Rx for CHANGE
Clinician-Assisted Tobacco Cessation
TRAINING OVERVIEW
Epidemiology of Tobacco Use
Forms of Tobacco
Nicotine Pharmacology & Principles of Addiction
Drug Interactions with Smoking
Assisting Patients with Quitting
Medications for Cessation
Tobacco Trigger Tapes
Role Playing with Case Scenarios and Video Counseling
Sessions
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…
All forms of tobacco are harmful.
WORLDWIDE PREVALENCE of ADULT TOBACCO USE (Men/Women)
World Lung Foundation. The Tobacco Atlas, 2017.
U.S. data from: Centers for Disease Control and Prevention (CDC). (2018). MMWR 67:1225–1232.
Canada 17/13
USA 16/12
Brazil 17/11
Greece 41/35
Russian Federation 51/17
China 45/2
UK 23/20
France 34/28
South Africa 22/9
Japan 36/11
India 23/3 Iran
23/2
Australia 15/12 Mexico
16/5
TRENDS in ADULT SMOKING, by SEX—U.S., 1955–2017
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;
1965–2017 NHIS. Estimates since 1992 include some-day smoking.
Percent
68% want to quit
55% tried to quit in the past year
Males
Females
15.8%
12.2%
14.0% of adults are current
smokers
Year
STATE-SPECIFIC PREVALENCE of
SMOKING among ADULTS, 2014–2015
* Has smoked ≥ 100 cigarettes during lifetime and currently smokes either every day or some days.
`
≥ 18.0%
15.0 – 17.9%
12.0 – 14.9%
8.0 – 11.9%
Prevalence of current* cigarette smoking
Centers for Disease Control and Prevention (CDC). (2018). MMWR 67:97–102.
PREVALENCE of ADULT SMOKING, by RACE/ETHNICITY—U.S., 2017
Centers for Disease Control and Prevention (CDC). (2018). MMWR 67:1225–1232.
7.1%
24.0%
14.9%
9.9%
20.6%
Percent
Asian American Indian/Alaska Native
Black White
Hispanic Multiple races
15.2%
PREVALENCE of ADULT SMOKING, by EDUCATION—U.S., 2017
Percent
Undergraduate degree No high school diploma GED diploma High school graduate Some college
7.1%
Graduate degree
23.1%
18.7%
17.4%
4.1%
36.8%
Centers for Disease Control and Prevention (CDC). (2018). MMWR 67:1225–1232.
TRENDS in TEEN SMOKING, by ETHNICITY—U.S., 1977–2016
Trends in cigarette smoking among 12th graders: 30-day prevalence of use
1977 1979
1981 1983
1985 1987
1989 1991
1993 1995
1997 1999
2001 2003
2005 2007
2009 2011
2013 2015 0
10 20 30 40 50
Year
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 $12.4 to market its products.
TOBACCO INDUSTRY MARKETING
$8.71 billion spent in the U.S. in 2016
$23.6 million a day
B ill io n s o f d o lla rs s p en t
Year
Federal Trade Commission (FTC). (2018). Cigarette Report for 2016.
1970 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
0 2 4 6 8 10 12 14
16
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
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
An EFFECTIVE MARKETING
STRATEGY: “LIGHT” CIGARETTES
The difference between Marlboro and Marlboro Lights…
an extra row of ventilation holes
Image courtesy of Mayo Clinic Nicotine Dependence Center - Research Program / Dr. Richard D. Hurt The Marlboro and Marlboro Lights logos are registered trademarks of Philip Morris USA.
1932
1936
1990
SMOKING in MOVIES
Cigarette smoking is pervasive in movies
Evident in at least ¾ of box-office hits
Average, 10.9 smoking incidents per hour
Superman II (1980)
There is a dose-response, causal relationship between exposure to
smoking in movies and youth smoking initiation
70% of adults support assigning an
“R” rating to movies with smoking.
National Cancer Institute. (2008). The Role of the Media in Promoting and Reducing Tobacco Use.
For more information on smoking in movies, go to http://smokefreemovies.ucsf.edu Charlesworth and Glantz. (2005). Pediatrics 116:1516–1528.
FDA REGULATION of TOBACCO PRODUCTS
The FDA Center for Tobacco Control Products is responsible for regulation of:
Cigarettes
Cigarette tobacco
Roll-your-own tobacco
Smokeless tobacco
E-cigarettes*
*Not a tobacco product.
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 16 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.
