Tobacco Dependence
Nancy A. Rigotti, M.D.
Director, Tobacco Research & Treatment Center
Massachusetts General Hospital
Associate Professor of Medicine
Harvard Medical School
William C. Bailey, M.D.
Professor of Medicine and Director
Eminent Scholar Chair in Pulmonary Diseases
UAB Lung Health Center
Birmingham, AL
PACE
(Prevention and Cessation Education)
Collaboration of 12 US medical schools funded by the
National Cancer Institute
Boston University
Case Western Reserve University
Dartmouth College
Harvard University
Loma Linda University
University of Alabama – Birmingham
University of California – Los Angeles
University of Iowa
University of Kentucky
University of Massachusetts
University of Rochester
University of South Florida
WHERE YOU COME IN…
From curricular assessments at all 12 medical schools,
a national conference reached a consensus…
Most U.S. medical students graduate
without tobacco cessation and
prevention skills



Preceptorship Module
Community Experience Module
Pediatrics Module
PRECEPTORSHIP MODULE
Rationale



Students must practice new skills learned
in the classroom
Students model what they see in clinical
settings
Preceptors are key role models and
mentors
TOBACCO USE IN PERSPECTIVE
Leading preventable cause of death

>400,000 deaths per year in US


4 million deaths per year worldwide
Half of regular smokers die of a
tobacco- related disease
SMOKING DEATHS IN
PERSPECTIVE
2.3%
1.8%
1.2%
0.8%
0.7%
Firearms
Sexual
behavior
Illicit drug
use
3.1%
Motor
vehicle
Alcohol
consumption
3.5%
Toxic agents
16.6%
Microbial
agents
18.1%
Poor
diet/physical
inactivity
20%
18%
16%
14%
12%
10%
8%
6%
4%
2%
0%
Tobacco
Percent of all U.S. deaths
Actual Causes of Death in the United States, 2000
Actual Cause
Data from Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000.
JAMA. 2004;291(10):1238-1245.
6
PASSIVE SMOKING

