WHEN QUITTERS WIN

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WHEN QUITTERS WIN

• Richard P. Sargent, MD
• St. Peters Community Hospital
• Helena, Montana

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FINANCIAL OR OTHER RELATIONSHIP(S) DISCLOSURE

• I dont take Drug money
• travel paid for by ME
• FDA STATUS DISCLOSUREDr. Sargent will not be
  discussing any unlabeled or investigational use
  of a product.

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TOBACCO CESSATION

• THE QUICK AND DIRTY
• NICOTINE Addiction Chronic disease
• NRT is like dosing insulin
• basal level from patches
• boluses from gum, lozenges, inhalers (not from
  tobacco)
• step down process over three months.
• Varenicline nicotine receptor agonist

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Tobacco Dependence A Chronic Disease

• Similar to diabetes, heart failure, hypertension,
  hyperlipidemia
• Expectation for remission and relapse
• Provide ongoing treatment
• advice/counseling
• support
• appropriate pharmacotherapy

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Tobacco Cessation

• Do Nothing
• 5 annually (2-10)
• MD intervention
• 10-20 depending on how good you are
• QuitLines alone 20
• availability and impulsive decision
• Pharmocotherapy
• 28 (25-30)
• QuitLine with medication
• 33 quit rate.

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Nicotine is a Drug of Addiction

• After inhaling, nicotine reaches the brain in
  7-10 seconds
• Euphoria without being Stoned
• Immediate REINFORCEMENT of drug-taking behavior
• Moment to moment titration of dose to achieve the
  desired effects

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Nicotine is a Drug of Addiction

• Nicotine accumulates in the blood as cigarettes
  are smoked throughout the day gt TOLERANCE
• Half-life (T 1/2) is 2-3 hours
• Nicotine levels drop overnight gt EUPHORIA and
  STIMULATION with first cigarettes to maintain the
  addiction

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NEUROCHEMISTRY ADDICTION
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I FEEL GOOD!!!!!!!!!!

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RIDICULOUSLY SIMPLE NEUROANATOMY

• Strategic and emotional regulation of behavior
• Dopamine and norepinephrine

• Addiction Biology- Vol 8, No. 1 / March, 2003
  Pages 67 - 74

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RIDICULOUSLY SIMPLE NEUROANATOMY

• The Limbic System, Ancient, Primitive, Nicotinic
• emotion, location, physical activity, behavioral
  control, reward

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RIDICULOUSLY SIMPLE NEUROANATOMY

• Thalamus- relay for sensory information ?ADD
• Striatum- craving and pleasure (addiction)
• Ant. Cingulate Cortex-conflict, self regulation,
  decision-making and emotion, (weight control)
• formed during teens- how we know long term
  consequences Neuropsychopharmacology 2007

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Persistence

• Most Smokers Want to Quit

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WITHDRAWAL SYMPTOMS

• 46 try to quit every year,
• Most go Cold Turkey
• about 5 succeed.

• Sad, Depressed mood
• Increased appetite
• Headache
• Mouth ulcers
• Nausea
• Constipation
• Diarrhea
• Insomnia
• Restlessness
• Anxiety, Irritability, Frustration, Anger
• Difficulty concentrating

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WHAT WORKSto help inspire quitters

• Advertising works
• QuitLines work
• Persistence works
• NRT works
• Exercise Works
• Emotions Work---If you form an alliance

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Preparing to Quit

• Often an impulsive decision
• Set a quit date
• Tell family, friends, and coworkers
• Anticipate challenges
• Remove tobacco products from your environment
• Exercise Program

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Drugs Man

• Six first line FDA approved pharmacotherapies
• Bupropion SR
• Nicotine Gum
• Nicotine Inhaler
• Nicotine Nasal Spray
• Nicotine Patch
• Nicotine Lozenges

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More DRUGS, Man

• Second line Pharmacotherapies
• Clonidine
• Oral
• Transdermal
• Nortriptyline
• Lighter smokers - lower NRT
• 10-15 cigarettes/day
• no adjustment for bupropion

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Nicotine Patch TherapyInitial Dosing Based on
Smoking Rate Mayo Clinic Model

• lt10 cpd 7-14 mg/d
• 10-20 cpd 14-22 mg/d
• 21-40 cpd 22-44 mg/d
• gt40 cpd 44 mg/d

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Dosing Your Drugs

• NRT is like dosing insulin
• basal level from patches
• boluses from gum, lozenges, inhalers, sprays (not
  from tobacco)
• step down process over three months.

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Spit Tobacco - Pharmacology

• Lozenges seem to work better than patches
• no data on gum

Blood nicotine concentration (ng/ml
Benowitz, 1988
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NRT Side Effects

• Insomnia and vivid dreams
• Take the patch off at night, plan on lozenge/gum
  in the morning
• Dizziness
• Nausea
• Headaches
• Lower the dose of NRT

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Nicotine Replacement Therapy is Safe

• No exposure to carbon monoxide
• NRT has no effect on coagulation (clotting)
• Pharmacokinetics of nicotine from smoking is
  different than with NRT
• Levels of nicotine achieved with standard dosing
  of NRT is less than with usual tobacco use
• Up to 33 Quit with NRT

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I NEED A NEW DRUG Varenicline (Chantix)