ANNUAL U.S. DEATHS ATTRIBUTABLE to SMOKING, 2005–2009
33%
27%
23%
9%
7%
<1%
Cardiovascular & metabolic diseases 160,600
Lung cancer 130,659
Pulmonary diseases 113,100
Second-hand smoke 41,280
Cancers other than lung 36,000
Other 1,633
Percent of all smoking- attributable deaths
TOTAL: >480,000 deaths annually
U.S. Department of Health and Human Services (USDHHS). (2014).
The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General.
CORONARY HEART DISEASE and STROKE with LOW CIGARETTE CONSUMPTION
Men Women
0 10 20 30 40 50 60
Heart disease Stroke
Smoking 1 cigarette/day:
40-50% of the additional risk associated with smoking 20 cigarettes/day
Smokers should aim to quit completely.
Hackshaw et al. (2018). BMJ 360:j2984. [Meta-analysis of 55 publications representing 141 cohort studies]
Pe rc en t of a dd iti on al r is k
Additional risk associated with smoking 1 cigarette per day
(compared to never smokers)
ANNUAL SMOKING-ATTRIBUTABLE ECONOMIC COSTS
Health-care expenditures
Societal costs: $19.16 per pack of cigarettes smoked
Lost productivity costs due to premature mortality
Total economic burden of smoking, per year
Billions of US dollars
$132.5 billion
$156.4 billion
$288.9 billion
U.S. Department of Health and Human Services (USDHHS). (2014).
The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General.
2014 REPORT of the SURGEON GENERAL:
HEALTH CONSEQUENCES OF SMOKING
Cigarette smoking is causally linked to diseases of nearly all organs of the body, diminished health status, and harm to the fetus.
Additionally, smoking has many adverse effects on the body, such as causing inflammation and impairing immune function.
Exposure to secondhand smoke is causally linked to cancer,
respiratory, and cardiovascular diseases, and to adverse effects on the health of infants and children.
Disease risks from smoking by women have risen over the last 50 years and for many tobacco-related diseases are now equal to those for men.
MAJOR DISEASE-RELATED CONCLUSIONS:
U.S. Department of Health and Human Services (USDHHS). (2014).
The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General.
HEALTH CONSEQUENCES of SMOKING
Cancers
Bladder/kidney/ureter
Blood (acute myeloid leukemia)
Cervix
Colon/rectum
Esophagus/stomach
Liver
Lung
Oropharynx/larynx
Pancreatic
Pulmonary diseases
Asthma
COPD
Pneumonia/tuberculosis
Chronic respiratory symptoms
Cardiovascular diseases
Aortic aneurysm
Coronary heart disease
Cerebrovascular disease
Peripheral vascular disease
Reproductive effects
Reduced fertility in women
Poor pregnancy outcomes (e.g., congenital defects, low birth weight, preterm delivery)
Infant mortality
Other: cataract, diabetes (type 2), erectile dysfunction, impaired immune function, osteoporosis, periodontitis, postoperative complications, rheumatoid arthritis
U.S. Department of Health and Human Services (USDHHS). (2014).
The Health Consequences of Smoking—50 Years of Progress: 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 LeukoplakiaImage courtesy of Dr. Sol Silverman - University of California San Francisco
HERMAN ® is reprinted with permission from LaughingStock Licensing Inc., Ottawa, Canada
All rights reserved.
U.S. Department of Health and Human Services (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
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
BENEFICIAL EFFECTS of QUITTING:
PULMONARY EFFECTS
Reprinted with permission. Fletcher & Peto. (1977). BMJ 1(6077):1645–1648.
Disability
Death
Smoked regularly and susceptible to effects of smoke
Never smoked or not susceptible to smoke
Stopped smoking at 45 (mild COPD)
Stopped smoking at 65 (severe COPD) 25
FEV 1 (% of value at age 25)
25 50 75 100
0
50 75
Age (years)
COPD = chronic obstructive pulmonary disease
AT ANY AGE, there are benefits of quitting.
Reduction in cumulative risk of
death from lung cancer in men
Reprinted with permission. Peto et al. (2000). BMJ 321(7257):323–329.
Cumulative risk (%)
Age in years
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.
FINANCIAL IMPACT of SMOKING
Packs per
day
Buying cigarettes every day for 50 years at $6.26 per pack*
(does not include interest)
Dollars lost, in thousands
$755,177
$503,451
$251,725 $114,245
$228,490
$342,735
* Average national cost, as of January 2019. Campaign for Tobacco-Free Kids, 2018.