53,000 deaths per year

Respiratory illness - children of smokers

Lung cancer - nonsmoking spouses of smokers

Cardiovascular disease - nonsmoking spouses
U.S. ADULT SMOKING PREVALENCE
1955-2000
60
50
Men
% CURRENT
SMOKERS
40
30
25.7%
Women
20
21.0%
10
0
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
YEAR
*Before 1992, current smokers were defined as persons who reported having smoked >100 cigarettes and who
currently smoked. Since 1992, current smokers were defined as persons who reported having smoked >100
cigarettes during their lifetime and who reported now smoking every day day or some days.
Source: 1955 Current Population Survey; 1965-2000 National Health Interview Survey.
Why should I treat tobacco dependence?
• Tobacco causes premature death of almost half a
million Americans each year
• 1/3 of all tobacco users in this country will die
prematurely from tobacco dependence losing an
average of 14 years
• 70% of smokers see a physician each year
• At least 70% of smokers want to quit
Are physicians intervening in tobacco use?
In 38 primary care practices:
Tobacco was discussed in 21% of encounters.
Discussion was:
– more common in the 58% of practices with standard forms for
recording smoking status
– more common during new patient visits
– less common with older patients
– less common with physicians in practice more than 10 years.
»
Ellerbeck, Ahluwalia, et al. Direct observation of smoking cessation activities in
primary care practice.
J Fam Pract. 2001;50:688-693
Barriers to treating tobacco dependence
“Not enough time.”
“Patients don’t want to hear about it.”
“I can’t help patients stop.”
“Not enough time”
“Minimal interventions lasting less
than 3 minutes increase overall
tobacco abstinence rates.”
The PHS Guideline
(Strength of Evidence = A)
“Patients don’t want to hear about it”
“Smoking cessation interventions during
physician visits were associated with
increased patient satisfaction with their care
among those who smoke.”
• 1,898 patients in a study who reported that they had
been asked about tobacco use or advised to quit
during the latest visit had 10% greater satisfaction
rating and 5% less dissatisfaction than those not
reporting such discussions
Mayo Clin Proc. 2001;76:138-143.
“I can’t help patients stop”
Effective clinical interventions
exist:
The Public Health Service
Clinical Practice Guideline
Treating Tobacco Use and
Dependence was published in
June, 2000 and offers effective
treatments for tobacco
dependence.
Tobacco dependence is a chronic disease
• Tobacco dependence requires ongoing rather
than acute care
• Relapse is a component of the chronic nature
of the nicotine dependence — not an
indication of personal failure by the patient or
the clinician
Tobacco results in a true drug dependence
• Tobacco dependence exhibits classic characteristics
of drug dependence
• Nicotine is:
– Psychoactive
– Tolerance producing
• Causes physical dependence characterized by
withdrawal symptoms upon cessation
The 5 A’s For Patients Willing To Quit
• ASK about tobacco use.
• ADVISE to quit.
• ASSESS willingness to make a quit
attempt.
• ASSIST in quit attempt.
• ARRANGE for follow-up.
ASK
EVERY patient at EVERY visit
VITAL SIGNS
Blood Pressure: _______________________________
Pulse: ________________ Weight: _______________
Temperature: ________________________________
Respiratory Rate: _____________________________
Tobacco Use:
Current
Former
Never (circle one)
ADVISE
• Once tobacco use status has been identified and
documented, advise all tobacco users to quit
• Even brief advice to quit results in greater quit rates
• Advice should be:
- clear
- strong
- personalized
“As your health care
provider, I must tell you that
the most important thing you
can do to improve your
health is to stop smoking.”
ASSESS
After providing a clear, strong,
and personalized message to
quit, you must determine
whether the patient is willing
to quit at this time
“Are you willing
to try to quit at
this time? I can
help you.”
ASSIST
•
•
•
•
Help develop a quit plan
Provide practical counseling
Provide intra-treatment social support
Help your patient obtain extra-treatment social
support
• Recommend pharmacotherapy except in special
circumstances
• Provide supplementary materials
Developing a quit plan
• Set a quit date
• Review past quit attempts
• Anticipate challenges
• Remove tobacco products
• Avoid
– Alcohol use
– Exposure to tobacco
Counsel your patients to quit
“Minimal interventions lasting less than 3 minutes increase overall
tobacco abstinence rates”
The PHS Guideline
(Strength of Evidence = A)
“There is a strong dose-response relation between the session length
of person-to-person contact and successful treatment outcomes.
Intensive interventions are more effective than less intensive
interventions and should be used whenever possible”
The PHS Guideline
(Strength of Evidence = A)
First-line pharmacotherapies
• Bupropion SR
• Nicotine gum
• Nicotine inhaler
• Nicotine nasal spray
• Nicotine patch
Bupropion SR
• Only non-nicotine medication approved by the
FDA as an aid to smoking cessation treatment
• Available by prescription only (USA)
• Mechanism of action: presumably blocks neural
reuptake of dopamine and/or norepinephrine
Bupropion SR
Contraindications
Seizure disorder
MAO inhibitor within previous 2 weeks
Hx of anorexia nervosa or bulimia
Current use of Wellbutrin
Side effects
Insomnia
Dry mouth
Bupropion SR
• Dosing:
–
–
–
–
start 1-2 weeks before quit date
150 mg orally once daily x 3 day
150 mg orally twice daily x 7-12 weeks
no taper necessary at end of treatment
• Maintenance - efficacious as maintenance
medication for <6 months post-cessation
Nicotine Replacement Therapy (NRT)
• Nicotine is active ingredient
• Supplied as steady dose (patch) or self-administered
(gum, inhaler, nasal spray, lozenge)
• Self-administered products should be used on
scheduled basis initially before tapered to ad lib use
and eventual discontinuation
Nicotine Replacement Therapy (NRT)
• No evidence of increased cardiovascular risk
with NRT
• Medical contraindications:
– immediate myocardial infarction (< 2
weeks)
– serious arrhythmia
– serious or worsening angina pectoris
– accelerated hypertension
Nicotine Replacement Therapy (NRT)
•
•
•
•
Nicotine gum
Nicotine patch
Nicotine inhaler
Nicotine nasal spray
Nicotine gum
•
•
•
•
2 mg vs 4 mg
Chew and park
Absorbed in a basic environment
Use enough pieces each day
Nicotine patch
• Available as both prescription and OTC
• A new patch is applied each morning
• Rotating placement site can reduce irritation
Nicotine inhaler
• Available by prescription
• Frequent puffing is required
• Eating or drinking before and during administration
should be avoided
Nicotine nasal spray
• Available by prescription
• Patient should not sniff, swallow, or
inhale the medication
• Initial dosing should be 1 to 2 doses per
hour, increasing as needed
• Dosing should not exceed 40 per day
Combination Pharmacotherapy
Combination NRT
• Patch + gum or patch + nasal spray are more
effective than a single NRT
• Encourage use in patients unable to quit
using single agent
• Caution patients on risk of nicotine overdose
• Currently combination therapy is not an
FDA-approved treatment option
ARRANGE
• Schedule a follow-up contact within one week
after the quit date
– Telephone contact
– Quit lines
• The majority of relapse occurs in the first two
weeks after quitting
Relapse
• Preventing Relapse
– Congratulate success
– Encourage continued abstinence
– Discuss with your patient:
• benefits of quitting
• barriers
“How has stopping
tobacco use helped
you?.”
• If your patient has used tobacco, remind him or her
that the relapse should be viewed as a learning
experience
• Relapse is consistent with the chronic nature of
tobacco dependence; not a sign of failure
Treating patients who are not ready to
make a quit attempt
• RELEVANCE: Tailor advice and discussion
to each patient.
• RISKS: Outline risks of continued smoking.
• REWARDS: Outline the benefits of quitting.
• ROADBLOCKS: Identify barriers to
quitting.
• REPETITION: Reinforce the motivational
message at every visit.
“Not since the polio vaccine has this nation had
a better opportunity to make a significant
impact in public health.”
David Satcher, MD, PhD,
Former U.S. Surgeon General
HELPING YOUR STUDENT
USE THE 5 A’s
 Model the behavior
 Supervise
 Provide feedback to student
STUDENTS COUNSEL MORE WHEN THEIR
PRECEPTORS…
SERVE AS ROLE MODEL
 Counsel patients about smoking
and
discuss smoking cessation strategies
while the student observes
STUDENTS COUNSEL MORE WHEN THEIR
PRECEPTORS…
USE TEACHING SKILLS
 Set clear goals and expectations
 Use the patient interaction as a
teachable moment
 Give feedback on performance