SHA24/067001

Smoking; What Every Cardiologist Must Practice Omar Shafey, PhD, MPH Sr. Officer, Medical Research Section Public Health and Research Division Saudi Heart Association 24 10 Gulf Heart Association Conference Riyadh, KSA 16 February 2013 th

Objectives •Nicotine pharmacology and neurobiology of addiction.

• Health effects of smoking and benefits of quitting.

• Assessment and monitoring • Helping patients quit : Motivational interviewing & relapse prevention.

• Pharmacological interventions.

Tobacco’s Addiction Potential

Tobacco, 1 in 3

WHO FCTC

Heroin, 1 in 4-5 Inhalant drugs, 1 in 20 Psychedelic drugs, 1 in 20 Analgesic Drugs, 1 in 11 Anxiolytic, sedative, & hypnotic drugs, 1 in 11

Crack + HCl, 1 in 5 (??)

Cocaine HCl, 1 in 6

Estimated fraction of drug users who become dependent

Alcohol, 1 in 7-8

Cannabis, 1 in 9-11

02/12/13 (Adapted from Anthony et al., 1994; Chen & Anthony, 2004)

Stimulants other than cocaine, 1 in 9

NEUROCHEMICAL EFFECTS of NICOTINE  N  Dopamine  I  Norepinephrin e  C  Acetylcholine  O  Glutamate  Serotonin T  I  β-Endorphin   GABA N

Pleasure, reward Arousal, appetite suppression Arousal, cognitive enhancement Learning, memory enhancement Mood modulation, appetite suppression Reduction of anxiety and tension Reduction of anxiety and tension

E Benowitz. (1999). Nicotine Tob Res 1(Suppl):S159–S163.

NEUROCHEMICALLY-INDUCED EFFECTS of NICOTINE WITHDRAWAL Depression  Insomnia  Irritability/frustration/anger  Anxiety  Difficulty concentrating  Restlessness  Increased appetite/weight gain  Decreased heart rate  Cravings* 

* Not considered a withdrawal symptom by DSM-IV criteria.

Most symptoms peak 24–48hr after quitting and subside within 2–4 weeks.

American Psychiatric Association. (1994). DSM-IV. Hughes et al. (1991). Arch Gen Psychiatry 48:52–59.

Hughes & Hatsukami. (1998). Tob Control 7:92–93.

Tobacco’s Health Effects

WHO FCTC

• Entered into force 27 February 2005 Second-Hand  174 Parties to the treaty (countriesSmoke that have ratified)  Covers 87.4% of world population  UAE ratified on 7 November 2005  U.S. refuses to ratify  Conference of the Parties – governing body meets regularly to review treaty implementation Smoking 02/12/13 MPOWER Report

Tobacco Atlas

Tobacco Is a Risk Factor for 6 of the World’s 8 Leading Causes of Death

WHO FCTC

• Entered into force 27 February 2005  174 Parties to the treaty (countries that have ratified)  Covers 87.4% of world population  UAE ratified on 7 November 2005  U.S. refuses to ratify  Conference of the Parties – governing body meets regularly to review treaty implementation Hatched areas indicate proportion of deaths related to tobacco use.

02/12/13

MPOWER Report

Tobacco Mortality by Cause

WHO FCTC

• Entered into force 27 February 2005  174 Parties to the treaty (countries that have ratified)  Covers 87.4% of world population  UAE ratified on 7 November 2005  U.S. refuses to ratify  Conference of the Parties – governing body meets regularly to review treaty implementation 02/12/13

Tobacco Atlas

Health Benefits of Quitting Smoking Start Immediately1 Time After Quitting 15 years CHD risk same as a nonsmoker`

20 minutes Heart rate drops

10 years

Lung cancer death rate half that of smoker; decreased risk of mouth, throat, oesophagus, bladder, kidney and pancreas cancer

12 hours Blood CO levels return to normal

2 wks – 3 mo

Heart attack risk begins to drop, lung function increases

1 – 9 months

1 year Excess CHD risk half that of a smoker

Coughing and shortness of breath decrease

US Department of Health and Human Services. The health consequences of smoking: What it means to you. US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 2004.

9

Initial Intake Questions • Smoking history – How long have you been smoking?

– How much do you smoke?

– Ever tried to quit?

– Used anything to help you quit?

– Longest you’ve ever been quit?

• Motivation level – On a scale of 1-10, with 10 being most ready to quit, where would you say you are?*** – Would you be willing to set a quit day in the next 30 days?

– *** If 5 or below, probe further: – If you weren’t at all concerned that you might not be successful at quitting, would that number change?

• Program description • Discussion of possible medications – Motivation levels can change after patients hear about the program 02/12/13

10

Assess Motivation and Readiness to Change

Precontemplatio n

Relapse

Doesn't acknowledge behaviour as a problem. Unwilling to change.

