacco industry documents indicate otherwise
Documents available at http://legacy.library.ucsf.edu
The cigarette is a heavily engineered product.
Designed and marketed to maximize bioavailability of nicotine and addictive potential
Profits over people
ANNUAL U.S. DEATHS ATTRIBUTABLE to SMOKING, 1997–2001
Centers for Disease Control and Prevention. (2005). MMWR 54:625–628.
32%
28%
23%
9%
8%
<1%
TOTAL: 437,902 deaths annually
Cardiovascular diseases 137,979
Lung cancer 123,836
Respiratory diseases 101,454 Second-hand smoke* 38,112 Cancers other than lung 34,693
Other 1,828
Percentage of all smoking- attributable deaths*
* In 2005, it was estimated that nearly 50,000 persons died due to second-hand smoke exposure.
COMPOUNDS in TOBACCO SMOKE
Carbon monoxide
Hydrogen cyanide
Ammonia
Benzene
Formaldehyde
Nicotine
Nitrosamines
Lead
Cadmium
Polonium-210
An estimated 4,800 compounds in tobacco smoke, including 11 proven human carcinogens
Gases Particles
Nicotine is the addictive component of tobacco products,
but it does NOT cause the ill health effects of tobacco use.
2004 REPORT of the SURGEON GENERAL:
HEALTH CONSEQUENCES OF SMOKING
Smoking harms nearly every organ of the body, causing many diseases and reducing the health of smokers in general.
Quitting smoking has immediate as well as long-term benefits, reducing risks for diseases caused by smoking and improving health in general.
Smoking cigarettes with lower machine-measured yields of tar and nicotine provides no clear benefit to health.
The list of diseases caused by smoking has been expanded.
U.S. Department of Health and Human Services. (2004). The Health
Consequences of Smoking: A Report of the Surgeon General.
FOUR MAJOR CONCLUSIONS:
HEALTH CONSEQUENCES of SMOKING
Cancers
Acute myeloid leukemia
Bladder and kidney
Cervical
Esophageal
Gastric
Laryngeal
Lung
Oral cavity and pharyngeal
Pancreatic
Pulmonary diseases
Acute (e.g., pneumonia)
Chronic (e.g., COPD)
Cardiovascular diseases
Abdominal aortic aneurysm
Coronary heart disease
Cerebrovascular disease
Peripheral arterial disease
Reproductive effects
Reduced fertility in women
Poor pregnancy outcomes (e.g., low birth weight, preterm
delivery)
Infant mortality
Other effects: cataract, osteoporosis, periodontitis, poor surgical outcomes
U.S. Department of Health and Human Services. (2004). The Health
Consequences of Smoking: A Report of the Surgeon General.ANNUAL SMOKING-ATTRIBUTABLE ECONOMIC COSTS—U.S., 1995–1999
Annual lost productivity
costs (1995–1999)
Medical expenditures
(1998)
Billions of dollars
Men,
$55.4 billion Ambulatory care,
$27.2 billion
Prescription drugs,
$6.4 billion
Women,
$26.5 billion Nursing home,
$19.4 billion
Other care,
$5.4 billion
Centers for Disease Control and Prevention. (2002). MMWR 51:300–303.
Hospital care,
$17.1 billion
Societal costs:
$7.18 per pack
USDHHS. (2006). The Health Consequences of Involuntary Exposure to Tobacco Smoke:
Report of the Surgeon General.
There is no safe level of second-hand
smoke.
Second-hand smoke causes premature death and disease in nonsmokers (children and adults)
Children:
Increased risk for sudden infant death syndrome
(SIDS), acute respiratory infections, ear problems, and more severe asthma
2006 REPORT of the SURGEON GENERAL:
INVOLUNTARY EXPOSURE to TOBACCO SMOKE
Respiratory symptoms and slowed lung growth if parents smoke
Adults:
Immediate adverse effects on cardiovascular system
Increased risk for coronary heart disease and lung cancer
Millions of Americans are exposed to smoke in their homes/workplaces
Indoor spaces: eliminating smoking fully protects nonsmokers
Separating smoking areas, cleaning the air, and ventilation are ineffective
FINANCIAL IMPACT of SMOKING
Packs per day
Buying cigarettes every day for 50 years @ $4.32 per pack Money banked monthly, earning 4% interest
Dollars lost, in thousands
$755,177
$503,451
$251,725
$251,725
$503,451
$755,177
Y ea rs o f lif e ga in ed
Age at cessation (years)
Prospective study of 34,439 male British doctors
Mortality was monitored for 50 years (1951–2001)
On average, cigarette smokers die approximately
10 years younger than do nonsmokers.
