Rx for CHANGE
Clinician-Assisted Tobacco Cessation
for Patients with Cancer
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…
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
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.HEALTH CONSEQUENCES of SMOKELESS TOBACCO USE
Periodontal effects
Gingival recession
Bone attachment loss
Dental caries
Oral leukoplakia Cancer
Oral cancer
Pharyngeal cancer
Oral Leukoplakia
Image courtesy of Dr. Sol Silverman - University of California San Francisco
Use of alcohol in combination with moist snuff increases
the risk of oral cancers.
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.
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
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
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%
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.
TOBACCO USE and the
DEVELOPMENT of CANCER
TOBACCO:
CANCERS CAUSED by TOBACCO
Lung
Larynx
Oral cavity and pharynx
Esophagus
Pancreas
Bladder and kidney
Cervix
Stomach
Bone marrow
(acute myeloid leukemia)
USDHHS. (2004). The Health Consequences of Smoking: A Report of the Surgeon General.
Sufficient evidence exists to infer a CAUSAL relationship
between tobacco use and these cancers.
TOBACCO and CANCER:
CARCINOGENS in TOBACCO PRODUCTS
Polycyclic aromatic hydrocarbons (PAHs)
Benzopyrene
Benzanthracene
Tobacco-specific nitrosamines (TSNAs)
Aromatic amines
Formaldehyde
Benzene
Vinyl chloride
Cadmium
Radioactive polonium-210
An estimated 4,800 compounds in tobacco smoke, including 11 proven human carcinogens
Nicotine does NOT cause the ill health effects of tobacco use.
Compounds in tobacco function as
Carcinogens
Initiate tumor growth
Tumor promoters
Stimulate the development of established tumors
Co-carcinogens
Enhance the mutagenic potential of carcinogens; possess little or no direct carcinogenic activity
Irritants
Induce inflammation and compromise tissue integrity
TOBACCO and CANCER:
MECHANISM of CARCINOGENESIS
TOBACCO and CANCER:
CELL DIVISION
A cancer cell dividing its chromosomes (shown in white) into two new cells
Image courtesy of Dr. Paul D. Andrews / University of Dundee
TOBACCO and CANCER:
MECHANISM of CARCINOGENESIS (cont’d)
Formation of DNA adducts
Covalent binding product of
carcinogen (or its metabolite) to DNA
Leads to miscoding and point mutations
Mutations of oncogenes or tumor suppressor genes can lead to
uncontrolled cellular growth and
development of cancer
TOBACCO and CANCER:
MECHANISM of CARCINOGENESIS (cont’d)
TSNAs PAHs
Other carcinogens Nicotine
addiction
DNA adducts
Mutations
Other changes Cancer
Excretion
Normal DNA
Apoptosis
Tobacco use Metabolic
detoxification
Metabolic activation
Repair
Persistence/miscoding
Reprinted with permission. Hecht. J Natl Cancer Inst 1999;91:1194–1210.
TOBACCO USE and the DEVELOPMENT of CANCER: SUMMARY
Tobacco products cause a variety of cancers
Carcinogens present in tobacco products are responsible for these cancers
Carcinogenesis likely involves a multistep process:
Formation of DNA adducts
Permanent cellular mutations
Unregulated cellular growth
TOBACCO USE and the
TREATMENT of CANCER
A large proportion of patients are current or former smokers at the time of cancer diagnosis
Prevalence of ever smoking is highest among patients with tobacco-related cancers
90% -- lung cancer
80% -- head and neck cancer
20–50% of patients with cancer continue to smoke after diagnosis
A large proportion of patients who quit smoking will relapse after completing their treatment
PREVALENCE of SMOKING
AMONG PATIENTS with CANCER
Cancer diagnosis provides an important “window of opportunity”
Cancer diagnosis provides an important “window of opportunity”
for promoting tobacco cessation.
for promoting tobacco cessation.
ANNUAL NUMBER of CANCER DEATHS ATTRIBUTABLE to SMOKING, 1997-2001
Centers for Disease Control and Prevention. (2005). MMWR 54:625–628.
Graph provided by American Cancer Society, 2008.SMOKING and CANCER:
TREATMENT, SURVIVAL, QUALITY of LIFE
Negatively impacts cancer treatment response
Surgery
Radiation
Chemotherapy
Increases odds for development of second primary tumors
Negatively impacts survival outcomes
Reduces quality of life
Clinicians can impact cancer outcomes by assisting Clinicians can impact cancer outcomes by assisting
patients and their family members with quitting smoking.
patients and their family members with quitting smoking.