Lapses and conducts self-reflection.

Stages of Change Model

Contemplation Understands the need to modify behaviour.

Willing to change, but ambivalent.

Maintenance

Preparation

Sustains the changed behaviour and tries to avoid relapse.

Action Puts a plan into motion.

Takes personal ownership of the change.

Prochaska JP et al. Am Psych 1992; 47(9):1102-14.

Zimmerman GL et al. Am Fam Physician. 2000; 61(5):1409-16.

Develops a plan to make a change.

Fagerström test for nicotine dependence Score:

3

2

1

0

<5

5 –30

31- 60

>60

2. Do you find it difficult not to smoke where you shouldn’t - such as bus or school

Yes

No

3. Which cigarette would you most hate to give up?

First

Any other

1. Time to first cigarette after waking (minutes)

4. How many cigarettes do you smoke each day?

>31

21- 30 11 – 20

<10

5. Do you smoke more frequently during the first hours after waking up?

Yes

No

6. Do you still smoke if you are so sick that you are in bed most of the day?

Yes

No

Multiple Quit Attempts May Be Necessary • More than 70% of US smokers want to quit1

– Approximately 44% try to quit each year – Only 4% to 7% who try to quit achieve abstinence

• Similar percentages in countries with established tobacco control programmes (e.g., Australia, Canada, UK)2 – 30% to 50% try to quit; <5% achieve long-term abstinence unaided

• Most smokers will attempt to quit 6 to 9 times in their lifetimes3 • Some smokers succeed after making several attempts4 – Past failure does not prevent future success – Length of prior abstinence is related to quitting success

1. Fiore MC et al. Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update.

US Department of Health and Human Services. Public Health Service; 2008. Available at: www.surgeongeneral.gov/tobacco/default.htm.

• Foulds J et al. Expert Opin Emerg Drugs 2004; 9(1):39-53.

• Women and Smoking: A Report of the Surgeon General. Washington, DC, US Department of Health and Human Services; 2001. Available at: http://www.surgeongeneral.gov/library/womenandtobacco/.

• Grandes G et al. Br J Gen Pract 2003; 53(487):101-7.

IS the PATIENT READY to QUIT? Does the patient now use tobacco?

Yes

Is the patient now ready to quit?

No

Promote motivation

No

Did the patient once use tobacco?

Yes

Yes

Provide treatment The 5 Aâ&#x20AC;&#x2122;s

Prevent relapse*

No

Encourage continued abstinence

*Relapse prevention interventions not necessary if patient has not used tobacco for many years and is not at risk for re-initiation.

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Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline.

Rockville, MD: USDHHS, PHS.

ASSESSING READINESS to QUIT 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.

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STAGE 1: NOT READY to QUIT Counseling Strategies • DOs • 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 02/12/13

DON’Ts 

Persuade



“Cheerlead”





Tell patient how bad tobacco is, in a judgmental manner Provide a treatment plan

IS the PATIENT READY to QUIT? Does the patient now use tobacco?

Yes

Is the patient now ready to quit?

No

Promote motivation

No

Did the patient once use tobacco?

Yes

Yes

Provide treatment The 5 Aâ&#x20AC;&#x2122;s

Prevent relapse*

No

Encourage continued abstinence

*Relapse prevention interventions not necessary if patient has not used tobacco for many years and is not at risk for reinitiation.

02/12/13

Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline.

Rockville, MD: USDHHS, PHS.

ASSESSING READINESS to QUIT STAGE 2: Ready to quit

• 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.

GOAL: Achieve cessation.

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A Brief Intervention: The 5 A’s Ask

… about smoking status

Advise

… to quit

Assess

… willingness to quit

Assist

… by offering treatment

Arrange

… follow-up

Fiore MC et al. Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update.

US Department of Health and Human Services. Public Health Service; 2008. Available at: www.surgeongeneral.gov/tobacco/default.htm.

STAGE 2: READY to QUIT Assess Tobacco Use History

• Praise the patient’s readiness • Assess tobacco use history – Current use: type(s) of tobacco, brand, amount – Past use: duration, recent changes – Past quit attempts: • Number, date, length • Methods used, compliance, duration • Reasons for relapse

02/12/13

Arrange follow-up care ARRANGE Counseling Sessions Number of sessions

Estimated quit rate*

0 to 1

12.4%

2 to 3

16.3%

4 to 8 More than 8

20.9% 24.7% * 5 months (or more) postcessation

PROVIDE ASSISTANCE THROUGHOUT THE QUIT ATTEMPT Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline.

Rockville, MD: USDHHS, PHS.