Annual cost of smoking 1 pack per day:
$2,285
EPIDEMIOLOGY of TOBACCO USE: SUMMARY
Fewer than one in five adults are current smokers; smoking prevalence varies by sociodemographic characteristics
Nearly half a million U.S. deaths are attributable to smoking annually
Smoking costs the U.S. an estimated $288.9 billion annually
For the individual, a smoking a pack-a-day costs $2,285 annually, plus associated health-care costs
At any age, there are benefits to quitting smoking
The biggest opponent to tobacco control efforts is the
tobacco industry
FORMS of TOBACCO
FORMS of TOBACCO
Cigarettes
Smokeless tobacco (chewing tobacco, oral snuff)
Pipes
Cigars
Clove cigarettes
Bidis
Hookah (waterpipe smoking)
Electronic cigarettes (“e-cigarettes”)*
Image courtesy of the Centers for Disease Control and Prevention / Rick Ward
*e-cigarettes are devices that deliver nicotine and are not a form of tobacco.
AMERICAN CIGARETTES
Most common form of tobacco used in U.S.
Sold in packs (20 cigarettes/pack)
Total nicotine content, per cigarette:
- Average 13.5 mg (range, 11.9 to 14.5 mg)
Machine-measured nicotine yield:
Smoker’s nicotine yield, per cigarette:
- Approximately 1 to 2 mg
Marlboro and Marlboro Light are registered trademarks of Philip Morris, Inc.
Type of cigarette Yield per cigarette Full-flavor (regular) 1.1 mg
Light 0.8 mg
Ultra-light 0.4 mg
Average (all brands) 0.9 mg
SMOKELESS TOBACCO
Chewing tobacco
Looseleaf
Plug
Twist
Snuff
Moist
Dry
The Copenhagen and Skoal logos are registered trademarks of U.S. Smokeless Tobacco Company, and Red Man is a registered trademark of Swedish Match.
SMOKELESS FORMS of TOBACCO
Estimated 8.8 million users in the U.S. in 2013 (3.4%)
Adult males (6.5%) more likely than adult females (0.4%) to be current users
Prevalence highest among
Young adults aged 18-25 years
Residents of the Midwest and Southern U.S.
Residents of nonmetropolitan areas
Significant health risks
Numerous carcinogens
Nicotine exposure comparable to that of smokers, leading to
Physical dependence
Withdrawal symptoms after abstinence
NICOTINE CONTENT in
SMOKELESS TOBACCO PRODUCTS
Dose Product pH Total free
nicotine (mg/g)
Low Hawken Wintergreen 5.2 – 5.7 0.01 – 0.02 Skoal Bandits Wintergreen 6.9 – 7.1 0.5 – 1.0 Medium Skoal Long Cut Straight 7.5 – 7.6 2.4 – 3.7
High Kodiak Wintergreen 8.2 – 8.4 5.8 – 6.5
Copenhagen 7.6 – 8.6 3.1 – 9.4
Data from Hatsukami et al. (2007). Am J Prev Med 33(6S):S368–78.
HEALTH CONSEQUENCES of SMOKELESS TOBACCO USE
Periodontal effects
Gingival recession
Bone attachment loss
Dental caries
Oral leukoplakia Cancer
Oral cancer
Pharyngeal cancer
Oral LeukoplakiaImage courtesy of Dr. Sol Silverman - University of California San Francisco
PIPE TOBACCO
Prevalence of pipe smoking in the U.S. is less than 1%
Pipe smokers have an increased risk of death due to:
Cancer (lung, oral cavity, esophagus, larynx)
Chronic obstructive pulmonary disease
Risk of smoking tobacco-related death:
cigarettes > pipes ≈ cigars
CIGARS
Estimated 12.4 million cigar smokers in the U.S. in 2013
Tobacco content of cigars varies greatly
One cigar can deliver enough nicotine to establish and
maintain dependence
Cigar smoking is not a safe alternative to cigarette
smoking
CLOVE CIGARETTES
(also known as KRETEKS)
Mixture of tobacco and cloves
Imported from Indonesia
In 2012, an estimated 3.0% of 12
thgraders in the U.S. reported
smoking kreteks in the past year
Two times the tar and nicotine
content of standard cigarettes
BIDIS
Imported from India
Resemble marijuana joints
Available in candy flavors
In 2010, an estimated 1.4% of 12 th graders in the U.S. reported smoking bidis in the past year
Deliver 3-fold higher levels of carbon monoxide and nicotine and 5-fold higher levels of tar when compared to standard cigarettes
Image courtesy of the Centers for Disease Control and Prevention / Dr. Clifford H. Watson
HOOKAH (WATERPIPE SMOKING)
Also known as
Shisha, Narghile, Goza, Hubble bubble
Tobacco flavored with fruit pulp, honey, and molasses
Increasingly popular among young adults in coffee houses, bars, and lounges
In 2012, 18.3% of 12
thgraders and 25.7% of U.S. college students had smoked hookah in the past year
Nicotine, tar and carbon monoxide levels
comparable to or higher than those in cigarette smoke
Image courtesy of Mr. Sami Romman / www.hookah-shisha.com
Generally similar in appearance to cigarettes, cigars, pipes, or pens
Battery-operated devices that create a vapor for inhalation
Simulates smoking but does not involve combustion of tobacco
Also known as
E-cigarette
E-hookah, Hookah pen
Vapes, Vape pen, Vape pipe
Electronic nicotine delivery system (ENDS)
ELECTRONIC CIGARETTES
Power source
Rechargeable or disposable battery
Cartridge containing liquid solution
Propylene glycol
Glycerin
Flavorings (tobacco, fruit, chocolate, mint, cola, candy, etc.)