SMOKING…
EFFECTS of SMOKING on
CANCER THERAPY: SURGERY
Smoking is associated with poor surgical outcomes
Respiratory complications during anesthesia
Cardiopulmonary complications
Infections and impaired wound healing
Cerebrovascular complications
Increased post-operative intensive care admissions
Cessation interventions before surgery can reduce risk of complications
Best when offered at least 6 weeks prior to surgery
EFFECTS of SMOKING on
CANCER THERAPY: RADIATION
Smoking reduces treatment efficacy
Patients who smoke experience increased incidence of complications
Toxicity
Side effects
Overall morbidity
Smoking is associated with reduced survival
rates
EFFECTS of SMOKING on CANCER THERAPY: CHEMOTHERAPY
Smoking may decrease the therapeutic effects of chemotherapy and other medications
Drug interactions with smoking -- increased hepatic metabolism (e.g., irinotecan, erlotinib)
More research is needed to delineate effects of smoking on chemotherapy outcomes
What is nicotine’s effects on cancer cells, and how does it impact treatment?
Does the lack of smoking data in patient charts impact our ability to understand the relationship between smoking and outcomes?
How does smokers’ increased risk of co- morbid disease impact their likelihood for entry into clinical trials?
HANDOUT
EFFECTS of SMOKING on
SECOND PRIMARY TUMORS
Continued smoking after diagnosis increases risk for second primary tumors -- this applies to:
The initial tumor site and other sites
Malignancies related to smoking
Malignancies not related to smoking
Dose-response relationship of intense cigarette use increases the risk for second primary tumors
Continued exposure to tobacco after cancer diagnosis
may be the more important risk factor
EFFECTS of SMOKING on
CANCER SURVIVAL OUTCOMES
Survival is reduced in patients who smoke
As a direct result of malignancy
As a consequence of other smoking-related disease(s)
Smoking history
>30 pack-years has been shown to be an independent
prognostic factor for both short- and long-term survival rates
Tobacco mutagenicity may play a role in the growth and extension of certain cancers
Presents further obstacles for survival
Quitting smoking before diagnosis and treatment
can positively influence survival.
Smoking after diagnosis negatively impacts
Overall quality of life (QOL)
Risk for co-morbid diseases, which
independently have a negative impact on QOL
Symptom distress
Higher in persistent smokers, compared to never smokers
EFFECTS of SMOKING on QUALITY
OF LIFE in PATIENTS WITH CANCER
HOW DOES SMOKING CESSATION IMPROVE CANCER PROGNOSIS?
Quitting prior to diagnosis and treatment has a positive influence on prognosis and survival
Examples
Head and neck cancer
Quitting 12 weeks and 1 yr prior to diagnosis reduces mortality by 40% and 70%, respectively
Non-small cell lung cancer
Quitting at any point prior to lung operation is beneficial to
prognosis and long-term survival
WHAT FACTORS POSITIVELY INFLUENCE QUITTING in PATIENTS WITH CANCER?
Patient awareness of the link between smoking and their
diagnosed smoking-related cancer
Patient concern about recurrent disease and the effects of smoking on treatment success
Advice given in the context of
medical care
MORE INTENSIVE or TAILORED INTERVENTIONS MAY BE NEEDED
Patients with cancer tend to have:
Higher levels of nicotine dependence
Higher levels of psychiatric co-morbidity
Higher need for treatment support
High percentage of household smokers
Poorer general health and physical functioning
More stress and emotional distress
Cancer disease-related issues need to be taken into account in treatment decisions and patient monitoring
Impact of smoking on surgery, radiation, and chemotherapy
Systematic advice (from multiple providers), with stepped-care
approach for patients experiencing difficulty with quitting
RELAPSE in
PATIENTS WITH CANCER
Up to one third or one half of patients will either
continue to smoke after diagnosis or relapse after an initial quit attempt
Relapse is often delayed in patients with cancer, compared to healthy patients
Follow-up and monitoring is needed
In relapsers:
Encourage a subsequent quit attempt, to avoid additional
post-diagnosis risk due to smoking
SUMMARY: REASONS TO QUIT for PATIENTS WITH CANCER
Reduced risk for complications related to cancer therapy and surgery
Improved survival
Improved quality of life
Reduced risk of second primary tumor(s)
TOBACCO CESSATION is an essential
component of treatment for patients with cancer.
TREATING TOBACCO USE and DEPENDENCE:
MEDICATIONS for QUITTING
HANDOUT
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
PHARMACOLOGIC METHODS:
FIRST-LINE THERAPIES
Three general classes of FDA-approved drugs for smoking cessation:
Nicotine replacement therapy (NRT)
Nicotine gum, patch, lozenge, nasal spray, inhaler
Psychotropics
Sustained-release bupropion
Partial nicotinic receptor agonist
Varenicline
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.”