STAGE 2: READY to QUIT Discuss Key Issues

• Reasons/motivation to quit (or avoid relapse) • Confidence in ability to quit (or avoid relapse) • 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 When drinking coffee  While driving in the car  When bored or stressed  While watching television  While at a bar with friends 02/12/13 

   

After meals During breaks at work While on the telephone While with specific friends or family members who use tobacco

STAGE 3: RECENT QUITTERS Evaluate the Quit Attempt • Status of attempt

– Ask about social support – Identify ongoing temptations and triggers for relapse (negative affect, smokers, eating, alcohol, cravings, stress) – Encourage healthy behaviors to replace tobacco use

• 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?

– How and when should pharmacotherapy be terminated?

02/12/13

STAGE 3: RECENT QUITTERS Facilitate Quitting Process

Relapse Prevention Congratulate success!

• Encourage continued abstinence •

– Discuss benefits of quitting, problems encountered, successes achieved, and potential barriers to continued abstinence – Ask about strong or prolonged withdrawal symptoms (c hange dose, combine or extend use of medications) – Promote smoke-free environments

•

Social support

– Discuss ongoing sources of support – Schedule additional follow-up as needed; refer to support groups

02/12/13

ASSESSING READINESS to QUIT STAGE 4: Former tobacco user

• Tobacco-free for 6 months –

Patients remain vulnerable to relapse.

–

Ongoing relapse prevention is needed.

GOAL: Remain tobacco-free for life.

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STAGE 4: FORMER TOBACCO USERS 

Assess status of quit attempt



Slips and relapse



Medication compliance, plans for termination  Has pharmacotherapy been terminated?



Continue to offer tips for relapse prevention



Encourage healthy behaviors



Congratulate continued success

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Continue to assist throughout the quit attempt.

Defining Success • Clinicians should adjust their definition of success when treating the tobaccodependent patient • Clinicians are accustomed to near 100% success with some other conditions

– e.g., vaccinating a patient against rubella – e.g., treating a bacterial infection with antibiotics

• When treating the dependent tobacco user – a 20% quit rate or better is considered successful Huber GL, Mahajan VK. Dis Manage Health Outcomes 2008; 16(5):335-43.

First-Line Pharmacotherapies for Tobacco Dependence US FDA Approved Smoking Cessation Pharmacotherapies • NRT – Patch – Gum – Inhaler – Nasal spray – Sublingual tablets/lozenges

• Bupropion SR • Varenicline Fiore MC et al. Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update.

US Department of Health and Human Services. Public Health Service; 2008.

Available at: www.surgeongeneral.gov/tobacco/default.htm.

Meta-analysis of First-line Smoking Cessation Pharmacotherapies â&#x20AC;˘ Effectiveness and abstinence rates for various medications compared with placebo 6 months after quitting Medication Placebo Varenicline (2 mg/day)

Estimated OR (95% CI) 1.0 3.1 (2.5, 3.8)

Estimated abstinence rate (95% CI) 13.8 33.2 (28.9, 37.8)

Nicotine nasal spray High-dose nicotine patch (>25 mg) Long-term nicotine gum (>14 weeks) Varenicline (1 mg/day) Nicotine inhaler Bupropion SR Nicotine patch (6-14 weeks) Long-term nicotine patch (>14 weeks) Nicotine gum (6â&#x20AC;&#x201C;14 weeks)

2.3 (1.7, 3.0) 2.3 (1.7, 3.0) 2.2 (1.5, 3.2) 2.1 (1.5, 3.0) 2.1 (1.5, 2.9) 2.0 (1.8, 2.2) 1.9 (1.7, 2.2) 1.9 (1.7, 2.3) 1.5 (1.2, 1.7)

26.7 (21.5, 32.7) 26.5 (21.3, 32.5) 26.1 (19.7, 33.6) 25.4 (19.6, 32.2) 24.8 (19.1, 31.6) 24.2 (22.2, 26.4) 23.4 (21.3, 25.8) 23.7 (21.0, 26.6) 19.0 (16.5, 21.9)

Fiore MC et al. Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update.

US Department of Health and Human Services. Public Health Service; 2008.

Available at: www.surgeongeneral.gov/tobacco/default.htm.

Conclusions 1. Smoking is the leading preventable cause of disease and premature death.

2. However, the prevalence of smoking remains unacceptably high and in some areas continues to increase.

3. Quitting improves health outcomes and can reverse disease progression.

4. Quitting early in life provides the greatest benefits to overall survival.

02/12/13

Conclusions (continued) 5. Dialogue with a healthcare practitioner is an important first step towards quitting.

6. Even brief counseling can aid cessation, together with effective pharmacotherapies.

7. Varenicline , bupropion & NRT are available in many countries to help treat nicotine addiction.

02/12/13

Smoking; What Every Cardiologist Must Practice Omar Shafey, PhD, MPH Sr. Officer, Medical Research Section Public Health and Research Division