• Availability -Rx Starter Pack, Maintenance Pack
• Contraindications -- hypersens. to
  drug/class/compon., children lt18 yo, pregnancy
• Side Effects -- Nausea, Sleep disorder,
  sleeplessness, Constipation, Headache, Loss of
  taste, Altered Taste, Gas, adverse
  neuropsychiatric effects
• Dosing -- 0.5 mg QD x3 then 0.5 mg bid for four
  days then 1 mg bid
• Duration -- for three months. If quit continue
  for 3 more months
• Cost (estimate) 4 - 6 per day

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NAUSEA NEUROANATOMY

• Brain Stem Midbrain, pons and medulla vital
  functions, respiration and vomit reflex.
• Reduce the dosage

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OH WOW!, MAN

• CHANTIX DREAMS
• Limbic System
• NRT Warning
• Take patch off at night
• change timing of dose
• reduce dose

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FDA Psychiatric Problems

• ...Psychiatric illness to worsen or recur.
• Where does this drug work?
• Bupropion has it in the label
• antidepressant experience
• epilepsy drugs
• Psychiatric problems on the Cigarette warning
  label

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PSYCHEDELIC NEUROANATOMY

• The Limbic System
• emotion, location, physical activity, behavioral
  control, reward
• Thalamus- relay for sensory information ?ADD
• Striatum- craving and pleasure (addiction)
• Ant. Cingulate Cortex-conflict, self regulation,
  decision-making and emotion, (weight control)

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Neuropsychiatric disorders

• It is real
• Not strictly in pre-existing path.
• Very frightening for patients
• discontinue the drug
• stories from the front line

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New Therapies in the Pipeline

• Sublingual Nicotine (available in Europe)
• Rimonabant a cannabinoid receptor
  agonist
• Nicotine Vaccines

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Practical Problem Solving

• Abstinence-Relapse
• Review past quit experience
• Success
• Triggers for relapse
• Anticipate triggers, challenges
• Alcohol can lead to relapse
• Other smokers limit exposure

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Practical Pointers

• Recognize danger situations
• Negative mood
• Time pressures
• Etc.
• Develop coping skills
• Anticipating / avoid temptations
• Cognitive and lifestyle strategies to limit
  negative mood, stress, etc
• Cognitive and lifestyle strategies to deal with
  tobacco urges
• Provide basic information

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QuitLines Work
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SMOKINGIts like being a little bit pregnant
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Heart Disease Risk and Dose

• From Terry F Pechacek and Stephen Babb
• How acute and reversible are the cardiovascular
  risks of secondhand smoke?
• BMJ, Apr 2004 328 980 - 983.

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HEART DISEASE
CARDIO 2000 DATA
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Dealing with Backlash

• Moral Decisions and emotions
• You are not dealing with happy people
• Call it what it is Addiction
• There is no right to smoke.
• Protecting the health of others.
• Health effects of exposure to non-smokers and to
  smokers

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THERE IS NO RIGHT TO SMOKE
LIMITS ON CONSTITUTIONAL RIGHTS

• FREEDOM OF SPEECH
• RIGHT TO KEEP AND BEAR ARMS
• THE EXERCISE OF YOUR RIGHTS MAY NOT HARM OTHERS

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ITS THE LAW THERE IS NO RIGHT TO SMOKE

• Court upheld workplace smoking ban despite
  smoking worker's argument that his "private
  rights and interests" are affected. Rossie v.
  State, 395 N.W. 2d 801 (Ct. of Appeals Wisc.
  1986)
• "The right to smoke in public places is not a
  protected right, even for adults."Craig v.
  Buncombe County Board of Education, 343 S.E.2d
  222 (Ct. of Appeals NC 1986)

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Recruiting smokers to our side.

• Lets Make a Deal!
• Lets Talk Addiction
• Get on Message
• Nicotine is addictive
• Share that message with your younger generations

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Advise Teaching Moments

• Have RELEVANT New information
• Compassionate, Caring and Strongly worded Advice
  in the right situation (ICU, PAD, New finding
  Family History)
• Correct Misconceptions

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ADVERTISING(recruiting quitters)

• Memorable
• Emotional
• Music, Slogan or Jingle
• Repetition for penetration
• Forms an alliance with the smoker

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HUMOR
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GROTESQUE IMAGES
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Money
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WHOS THE BOOGEYMAN
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Special Thanks to

• Greg Holzman, MD, MPH Montana Department of
  Public Health and Human Services
• 
  
• Keith Popovich, MD introduced me as
  Doc Hollywood

• Linda Lee Montana Tobacco Use Prevention
  Program llee_at_mt.gov
• Dick Paulson American Lung
  Assoc. of the Northern Rockies

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What Would Motivate You?Humor
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THANK YOU

• RICHARD P.
• SARGENT, MD

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What harm is there is a little second hand smoke?

• PHILLIP MORRIS KNEW IN 1961

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THE AIR IN BARS IS TOXIC
Air-quality tests show that spending a night in a
New York bar is worse for your health than
breathing exhaust fumes at the mouth of the
Holland Tunnel. The results, based on carbon
monoxide readings measured in micrograms per
cubic meter
Central Park 6 Columbus
Circle 8 Mouth of the Holland
Tunnel 17 Typical nonsmoking bar
21 Port Authority Bus Terminal
48 Typical smoky bar
866
Excerpts from ON MAYOR'S BAN WAGON Other cities
target cigarettes By DAVID SALTONSTALL Daily
News (New York) 10/03/02