Nicotine (0-36 mg/mL)
Electronic atomizer/vaporizer
Heating element vaporizes liquid at temperatures 65-120 °C
ELECTRONIC CIGARETTES:
Components
Propylene glycol may cause respiratory irritation and increase the risk for asthma
Glycerin may cause lipoid pneumonia on inhalation
Nicotine is highly addictive and can be harmful
Refill cartridges with high concentrations of nicotine are a poisoning risk, especially in children
Carcinogenic substances are found in some aerosols
Use of e-cigarettes leads to emission of propylene glycol, particles, nicotine, and carcinogens into indoor air
Long-term safety of second hand exposure to e-cigarette aerosols is unknown
Electronic cigarettes are not proven to be safe.
ELECTRONIC CIGARETTES:
Potential health risks
E-cigarettes are not emission-free
During vaping sessions, compounds and particles emitted into the indoor air include
Propylene glycol
Glycerin
Heavy metals
Levels of most substances lower than conventional cigarettes
Long-term safety of second-hand exposure to e- cigarette aerosols is unknown
Nicotine
Flavoring agents
Polycyclic aromatic hydrocarbons
German Cancer Research Center (Ed). Electronic Cigarettes—An Overview. Heidelberg, 2013.
Schober et al., Int J Hyg Environ Health 2014; 217:628-37.
ELECTRONIC CIGARETTES:
Indoor Air Pollution
Predominantly used by smokers and smokers who are considering quitting
Used as an alternative to cigarette smoking and as an aid for cessation
Perceived as less harmful than conventional cigarettes
Use is increasing among adolescents and young adults
ELECTRONIC CIGARETTES:
Current Trends and Evidence
Can reduce the desire (craving) to smoke cigarettes and alleviate nicotine withdrawal symptoms
Some smokers reduce the number of cigarettes smoked or quit smoking as a result of using e- cigarettes
Have not been proven effective as an aid for sustained smoking cessation
ELECTRONIC CIGARETTES:
Current Trends and Evidence, cont’d
Long-term safety and efficacy data are lacking.
FORMS of TOBACCO: SUMMARY
Cigarettes are, by far, the most common form of tobacco used in the U.S.
Other forms of tobacco and nicotine delivery devices exist, and some are increasing in popularity.
All forms of tobacco are harmful.
The safety/efficacy of e-cigarettes is not established.
Attention to all forms of tobacco is needed.
NICOTINE PHARMACOLOGY and
PRINCIPLES of ADDICTION
NICOTINE ADDICTION
U.S. Surgeon General’s Report
Cigarettes and other forms of tobacco are addicting.
Nicotine is the drug in tobacco that causes addiction.
The pharmacologic and behavioral processes that determine tobacco addiction are similar to those that determine addiction to drugs such as heroin and cocaine.
U.S. Department of Health and Human Services. (1988). The Health Consequences of Smoking: Nicotine Addiction. A Report of the Surgeon General.
Nicotiana tabacum Natural liquid alkaloid
Colorless, volatile base pK a = 8.0
N CH
3N
H
Pyridine ring
Pyrrolidine ring
CHEMISTRY of NICOTINE
PHARMACOLOGY
Effects of the body on the drug
Absorption
Distribution
Metabolism
Excretion
Effects of the drug on the body Pharmacokinetics
Pharmacodynamics
NICOTINE ABSORPTION
Absorption is pH dependent
In acidic media
Ionized poorly absorbed across membranes
In alkaline media
Nonionized well absorbed across membranes
At physiologic pH (7.4), ~31% of nicotine is nonionized
At physiologic pH,
nicotine is readily absorbed.
NICOTINE ABSORPTION:
BUCCAL (ORAL) MUCOSA
The pH inside the mouth is 7.0.