Among those who continue smoking, at least half will
die due to a tobacco-related disease.
SMOKING CESSATION:
REDUCED RISK of DEATH
Doll et al. (2004). BMJ 328(7455):1519–1527.
QUITTING: HEALTH BENEFITS
Lung cilia regain normal function
Ability to clear lungs of mucus increases
Coughing, fatigue, shortness of breath decrease
Excess risk of CHD decreases to half that of a continuing smoker
Risk of stroke is reduced to that of people who have never
smoked Lung cancer death rate
drops to half that of a continuing smoker Risk of cancer of mouth,
throat, esophagus, bladder, kidney, pancreas decrease
Risk of CHD is similar to that of people who have never smoked
2 weeks to 3 months
1 to 9 months
1 year
5 years
10 years
after 15 years
Time Since Quit Date Circulation improves,
walking becomes easier Lung function increases
up to 30%
BENEFITS of QUITTING for
SURGICAL PATIENTS
WHY SHOULD SURGICAL PROVIDERS ADDRESS TOBACCO USE?
Quitting Smoking Improves Surgical
Outcomes
Surgery May Promote Quitting
Smoking
TOBACCO CESSATION IMPROVES SURGICAL OUTCOMES
Quitting reduces the incidence of:
Cardiovascular complications
Respiratory complications
Wound-related complications
SHORT-TERM CARDIOVASCULAR
BENEFITS OF SMOKING CESSATION
Nicotine
Half life, approximately 1–2 hours
Decreases in heart rate and systolic blood pressure within 12 hours
Carbon monoxide
Half life, approximately 4 hours
Carboxyhemoglobin level near normal at 12 hours
Preoperative abstinence decreases the frequency of intraoperative ischemia*
*Woehlck et al. (1999). Anesth Analg 89:856-860.
SMOKING CESSATION REDUCES POSTOPERATIVE COMPLICATIONS
120 orthopedic patient randomized to tobacco intervention or control, 6–8 weeks prior to
surgery
~80% of intervention patients were able to quit or reduce smoking
Møller et al. (2002). Lancet 359:114–117.
WHY SHOULD SURGICAL CARE CLINICIANS BOTHER?
Quitting Smoking Improves Surgical
Outcomes
Surgery May Promote Quitting
Smoking
SURGERY PROMOTES TOBACCO CESSATION
Opportunity for providers to intervene
Contact with healthcare system
Forced abstinence in smoke-free facilities
Major medical interventions improve quit rates
Occurs even in the absence of tobacco interventions
May also improve the effectiveness of tobacco
interventions
SMOKING CESSATION AFTER SURGERY
P er ce n t ab st in en t at 1 y ea r
BARRIERS TO PERIOPERATIVE SMOKING CESSATION
“Quitting just before surgery increases pulmonary complications.”
“Nicotine replacement therapy is dangerous.”
“Surgical patients are already too stressed.”
“Patients don’t want to hear about their
smoking—they have enough to worry about.”
RECENT SMOKING CESSATION DOES NOT INCREASE PULMONARY COMPLICATIONS
300 patients for lung cancer resection
“Recent” quitters:
>1 week, <2 months
“Past” quitters:
>2 months
Barrera et al. (2005). Chest 127:1977–1983.
(n=13) (n=39) (n=184) (n=64)
P er ce n t
NICOTINE REPLACEMENT
THERAPY AND WOUND HEALING
48 smokers randomized to continuous smoking or abstinence, with or
without nicotine replacement
Standardized wounds over a 12-week period
Sorensen et al. (2003). Ann Surg 238:1–5.
P er ce n t
PERIOPERATIVE STRESS IN SURGICAL PATIENTS
Warner et al. (2004). Anesthesiology 199:1125–1137.
141 smokers, 150 non-
smokers for elective surgery
Perceived stress measured from before surgery up to one week postoperatively
(POD=postop day)
Smoking status does not affect changes in perceived stress
No evidence for significant cigarette cravings
Time
WHAT DO PATIENTS WHO SMOKE EXPECT?