PHARMACOTHERAPY:
USE in PREGNANCY
The Clinical Practice Guideline makes no recommendation regarding use of medications in pregnant smokers
Insufficient evidence of effectiveness
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.
PHARMACOTHERAPY:
OTHER SPECIAL POPULATIONS
Pharmacotherapy is not recommended for:
Smokeless tobacco users
No FDA indication for smokeless tobacco cessation
Individuals smoking fewer than 10 cigarettes per day
Adolescents
Nonprescription sales (patch, gum, lozenge) are restricted to adults ≥18 years of age
NRT use in minors requires a prescription
Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update.
Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.
Recommended treatment is behavioral counseling.
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.
Polacrilex gum
Nicorette ( OTC)
Generic nicotine gum (OTC)
Lozenge
Commit (OTC)
Generic nicotine lozenge (OTC)
Transdermal patch
NicoDerm CQ (OTC)
Generic nicotine patches (OTC, Rx)
Nasal spray
Nicotrol NS (Rx)
Inhaler
Nicotrol (Rx)
NRT: PRODUCTS
Patients should stop using all forms of tobacco
upon initiation of the NRT regimen.
PLASMA NICOTINE CONCENTRATIONS for NICOTINE-CONTAINING PRODUCTS
0 10 20 30 40 50 60 Time (minutes)
Cigarette
Moist snuff
NRT: PRECAUTIONS
Patients with underlying cardiovascular disease
Recent myocardial infarction (within past 2 weeks)
Serious arrhythmias
Serious or worsening angina
NRT products may be appropriate for these patients
if they are under medical supervision.
NICOTINE GUM
Nicorette (GlaxoSmithKline); generics
Resin complex
Nicotine
Polacrilin
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 GUM: DOSING
Dosage based on current smoking patterns:
If patient smokes Recommended strength
25 cigarettes/day 4 mg
<25 cigarettes/day 2 mg
NICOTINE GUM: DOSING (cont’d)
Recommended Usage Schedule for Nicotine Gum Weeks 1–6 Weeks 7–9 Weeks 10–12 1 piece q 1–2 h 1 piece q 2–4 h 1 piece q 4–8 h
DO NOT USE MORE THAN 24 PIECES PER DAY.
NICOTINE GUM:
CHEWING TECHNIQUE SUMMARY
Park between cheek & gum
Stop chewing at
first sign of peppery taste or tingling
sensation Chew slowly
Chew again
when peppery
taste or tingle
fades
NICOTINE LOZENGE
Commit (GlaxoSmithKline); generics
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
NICOTINE LOZENGE: DOSING
Dosage is based on the “time to first cigarette”
(TTFC) as an indicator of nicotine addiction
Use Commit Lozenge 2 mg:
If you smoke your first cigarette more than 30 minutes after waking up
Use Commit Lozenge 4 mg:
If you smoke your first
cigarette of the day within 30
minutes of waking up
NICOTINE LOZENGE:
DOSING (cont’d)
Recommended Usage Schedule for Commit Lozenge
Weeks 1–6 Weeks 7–9 Weeks 10–12 1 lozenge
q 1–2 h
1 lozenge q 2–4 h
1 lozenge q 4–8 h
DO NOT USE MORE THAN 20 LOZENGES PER DAY.
NICOTINE LOZENGE:
DIRECTIONS for USE
Use according to recommended dosing schedule
Place in mouth and allow to dissolve
slowly (nicotine release may cause warm, tingling sensation)
Do not chew or swallow lozenge.
Occasionally rotate to different areas of the mouth.
Lozenge will dissolve completely in about 2030 minutes.
Do NOT eat or drink for 15 minutes BEFORE or while using the
nicotine lozenge.