Acidic media (limited absorption)
Cigarettes
Alkaline media
(significant absorption) Pipes, cigars,
spit tobacco,
oral nicotine products
Beverages can alter pH, affect absorption.
NICOTINE ABSORPTION: SKIN and GASTROINTESTINAL TRACT
Nicotine is readily absorbed through intact skin.
Nicotine is well absorbed in the small intestine but has low bioavailability (20-45%) due to
first-pass hepatic metabolism.
NICOTINE ABSORPTION: LUNG
Nicotine is “distilled” from burning tobacco and carried in tar droplets.
Nicotine is rapidly absorbed across respiratory epithelium.
Lung pH = 7.4
Large alveolar surface area
Extensive capillary system in lung
Approximately 1 mg of nicotine is absorbed from
each cigarette.
NICOTINE DISTRIBUTION
Henningfield et al. (1993). Drug Alcohol Depend 33:23–29.
Arterial
Venous
Nicotine reaches the brain within 10–20 seconds.
Metabolized and excreted
in urine
NICOTINE METABOLISM
CH
3N
H 10–20%
excreted unchanged
in urine
Adapted and reprinted with permission. Benowitz et al. (1994). J Pharmacol Exp Ther 268:296–303
.
70–80%
cotinine ~ 10% other metabolites
N
NICOTINE EXCRETION
Half-life
Nicotine t ½ = 2 hr
Cotinine t ½ = 16 hr
Excretion
Occurs through kidneys (pH dependent;
h with acidic pH)
Through breast milk
NICOTINE
PHARMACODYNAMICS
Nicotine binds to receptors in the brain and other
sites in the body.
Other:
Neuromuscular junction Sensory receptors
Other organs
Central nervous system
Exocrine glands Adrenal medulla
Peripheral nervous system Gastrointestinal system
Cardiovascular system
Nicotine has predominantly stimulatory effects.
NICOTINE
PHARMACODYNAMICS (cont’d)
Central nervous system
Pleasure
Arousal, enhanced vigilance
Improved task performance
Anxiety relief
Other
Appetite suppression
Increased metabolic rate
Skeletal muscle relaxation
Cardiovascular system
Heart rate
Cardiac output
Blood pressure
Coronary vasoconstriction
Cutaneous vasoconstriction
NEUROCHEMICAL and RELATED EFFECTS of NICOTINE
Dopamine
Norepinephrine
Acetylcholine
Glutamate
Serotonin
-Endorphin
GABA
N I C O T I N
E
Pleasure, appetite suppression
Arousal, appetite suppression
Arousal, cognitive enhancement
Learning, memory enhancement
Mood modulation, appetite suppression
Reduction of anxiety and tension
Reduction of anxiety and tension
Benowitz. (2008). Clin Pharmacol Ther 83:531–541.
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 addiction is a chronic condition with a biological basis.
Nicotine enters brain
Stimulation of
nicotine receptors Dopamine release
DOPAMINE REWARD PATHWAY
Prefrontal cortex
Nucleus accumbens
Ventral tegmental
area
CHRONIC ADMINISTRATION of
NICOTINE: EFFECTS on the BRAIN
Perry et al. (1999). J Pharmacol Exp Ther 289:1545–1552.
Nonsmoker Smoker
Human smokers have increased nicotine receptors in the prefrontal cortex.
High
Low
Image courtesy of George Washington University / Dr. David C. Perry
NICOTINE WITHDRAWAL SYMPTOMS:
Time Course*
Quit date
12 weeks
Recent quitter Former
tobacco user
1 week 4 weeks
Irritability / Frustration / Anger Anxiety
Difficulty concentrating Restlessness / Impatience Depressed mood / Depression Insomnia
Impaired task performance Increased appetite
Weight gain Cravings
6 months
Data from 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.
*Timeline aspect of the figure is not according to scale.
Can persist for months to years after quitting
NICOTINE ADDICTION CYCLE
Reprinted with permission. Benowitz. (1992). Med Clin N Am 2:415–437.
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.ASSESSING
NICOTINE DEPENDENCE
Fagerström Test for Nicotine Dependence (FTND)
Developed in 1978 (8 items); revised in 1991 (6 items)
Most common research measure of nicotine dependence;
sometimes used in clinical practice
Responses coded such that higher scores indicate higher levels of dependence
Scores range from 0 to 10; score of greater than 5 indicates substantial dependence
Heatherton et al. (1991). British Journal of Addiction 86:1119–1127.
CLOSE TO HOME © 2000 John McPherson.
