Tobacco & Nicotine: Vital Statistics Addiction and Treatment - PDF document

Tobacco & Nicotine: Vital Statistics Addiction and Treatment • 47 million US smokers Tim McAfee, MD, MPH • 440,000 deaths/year Chief Medical Officer - Free & Clear • >8 million disabled 206-876-2551 - tim.mcafee@freeclear.com • Smokers die ~ 8-13 years earlier Affiliate Assistant Professor, University of Washington, School of Public Health • 5 million smoking deaths/year in world More than 440,000 Annual Deaths Quitting Stats Attributable to Cigarette Smoking—United States Other 19+ % of Americans smoke tobacco Cancers Lung 31,000 Cancer 70+% want to quit 125,000 Ischemic Heart One in 20 quit attempts succeed Disease 82,000 Of those making a quit attempt: Other Stroke Diagnoses ~20% use a medication 17,000 Chronic Lung 105,000 ~2% use behavioral support Disease 82,000 Source: MMWR, 2005 Impact of Quitting Smoking Addiction • Prospective study of 34,439 male British MDs • Mortality monitored for 50 years ( 1951–2001) Years of life gained Sir Richard Doll 1912 – 2005 Age at cessation (years) Doll et al. (2004). BMJ 328(7455):1519–1527 1

Nicotine The Masters Speak… • Tertiary amine – pyridine and pyrrolidine ring • “ We are in the business of – strongly alkaline selling nicotine, an addictive • Evolved as insecticide in tobacco drug effective in the release of • Binds to nicotinic-cholinergic stress mechanisms” receptors – stimulus effect in locus ceruleus Brown & Williamson, VP – reward effect in limbic system Addison Yeaman, 1963 – releases acetylcholine, norepinephrine, dopamine, serotonin, vasopressin, beta-endorphin, growth hormone & ACTH Your turn… Drug Dependence Criteria • Tolerance • Psychoactive effects • Is nicotine addictive? • Withdrawal • How is it different and the same as • Use despite harm to self or others other substances classically thought of as addictive? • Cravings with compulsive use How is nicotine the same/ The Opportunity different from other addictive drugs? • Most tobacco users want to quit • Half make a serious attempt each year • 85+% who use nicotine, use daily • 5-7% who quit on their own succeed – 10% of cocaine/etoh users • Assistance increases absolute success • Withdrawal not life-threatening 15-40% – Can be for alcohol • Only one in 5 use meds • Most severe consequences • one in 50 get counseling delayed • 80% see a HCP each year • ? 2

Treatment MPH: How do we increase quit success in MPH MD/HCP Perspective a population (total quitters) ?? Increase quit attempts Sweet Spot Population prevalence Individual treatment Greatest good from Maximize the available resources probability of success Compare costs to: Compare costs to: Lung cancer treatment Raising taxes Increase use of evidence-based Increase effectiveness Cancer screening Clean indoor air regulation support during quit attempts of evidence-based support Substance abuse treatment Product regulation Road repair Denormalization Strategies to increase tobacco Task Force on Community use cessation Preventive Services • Increasing unit price: strongly recommend • Mass media campaigns (combine w other) • Independent, nonfederal Task Force - strongly recommend – evidence-based • Health Care System-level interventions – focus on non-clinical interventions – provider reminders: recommended • Reviewed 14 interventions to:* – provider education: insuff evidence – reduce ETS exposure – reduce tobacco use initiation – provider remind + education: strong rec – increase tobacco use cessation – reduce patient out-of-pocket costs: rec – multicomponent phone support: str. rec *Am J Prev Med February 2001 WHO recommends 3 treatment services for all countries • Primary-care advice to quit • Low-cost pharmacotherapy • Easily accessible and free quitlines 3

Case Study: Mr G • 53 y.o male with gradually increasing trouble breathing Past History: • A long-term condition • High blood pressure • Stakes are high • Smokes 1 pack/day • Relapse is part of nicotine dependence Social: • Married, 2 children, – 19/20 relapse without treatment non-smokers – 2/3 relapse even with best treatment Insured Through Work: – not an indication of personal failure • No cessation benefit The 5 A’s • ASK about tobacco use • ADVISE to quit • ASSESS willingness to make quit attempt • ASSIST in quit attempt • ARRANGE follow-up Treatment Methods In Use Group Counseling Counseling Telephone-based counseling 1:1 counseling Pharmacotherapy OTC Pharmacotherapy Rx Pharmacotherapy 4

25 Washington State Quit Line Pharmacotherapy • Increases cessation Available to all ― Half-hour coaching rates ― Triage • Can increase use of behavioral therapies Available to some ― Intensive Benefit: 4 calls & patches Nicotine Patch Pharmacologic Methods First-line Therapies • Available in 7mg, Three classes of FDA-approved drugs for 14mg, 21mg doses smoking cessation • Easy to use, conceal • Nicotine replacement therapy (NRT) – Nicotine gum, patch, lozenge, nasal spray, • Provides consistent inhaler nicotine levels • Psychotropics – Sustained-release bupropion • Not recommended in • Partial nicotinic receptor agonist patients with serious – Varenicline skin conditions 5

Nicotine Gum Nicotine Lozenge • Available in 2mg, • Available in 2mg, 4mg doses 4mg doses • Patients can titrate • Patients can titrate nicotine levels nicotine levels • Requires correct technique • A bit easier to use than nicotine gum • Not recommended in patients with • Can have GI side dentures effects Nicotine Inhaler What is Currently Approved? Front Line Treatments • Mimics hand to available with Rx only: mouth action of • Nicotine Inhaler smoking • Nicotine Spray • Patient can titrate nicotine levels • bupropion • varenicline • Possible initial throat and mouth irritation Nicotine Spray bupropion • Patient can titrate nicotine levels • Easy to use • Quick onset of action • As effective as patch • May be more effective • Might be useful in than other forms of patients with NRT depression • Can result in • Slight risk of seizure dependence • Contraindicated in a • Side effects can be number of conditions significant 6

varenicline varenicline – FDA Advisory • Reduces craving and withdrawal • Use with caution in patients with a history of psychiatric illness • High efficacy (includes depression). • Different • May cause changes in mechanism than behavior or mood. NRT • May impair ability to • Can cause drive or operate heavy machinery. nausea NRT: Can you use in combination? Common Misconceptions • I should use as little NRT as • Patch in combination with short acting (gum or spray) more effective than either alone possible. • Bupropion can be used with patch • Medications are a “Magic Bullet”. • Nicotine will give me a heart attack. Increased + = Success Maximizing Treatment Success NRT for Pregnancy and Youth • Evidence is inconclusive • Determine if benefits outweigh the risks. Medication plus counseling is the most effective treatment. 2008 US PHS Guidelines 7

Treatment Access: What Should I Recommend? • Patient preference is Convenient for us important. Inconvenient for smokers • Side-effect profiles vary. • Past experience may predict future experience. • Combination therapy is effective. Model for treating tobacco dependence Why variation in reach? Treatment Challenges • Size of service and promotion budget • Who does it? • Efforts to markedly increase reach use via revenue from tobacco taxes, health • Who pays? insurance or other sources have worked • Mainstreaming (up to 5-12%) • Overcoming Tobacco Control anti- treatment biases • Editorial comment: Taxing tobacco users • Avoiding hyper-medicalization on tobacco products and for healthcare • What the H*** are those 5 As again? while not providing treatment is a human rights and policy issue! 8

In Conclusion • Effective treatments for tobacco dependence exist • When made available without barriers and publicized, treatments are used • Gap between effectiveness and use is a social justice issue 9