TRANSDERMAL NICOTINE PATCH
NicoDerm CQ (GlaxoSmithKline); generic
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
TRANSDERMAL NICOTINE PATCH:
PREPARATION COMPARISON
Product NicoDerm CQ Generic Nicotine
delivery
24 hours 24 hours
Availability OTC Rx/OTC
Patch strengths 7 mg 14 mg 21 mg
7 mg
14 mg
21 mg
TRANSDERMAL NICOTINE PATCH:
DOSING
Product Light Smoker Heavy Smoker
NicoDerm CQ 10 cigarettes/day
Step 2 (14 mg x 6 weeks) Step 3 (7 mg x 2 weeks)
>10 cigarettes/day Step 1 (21 mg x 6 weeks) Step 2 (14 mg x 2 weeks) Step 3 (7 mg x 2 weeks) Generic
(formerly Habitrol)
10 cigarettes/day
Step 2 (14 mg x 6 weeks) Step 3 (7 mg x 2 weeks)
>10 cigarettes/day
Step 1 (21 mg x 4 weeks)
Step 2 (14 mg x 2 weeks)
Step 3 (7 mg x 2 weeks)
TRANSDERMAL NICOTINE PATCH:
DIRECTIONS for USE
Choose an area of skin on the
upper body or upper outer part of the arm
Make sure skin is clean, dry, hairless, and not irritated
Apply patch to different area each day
Do not use same area again for at
least 1 week
TRANSDERMAL NICOTINE PATCH:
ADDITIONAL PATIENT EDUCATION
Water will not harm the nicotine patch if it is applied correctly;
patients may bathe, swim, shower, or exercise while wearing the patch
Do not cut patches to adjust dose
Nicotine may evaporate from cut edges
Patch may be less effective
Keep new and used patches out of the reach of children and pets
Remove patch before MRI procedures
NICOTINE NASAL SPRAY
Nicotrol NS (Pfizer)
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
NICOTINE INHALER
Nicotrol Inhaler (Pfizer)
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
BUPROPION SR
Zyban (GlaxoSmithKline); generic
Nonnicotine cessation aid
Sustained-release antidepressant
Oral formulation
BUPROPION:
MECHANISM of ACTION
Atypical antidepressant thought to affect levels of various brain neurotransmitters
Dopamine
Norepinephrine
Clinical effects
craving for cigarettes
symptoms of nicotine withdrawal
BUPROPION:
CONTRAINDICATIONS
Patients with a seizure disorder
Patients taking
Wellbutrin, Wellbutrin SR, Wellbutrin XL
MAO inhibitors in preceding 14 days
Patients with a current or prior diagnosis of anorexia or bulimia nervosa
Patients undergoing abrupt discontinuation of alcohol
or sedatives (including benzodiazepines)
BUPROPION:
WARNINGS and PRECAUTIONS
Bupropion should be used with caution in the following populations:
Patients with a history of seizure
Patients with a history of cranial trauma
Patients taking medications that lower the seizure
threshold (antipsychotics, antidepressants, theophylline, systemic steroids)
Patients with severe hepatic cirrhosis
Patients with depressive or psychiatric disorders
VARENICLINE Chantix (Pfizer)
Nonnicotine cessation aid
Partial nicotinic receptor agonist
Oral formulation
VARENICLINE:
MECHANISM of ACTION
Binds with high affinity and selectivity at
4
2neuronal nicotinic acetylcholine receptors
Stimulates low-level agonist activity
Competitively inhibits binding of nicotine
Clinical effects
symptoms of nicotine withdrawal
Blocks dopaminergic stimulation responsible for
reinforcement & reward associated with smoking
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.
VARENICLINE: DOSING
Patients should begin therapy 1 week PRIOR to their quit date. The dose is gradually increased to minimize
treatment-related nausea and insomnia.
Treatment Day Dose
Day 1 to day 3 0.5 mg qd
Day 4 to day 7 0.5 mg bid
Day 8 to end of treatment* 1 mg bid
Initial dose titration
* Up to 12 weeks
VARENICLINE:
ADVERSE EFFECTS
Common (≥5% and 2-fold higher than placebo)
Nausea
Sleep disturbances (insomnia, abnormal dreams)
Constipation
Flatulence
Vomiting
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
COMBINATION PHARMACOTHERAPY
Combination NRT
Long-acting formulation (patch)
Produces relatively constant levels of nicotine
PLUS
Short-acting formulation (gum, inhaler, nasal spray)
Allows for acute dose titration as needed for nicotine withdrawal symptoms
Bupropion SR + Nicotine Patch
Regimens with enough evidence to be ‘recommended’ first-line
COMPLIANCE IS KEY to QUITTING
Promote compliance with prescribed regimens.
Under-dosing of NRT is common and can contribute to relapse
Use according to dosing schedule, NOT as needed.
Consider telling the patient:
“When you use this medication, it’s important to read all the directions thoroughly. The products work best in alleviating
withdrawal symptoms when used correctly, and according to the
recommended dosing schedule.”
COMPLIANCE IS KEY to QUITTING
Promote compliance with prescribed regimens.
Use according to dosing schedule, NOT as needed.
Consider telling the patient:
“When you use a cessation product it is important to read all the directions thoroughly before using the product. The
products work best in alleviating withdrawal symptoms when
used correctly, and according to the recommended dosing
schedule.”