Reprinted with permission of UNIVERSAL PRESS SYNDICATE.
All rights reserved.
FACTORS CONTRIBUTING to TOBACCO USE
Individual
Sociodemographics
Genetic predisposition
Coexisting medical conditions
Environment
Tobacco advertising
Conditioned stimuli
Social interactions
Pharmacology
Alleviation of withdrawal symptoms
Weight control
Pleasure, mood modulation
Tobacco
Use
TOBACCO DEPENDENCE:
A 2-PART PROBLEM
Tobacco Dependence
Treatment should address the physiological and the behavioral aspects of dependence.
Physiological Behavioral
Treatment Treatment
The addiction to nicotine
Medications for cessation
The habit of using tobacco
Behavior change program
NICOTINE PHARMACOLOGY and ADDICTION: SUMMARY
Tobacco products are effective delivery systems for the drug nicotine.
Nicotine is a highly addictive drug that induces a
constellation of pharmacologic effects, including activation of the dopamine reward pathway in the brain.
Tobacco use is complex, involving the interplay of a wide range of factors.
Treatment of tobacco use and dependence requires a
multifaceted treatment approach.
DRUG INTERACTIONS with
SMOKING
PHARMACOKINETIC DRUG
INTERACTIONS with SMOKING
Drugs that may have a decreased effect due to induction of CYP1A2:
Bendamustine
Haloperidol
Tasimelteon
Caffeine
Olanzapine
Theophylline
Clozapine
Riociguat
Erlotinib
Ropinirole
Fluvoxamine
Tacrine
Irinotecan (clearance increased and systemic exposure decreased, due to increased glucuronidation of its active metabolite)
Smoking cessation will reverse these effects.
• Constituents in tobacco smoke induce CYP1A2 enzymes, which metabolize caffeine
─ Caffeine levels increase ~56% upon quitting
• Nicotine withdrawal effects might be enhanced by increased caffeine levels
• Decrease caffeine intake by 50% when quitting;
no caffeine after 1PM for individuals with a typical bedtime
DRUG INTERACTION:
TOBACCO SMOKE and CAFFEINE
PHARMACODYNAMIC DRUG
INTERACTIONS with SMOKING
Smokers who use combined hormonal
contraceptives have an increased risk of serious cardiovascular adverse effects:
Stroke
Myocardial infarction
Thromboembolism
This interaction does not decrease the efficacy of hormonal contraceptives.
Women who are 35 years of age or older AND smoke at least 15 cigarettes per day
are at significantly elevated risk.
DRUG INTERACTIONS with SMOKING: SUMMARY
Clinicians should be aware of their patients’
smoking status:
Clinically significant interactions result the combustion products of tobacco smoke, not from nicotine.
Constituents in tobacco smoke (e.g., polycyclic aromatic
hydrocarbons; PAHs) may enhance the metabolism of other drugs, resulting in an altered pharmacologic response.
Changes in smoking status might alter the clinical response to the treatment of a wide variety of conditions.
Drug interactions with smoking should be considered when
patients start smoking, quit smoking, or markedly alter their levels
of smoking.
ASSISTING PATIENTS
with QUITTING
Update released May 2008
Sponsored by the U.S. Department of
Health and Human Services, Public Heath Service with:
Agency for Healthcare Research and Quality
National Heart, Lung, & Blood Institute
National Institute on Drug Abuse
Centers for Disease Control and Prevention
National Cancer Institute
CLINICAL PRACTICE GUIDELINE for
TREATING TOBACCO USE and DEPENDENCE
TOBACCO DEPENDENCE:
A 2-PART PROBLEM
Tobacco Dependence
Treatment should address the physiological and the behavioral aspects of dependence.
Physiological Behavioral
Treatment Treatment
The addiction to nicotine
Medications for cessation
The habit of using tobacco
Behavior change program
METHODS for QUITTING
Pharmacologic
FDA-approved medications
Nonpharmacologic
Counseling and other non-drug approaches
Counseling and medications are both effective, but the combination of counseling and
medication is more effective than either alone.
Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update.
Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.
NONPHARMACOLOGIC METHODS
Cold turkey: Just do it!
Unassisted tapering (fading)
Reduced frequency of use
Lower nicotine cigarettes
Special filters or holders
Assisted tapering
QuitKey (PICS, Inc.)
Computer developed taper based on patient’s smoking level
Includes telephone counseling support
NONPHARMACOLOGIC METHODS (cont’d)
Formal cessation programs
Self-help programs
Individual counseling
Group programs
Telephone counseling
1-800-QUITNOW
Web-based counseling
www.smokefree.gov
www.quitnet.com
www.becomeanex.org
Acupuncture therapy
Hypnotherapy
Massage therapy
EFFECTS of CLINICIAN INTERVENTIONS
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.