Essentially all smokers are aware of general health hazards
Most are not aware of how it might affect their surgery – and want to know!
They want information and options
Almost all will not be offended if you discuss their smoking…
But they do not want a sermon
Warner et al., unpublished observations.
THE REAL BARRIERS TO INTERVENTION
“I don’t know how.”
“I don’t have time.”
“It’s not my job.”
TOBACCO DEPENDENCE:
A 2-PART PROBLEM
Tobacco Dependence Tobacco Dependence
Treatment should address the physiological and the behavioral aspects of dependence.
Physiological
Physiological Behavioral Behavioral
Treatment Treatment
The addiction to nicotine
Medications for cessation
The habit of using tobacco
Behavior change program
TOBACCO DEPENDENCE and
MEDICATIONS for QUITTING
WHAT IS ADDICTION?
”Compulsive drug use, without medical purpose, in the face of
negative consequences”
Alan I. Leshner, Ph.D.
Former Director, National Institute on Drug Abuse
National Institutes of Health
NICOTINE DISTRIBUTION
Henningfield et al. (1993). Drug Alcohol Depend 33:23–29.
Arterial
Venous
Nicotine reaches the brain within 11 seconds.
Nicotine reaches the brain within 11 seconds.
Nicotine enters Nicotine enters
brain brain
Stimulation of Stimulation of
nicotine receptors nicotine receptors Dopamine release
Dopamine release
DOPAMINE REWARD PATHWAY
Prefrontal cortex
Nucleus accumbens
Ventral tegmental
area
BIOLOGY of NICOTINE ADDICTION:
ROLE of DOPAMINE
Nicotine stimulates dopamine release
Repeat administration
Tolerance develops
Discontinuation leads to withdrawal symptoms.
Pleasurable feelings
Nicotine addiction
is not just a bad habit.
Benowitz. (2008). Clin Pharmacol Ther 83:531–541.
Irritability/frustration/anger
Anxiety
Difficulty concentrating
Restlessness/impatience
Depressed mood/depression
Insomnia
Impaired performance
Increased appetite/weight gain
Cravings
NICOTINE PHARMACODYNAMICS:
WITHDRAWAL EFFECTS
Hughes. (2007). Nicotine Tob Res 9:315–327.
Most symptoms manifest within the first 1–2 days,
peak within the first week, and subside within
2–4 weeks.
HANDOUT
NICOTINE ADDICTION
Tobacco users maintain a minimum serum nicotine concentration in order to
Prevent withdrawal symptoms
Maintain pleasure/arousal
Modulate mood
Users self-titrate nicotine intake by
Smoking/dipping more frequently
Smoking more intensely
Obstructing vents on low-nicotine brand cigarettes
Benowitz. (2008). Clin Pharmacol Ther 83:531–541.
Nicotine polacrilex gum (OTC) – brand (Nicorette), generic Nicotine lozenge (OTC) – brand (Commit), generic
Nicotine transdermal patch (OTC, Rx) – brand (NicoDerm CQ, OTC), generic (OTC, Rx)
Nicotine nasal spray (Rx) – brand (Nicotrol NS) Nicotine inhaler (Rx) – brand (Nicotrol Inhaler) Bupropion SR (Rx) – brand (Zyban), generic Varenicline (Rx) – brand (Chantix)
These are the only medications that are These are the only medications that are
FDA-approved for smoking cessation.
FDA-approved for smoking cessation.
FDA-APPROVED MEDICATIONS for SMOKING CESSATION
OTC = Over the counter
PHARMACOTHERAPY
Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update.
Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.
Medications significantly improve success rates.
* Includes pregnant women, smokeless tobacco users, light smokers, and adolescents.
“Clinicians should encourage all patients attempting to quit to use effective medications for tobacco
dependence treatment, except where contraindicated or for specific
populations* for which there is
insufficient evidence of effectiveness.”
NRT: RATIONALE for USE
Reduces physical withdrawal from nicotine
Eliminates the immediate, reinforcing effects of nicotine that is rapidly absorbed via tobacco smoke
Allows patient to focus on behavioral and psychological aspects of tobacco cessation
NRT products approximately doubles quit rates.
NRT products approximately doubles quit rates.