COMPARATIVE DAILY COSTS of PHARMACOTHERAPY
$/ da y
Average $/pack of cigarettes, $4.32
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
ASSISTING PATIENTS with QUITTING
HANDOUT
TOBACCO CESSATION
REQUIRES BEHAVIOR CHANGE
Fewer than 5% of people who quit without assistance are successful in quitting for more than a year.
Many patients under-estimate the impact that counseling can have on their ability to quit
Few patients adequately PREPARE and PLAN for their quit attempt.
Many patients assume they can just “make themselves quit” when they are ready to do so.
Behavioral counseling is a key component of treatment
for tobacco use and dependence.
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
Est im ate d a bsti nen ce rat
e s nth mo 5+ at
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.
CANCER DIAGNOSIS:
A TEACHABLE MOMENT
“The window of opportunity remains open throughout treatment and into the period of cancer survivorship.”
-- Ellen R. Gritz, PhD
The University of Texas MD Anderson Cancer Center
Interest and motivation to quit is increased after cancer diagnosis
Particularly for cancers closely related to smoking, such as lung and head & neck cancer
Health-care providers should routinely address
smoking with patients and family members during
this window of opportunity
Tobacco users expect to be encouraged to quit by health professionals.
Screening for tobacco use and providing tobacco cessation counseling are positively
associated with patient satisfaction (Barzilai et al., 2001).
Barzilai et al. (2001). Prev Med 33:595–599.
Failure to address tobacco use tacitly implies that quitting is not important.
WHY SHOULD CLINICIANS
ADDRESS TOBACCO?
The 5 A’s
ASK about tobacco USE
ADVISE tobacco users to QUIT
ASSESS READINESS to make a quit attempt
ASSIST with the QUIT ATTEMPT
ARRANGE FOLLOW-UP care
HANDOUT
Ask about tobacco use
“Do you, or does anyone in your household, ever smoke or use any type of tobacco?”
“We ask all of our patients about tobacco use, because it can negatively impact your [surgery, radiation, chemotherapy] treatment.”
ASK
STEP 1: ASK
tobacco users to quit
“Quitting is an important component of your treatment for cancer.”
“Smoking slows the healing process after surgery.”
“Patients who smoke during radiation therapy have reduced treatment efficacy and lower survival than non-smokers.”
“Smoking interacts with many of the chemotherapy medications, and can reduce its effects.”
“It will be important for your family and close friends to either quit with you or to be supportive of your quitting.”
ADVISE
STEP 2: ADVISE
STEP 3: ASSESS
readiness to quit
Ask every tobacco user if s/he is willing to quit at this time.
If willing to quit, provide resources and assistance
See STEP 4, ASSIST
If NOT willing to quit at this time, provide resources and enhance motivation. Ask three questions:
“Do you ever plan to quit?” [If yes, continue with…]
“How will it benefit you to quit later, as opposed to now?”
“What is the worst thing that could happen if you were to quit tomorrow?”
ASSESS
STEP 4: ASSIST
tobacco users with a quit plan
Discuss reasons for quitting and benefits of quitting
Review past quit attempts -- what helped, what led to relapse
Discuss support from family, friends, and coworkers
Set a quit date -- within 2 weeks
Encourage use of pharmacotherapy when not contraindicated
Anticipate challenges, particularly during the first few weeks
Nicotine withdrawal, stress-related smoking, etc.
ASSIST
STEP 5: ARRANGE
follow-up care
Status of attempt
Ask about support from friends, family, co-workers
Identify ongoing temptations and triggers for relapse
(stress, negative affect, smokers, eating, alcohol, cravings)
Slips and relapse
Has the patient used tobacco at all -- even a puff?
Medication compliance, plans for termination
Is the regimen being followed?
Are withdrawal symptoms being alleviated?
ARRANGE
PROVIDE ASSISTANCE THROUGHOUT THE QUIT ATTEMPT
PROVIDE ASSISTANCE THROUGHOUT THE QUIT ATTEMPT
patients to other resources Referral options:
A doctor, nurse, pharmacist, or other clinician, for additional counseling
A local group program
The support program provided free with each smoking cessation medication
Websites like www.quitnet.org
The toll-free telephone quit line: 1-800-QUIT-NOW
REFER
IN THE ABSENCE OF TIME OR
EXPERTISE: REFER
REFERRAL to a TOLL-FREE TELEPHONE QUIT LINE
Referring patients to a toll-free quit line is simple and easily integrated into routine patient care.
Quit line callers receive one-on-one coaching from trained counselors
Follow-up counseling is provided
Quit lines are effective and are provided at no cost to the caller
1-800-QUIT-NOW
Sample cards, for distribution to patients.