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
2.5 2.4
n = 37 studies
The NUMBER of CLINICIAN TYPES CAN MAKE a DIFFERENCE, too
Compared to smokers who receive assistance from no clinicians, smokers who receive
assistance from two or more clinician types 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.
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; Conroy et al., 2005).
Barzilai et al. (2001). Prev Med 33:595–599; Conroy et al. (2005). Nicotine Tob Res 7 Suppl 1:S29–S34.
Failure to address tobacco use tacitly implies that quitting is not important.
WHY SHOULD CLINICIANS
ADDRESS TOBACCO?
ASK ADVISE ASSESS ASSIST ARRANGE
The 5 A’s
Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update.
Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.
The 5 A’s (cont’d)
about tobacco use
“Do you ever smoke or use other types of tobacco or nicotine, such as e-cigarettes?”
“I take time to ask all of my patients about tobacco use—because it’s important.”
“Condition X often is caused or worsened by smoking.
Do you, or does someone in your household smoke?”
“Medication X often is used for conditions linked with or caused by smoking. Do you, or does someone in your household smoke?”
ASK
tobacco users to quit (clear, strong, personalized)
“It’s important that you quit as soon as possible, and I can help you.”
“Cutting down while you are ill is not enough.”
“Occasional or light smoking is still harmful.”
“I realize that quitting is difficult. It is the most important thing you can do to protect your health now and in the future. I have training to help my patients quit, and when you are ready, I will work with you to design a specialized treatment plan.”
ADVISE
The 5 A’s (cont’d)
The 5 A’s (cont’d)
readiness to make a quit attempt ASSESS
with the quit attempt
Not ready to quit: enhance motivation (the 5 R’s)
Ready to quit: design a treatment plan
Recently quit: relapse prevention
ASSIST
follow-up care ARRANGE
The 5 A’s (cont’d)
Number of sessions Estimated quit rate*
0 to 1 12.4%
2 to 3 16.3%
4 to 8 20.9%
More than 8 24.7%
* 5 months (or more) postcessation
Provide assistance throughout the quit attempt.
Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update.
Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.
The 5 A’s: REVIEW
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
Faced with change, most people are not ready to act.
Change is a process, not a single step.
Typically, it takes multiple attempts.
HOW CAN I LIVE
WITHOUT TOBACCO?
The (DIFFICULT) DECISION
to QUIT
HELPING PATIENTS QUIT IS a CLINICIAN’S RESPONSIBILITY
THE DECISION TO QUIT LIES IN THE HANDS OF EACH PATIENT.
TOBACCO USERS DON’T PLAN TO FAIL.
MOST FAIL TO PLAN.
Clinicians have a professional obligation to address tobacco use and can have
an important role in helping patients
plan for their quit attempts.
STAGE 1: Not ready to quit in the next month STAGE 2: Ready to quit in the next month
STAGE 3: Recent quitter, quit within past 6 months STAGE 4: Former tobacco user, quit > 6 months ago
ASSESSING
READINESS to QUIT
Patients differ in their readiness to quit.
Assessing a patient’s readiness to quit enables clinicians
to deliver relevant, appropriate counseling messages.
Former tobacco
user
Recent quitter
Ready to quit
Not ready to quit Relapse
Not thinking about it
Thinking about it, not ready
For most patients, quitting is a cyclical process, and their readiness to quit (or stay quit) will change over time.
Assess
readiness to quit (or to stay quit)
at each patient contact.
ASSESSING
READINESS to QUIT (cont’d)
STAGE 1: Not ready to quit
Not thinking about quitting in the next month
Some patients are aware of the need to quit.
Patients struggle with ambivalence about change.
Patients are not ready to change, yet.
Pros of continued tobacco use outweigh the cons.
GOAL: Start thinking about quitting.
ASSESSING
READINESS to QUIT (cont’d)
STAGE 1: NOT READY to QUIT Counseling Strategies
DON’T
Persuade
“Cheerlead”
Tell patient how bad tobacco is, in a judgmental
manner
Provide a
treatment plan DO
Strongly advise to quit
Provide information
Ask noninvasive questions;
identify reasons for tobacco use
Raise awareness of health consequences/concerns
Demonstrate empathy, foster communication
Leave decision up to patient
Consider asking:
“Do you ever plan to quit?”
“What might be some of the benefits of quitting now, instead of later?”
“What would have to change for you to decide to quit sooner?”