PLASMA NICOTINE CONCENTRATIONS for NICOTINE-CONTAINING PRODUCTS
0 10 20 30 40 50 60 Time (minutes)
Cigarette
Moist snuff
NICOTINE GUM
Resin complex of nicotine and p olacrilin
Sugar-free chewing gum base
Contains buffering agents to enhance buccal absorption of nicotine
Available:
2 mg, 4 mg; original, cinnamon, fruit, mint
(various), and orange flavors
NICOTINE LOZENGE
Nicotine polacrilex formulation
Delivers ~25% more nicotine than equivalent gum dose
Sugar-free mint (various), cappuccino or cherry flavor
Contains buffering agents to enhance buccal absorption of nicotine
Available:
2 mg, 4 mg
TRANSDERMAL NICOTINE PATCH
Nicotine is well absorbed across the skin
Delivery to systemic circulation avoids hepatic first-pass metabolism
Plasma nicotine levels are lower and fluctuate less than with smoking
Available:
Brand or generic; nicotine delivery over 24 hours
21 mg, 14 mg, 7 mg
NICOTINE NASAL SPRAY
Aqueous solution of nicotine in a 10-ml spray bottle
Each metered dose actuation delivers
50 mcL spray
0.5 mg nicotine
~100 doses/bottle
Rapid absorption across nasal mucosa
Available:
Rx only
NICOTINE INHALER
Nicotine inhalation system consists of:
Mouthpiece
Cartridge with porous plug containing 10 mg nicotine and 1 mg menthol
Delivers 4 mg nicotine vapor, absorbed across buccal mucosa
Available:
Rx only
BUPROPION SR
Nonnicotine cessation aid
Oral formulation
Sustained-release antidepressant
Atypical antidepressant thought to affect levels of various brain neurotransmitters (dopamine,
norepinephrine)
Clinical effects
craving for cigarettes
symptoms of nicotine withdrawal
VARENICLINE
Nonnicotine cessation aid
Partial nicotinic receptor agonist
Oral formulation
Binds with high affinity and selectivity at
4
2neuronal nicotinic acetylcholine receptors
Stimulates low-level agonist activity
Competitively inhibits binding of nicotine
VARENICLINE:
CARDIOVASCULAR EFFECTS?
4 β 2 nicotinic receptor not known to have non-CNS effects
No evidence for effects on vascular function
More data needed
VARENICLINE: WARNING
In 2008, Pfizer added a warning label advising patients and caregivers:
Patients should stop taking varenicline and contact
their healthcare provider immediately if agitation,
depressed mood, or changes in behavior that are
not typical for them are observed, or if the patient
develops suicidal ideation or suicidal thoughts.
LONG-TERM (6 month) QUIT RATES for AVAILABLE CESSATION MEDICATIONS
Data adapted from Cahill et al. (2008). Cochrane Database Syst Rev; Stead et al. (2008).
Cochrane Database Syst Rev; Hughes et al. (2007). Cochrane Database Syst Rev
P er ce n t q u it
18.015.8
11.3
9.9
16.1
8.1
23.9
11.8
17.1
9.1
19.0
10.3 11.2
20.2
COMPARATIVE DAILY COSTS of PHARMACOTHERAPY
$/ da y
Average $/pack of cigarettes, $4.32
PHARMACOTHERAPY:
USE in PREGNANCY
The Clinical Practice Guideline makes no recommendation regarding use of medications in pregnant smokers
Insufficient evidence of effectiveness; concerns with safety
Category C: varenicline, bupropion SR
Category D: prescription formulations of NRT
“Because of the serious risks of smoking to the pregnant smoker and the fetus, whenever
possible pregnant smokers should be offered person-to-person psychosocial interventions that exceed minimal advice to quit.” (p. 165)
Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update.
Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.
CHANGING BEHAVIOR –
HOW YOU CAN HELP
TOBACCO CESSATION
REQUIRES BEHAVIOR CHANGE
Fewer than 5% of people who quit without assistance are successful in quitting for more than a year.
Few patients adequately PREPARE and PLAN for their quit attempt.
Many patients do not understand the need to change behavior
Patients think they can just “make themselves quit”
Behavioral counseling is a key component of treatment
for tobacco use and dependence.
Often, patients automatically smoke in the following situations:
Behavioral counseling helps patients learn to cope with these difficult situations without having a cigarette.