STAGE 1: NOT READY to QUIT Counseling Strategies (cont’d)
If YES If NO
Advise patients to quit, and offer to assist (if or when
they change their mind).
Most patients will agree: there is no “good” time to quit, and there are benefits to quitting sooner as opposed to later.
Responses will reveal some of the barriers to quitting.
The 5 R’s—Methods for enhancing motivation:
Relevance
Risks
Rewards
Roadblocks
Repetition
Tailored, motivational
messages
STAGE 1: NOT READY to QUIT Counseling Strategies (cont’d)
Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update.
Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.
STAGE 1: NOT READY to QUIT A Demonstration
CASE SCENARIO:
Ms. Lilly Vitale
You are a clinician providing care to Ms. Vitale, a young woman with
early-stage emphysema.
VIDEO # V6a
Ready to quit in the next month
Patients are aware of the need to, and the benefits of, making the behavioral change.
Patients are getting ready to take action.
STAGE 2: Ready to quit
GOAL: Achieve cessation.
ASSESSING
READINESS to QUIT (cont’d)
Assess tobacco use history
Discuss key issues
Facilitate quitting process
Practical counseling (problem solving/skills training)
Social support delivered as part of treatment
STAGE 2: READY to QUIT
Three Key Elements of Counseling
STAGE 2: READY to QUIT Assess Tobacco Use History
Praise the patient’s readiness
Assess tobacco use history
Current use: type(s) of tobacco, amount
Past use: duration, recent changes
Past quit attempts:
Number, date, length
Methods/medications used, adherence, duration
Reasons for relapse
Reasons/motivation to quit
Confidence in ability to quit
Triggers for tobacco use
What situations lead to temptations to use tobacco?
What led to relapse in the past?
Routines/situations associated with tobacco use
STAGE 2: READY to QUIT Discuss Key Issues
When drinking coffee
While driving in the car
When bored or stressed
While watching television
While at a bar with friends
After meals or after sex
During breaks at work
While on the telephone
While with specific friends or family
members who use tobacco
“Smoking gets rid of all my stress.”
“I can’t relax without a cigarette.”
There will always be stress in one’s life.
There are many ways to relax without a cigarette.
THE MYTHS
STRESS MANAGEMENT SUGGESTIONS:
Deep breathing, shifting focus, taking a break.
Smokers confuse the relief of withdrawal with the feeling of relaxation.
STAGE 2: READY to QUIT Discuss Key Issues (cont’d)
THE FACTS
Stress-Related Tobacco Use
HERMAN ® is reprinted with permission from LaughingStock Licensing Inc., Ottawa, Canada
All rights reserved.
On average, quitters gain 9 to 11 pounds,
but there is a wide range.
Discourage strict dieting while quitting
Encourage healthful diet and meal planning
Suggest increasing water intake or chewing sugarless gum
Recommend selection of nonfood rewards
When fear of weight gain is a barrier to quitting
Consider pharmacotherapy with evidence of delaying weight gain (bupropion SR or 4-mg nicotine gum or lozenge)
Assist patient with weight maintenance or refer patient to specialist or program
STAGE 2: READY to QUIT Discuss Key Issues (cont’d)
Concerns about Weight Gain
Most pass within 2–4 weeks after quitting
Cravings can last longer, up to several months or years
Often can be ameliorated with cognitive or behavioral coping strategies
Refer to Withdrawal Symptoms Information Sheet
Symptom, cause, duration, relief
STAGE 2: READY to QUIT Discuss Key Issues (cont’d)
Concerns about Withdrawal Symptoms
Most symptoms manifest within the
first 1–2 days, peak within the
first week, and subside within 2–4
weeks.
STAGE 2: READY to QUIT Discuss Key Issues (cont’d)
Living with Another Smoker
Discuss importance and negotiate where and when he/she will smoke, but do not make demands
“Please keep your cigarettes where I won’t find them.”
Give the smoker one ashtray: “Please keep this clean and hidden from me.”
Surprise the smoker with a gift at the end of your first
month of quitting as a thank you
Discuss methods for quitting
Discuss pros and cons of available methods
Pharmacotherapy: a treatment, not a crutch!
Importance of behavioral counseling
Set a quit date
Recommend Tobacco Use Log
Helps patients to understand when and why they use tobacco
Identifies activities or situations that trigger tobacco use
Can be used to develop coping strategies to overcome the temptation to use tobacco
STAGE 2: READY to QUIT
Facilitate Quitting Process
Continue regular tobacco use for 3 or more days
Each time any form of tobacco is used, log the following information:
Time of day
Activity or situation during use
“Importance” rating (scale of 1–3)