When drinking coffee
While driving in the car
When bored
While stressed
While at a bar with friends
After meals
During breaks at work
While on the telephone
While with specific friends or family members who use tobacco
CHANGING BEHAVIOR (cont’d)
1.0 1.1
1.7 2.2
n = 29 studies
Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update.
Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.
With help from a clinician, the odds of quitting approximately doubles.
Compared to patients who receive no assistance from a clinician, patients who receive assistance are 1.7–2.2 times as likely to quit successfully for 5 or more months.
CLINICIANS CAN MAKE a
DIFFERENCE
E st im at ed a b st in en ce r at e at 5 + m o n th s
1.0
1.8
(1.5,2.2)
2.5
(1.9,3.4) 2.4
(2.1,3.4) n = 37 studies
The NUMBER of CLINICIANS CAN MAKE a DIFFERENCE, too
Compared to smokers who receive assistance from no clinicians, smokers who receive
assistance from two or more clinicians are 2.4–
2.5 times as likely to quit successfully for 5 or more months.
Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update.
Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.
WHAT SHOULD WE DO FOR SURGICAL PATIENTS ?
ASK about tobacco USE
ADVISE tobacco users to QUIT
REFER to other resources
ASSIST ARRANGE
Patient receives assistance,
with follow-up counseling
arranged, from other
resources such as the
tobacco quitline
WHAT ARE
“TOBACCO QUITLINES”?
Tobacco cessation counseling, provided at no cost via telephone to all Americans
Staffed by trained specialists
Up to 4 – 6 personalized sessions (varies by state)
Some state quitlines offer nicotine replacement therapy at no cost
Up to 30% success rate for patients who complete sessions
Most health-care providers, and most patients,
are not familiar with tobacco quitlines.
ASK EVERY PATIENT ABOUT TOBACCO USE
Ask even if you already know the answer
Reinforces the message that tobacco use is clinically significant, and quitting is
important
ADVISE ALL PATIENTS WHO
SMOKE TO QUIT: Talking Points
Why quit for surgery?
Quit for as long as possible before and after surgery
Day of surgery is particularly important
Advise patient to “fast” from food and cigarettes
Benefits of quitting to wound healing, heart and lungs
Great opportunity to quit for good
Many people don’t have cravings
Need to be smoke free in the hospital anyway
REFER smokers to quitlines or other resources
What are quitlines? – talking points
Quitlines are free
Talk with a specialist, not a recording
Free stop smoking medications may be available
Can call anytime, even after surgery
Can help you stay off cigarettes even if you have already quit
Can also use proactive fax referral
1-800-QUIT-NOW
Am. Society of Anesthesiologists:
“QUIT CARD”
Amer. Society of Anesthesiologists:
PATIENT BROCHURE
OTHER RESOURCES FOR YOUR PATIENTS
Tobacco treatment specialists
Available in many practice settings
Often hospital-based
Websites
www.smokefree.gov
www.asahq.org/patientEducation/smokingcessation.htm
Insurers
e.g., Blue Cross/Shield, BluePrint for Health program
OTHER WEB RESOURCES FOR PROVIDERS
General portal for information
www.smokefree.gov
ASA-sponsored site providing information and resources for surgical patients and providers
www.asahq.org/patientEducation/smoking_cessationProvider.htm
Training materials for clinicians
http://rxforchange.ucsf.edu
CMS REIMBURSEMENT FOR TOBACCO INTERVENTIONS
Who is covered?
Patients who use tobacco and have a disease or adverse health effect found by the U.S. Surgeon General to be linked to tobacco use
CPT codes
99406: Smoking and tobacco-use cessation counseling visit; intermediate, > 3 minutes up to 10 minutes
99407: Smoking and tobacco-use cessation visit;
intensive, > 10 minutes
CMS REIMBURSEMENT FOR TOBACCO INTERVENTIONS
Cessation counseling attempt occurs when a
qualified physician or other Medicare-recognized
practitioner determines that a beneficiary meets the eligibility requirements above and initiates
treatment with a cessation counseling attempt
Two attempts (of up to 4 sessions) allowed every 12 months
No credentialing requirements as of yet
A COMPREHENSIVE APPROACH…
Every surgical patient has at least five points of contact when undergoing elective surgery
Initial surgical visit (scheduling)
Admission to facility
Preop visit by anesthesia provider
Discharge from facility
