Consensus Recommendations from an Expert Panel

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Adult Smoking Cessation Intervention Strategies
for Primary Care Providers
Consensus Recommendations from an Expert Panel
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Learning ObjectivesUpon completion of the
program, the health care provider should be able
to

• Asses an adult smokers readiness to quit
  smoking.
• Implement the 5 As of intervention
• Describe the effectiveness of FDA-approved
  first-line pharmacotherapies for smoking
  cessation (e.g., nicotine-replacement therapy,
  bupropion)
• Recognize the efficacy of behavioral therapies
  for smoking cessation
• Implement the basic elements of a counseling
  intervention for smoking cessation

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Sponsor Sponsored by the Illinois Academy of
Family Physicians / Family Practice Education
Network (IAFP/FPEN) Accreditation The Illinois
Academy of Family Physicians / Family Practice
Education Network is accredited by the
Accreditation Council for Continuing Medical
Education (ACCME) to provide continuing medical
education for physicians. Support This medical
education program, Adult Smoking Cessation
Intervention Strategies for Primary Care
Providers, is made possible through a grant from
the Illinois Department of Public Health,
Illinois Tobacco Free Communities Program.
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Expert Panel
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Introduction

• 
  

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Introduction

• Surgeon Generals widely-used guideline for
  treatment of tobacco use and dependence in
  clinical settings
• Barriers to cessation intervention
• Less than one-quarter of smokers who attempted to
  quit use any type of cessation aid.

Treating Tobacco Use and Dependence
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You know the numbers

• Since 1964, 12 million premature deaths
  attributed to smoking, nicotine dependence and
  its sequelae
• For every smoking premature death each year, at
  least 20 smokers suffer a smoking-related disease
• Rate of decline in adult smoking slowed in recent
  years.
• 25 of Americans, 12 years and older smoke.
• American Indians/Alaskan natives (37)
• Persons of two or more races (34)
• College grads (15), no high school diploma (35)
• Children whose parents smoke are more likely to
  smoke

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Smoking-Related Health Risks and the Benefits of
Quitting

• 
  

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Smoking kills and maims

• Harms nearly every organ in the body
• New information, losses in renal filtration rate
• 50 of current smokers will die of smoking
  related disease if they dont quit

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Source The Office of the U.S. Surgeon General.
The Health Consequences of Smoking. 2004 (Online
at http//www.surgeongeneral.gov/library/smokingco
nsequences).
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Cessation helps

• The Peter Jennings story
• Substantial reduction in risk of all-cause
  mortality among patients with CAD
• Decrease in mortality among patients who had MI
• Decreases cancer risk

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Practice Recommendation Clinicians should
encourage patients with coronary heart disease
who smoke to quit, since smoking cessation
isassociated with a substantial reduction in
risk of all-cause mortality among patients with
coronary heart disease. EBM Source Cochrane
Database of Systematic Reviews Smoking cessation
for the secondary prevention of coronary heart
disease (Cochrane Review) Cochrane Database Syst
Rev 2004. http//www.cochrane.org/cochrane/revabs
tr/AB003041.htm Strength of Evidence Results
from 20 prospective cohort studies (12,600
patients) that measured smoking status on two or
more occasions to ascertain those smokers who had
quit, and followed-up on patients for 2 years or
longer.
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Try, try and try again

• Slightly more than half who want to stop will
  attempt in a given year
• Of those only 3 abstinent for 12 months
• Typical quitter cycles through several periods
  of remission and relapse.

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Patient Evaluation in the Primary Care Setting

• 
  

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The magic 3 questions

• How much do you smoke (such as how often, how
  many cigarettes/day)
• When do you smoke your first cigarette of the
  day?
• What is the longest period of time between
  cigarettes before you crave another cigarette?

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Nicotine addiction likely

• Smoke more than 20 cigarettes per day
• Smoke 10-20 cigarettes per day with first
  cigarette within 30 minutes of waking

Nicotine addiction less so

• 10-20 cigarettes per day
• First cigarette more than 30 minutes after waking

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Social smokers

• Less than 10 cigarettes per day
• However, moderate amounts of addiction may be
  demonstrated

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Precontemplation
Contemplation
Preparation
Action
Maintenance
Termination
Relapse
Adapted from Knight J. Contemp Pediatr.
19971445-72.
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Stages of Change

• Focus on progression and change, not on immediate
  cessation

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Adapted from Velicer WF, et. Al. Addict Behav
1995 20299-320 Goldberg D, et.al. Dis Mon
200248445-485.
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Practice Recommendation Clinicians should screen
all adults for tobacco use and provide tobacco
cessation interventions for those who use
tobacco products. EBM Source Agency for
Healthcare Research and Quality U.S. Preventive
Services Task Force (USPSTF) Guideline Tobacco
Use and Counseling , 2003. http//www.ahrq.gov/cli
nic/uspstf/uspsbac.htm Strength of Evidence A
Level of Evidence The USPSTF found good evidence
that the service improves important health
outcomes and concludes that benefits
substantially outweigh harms.
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Motivating and Counseling Patients Who are Ready
to Quit Smoking
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Source Hughes JR. CA Cancer J Clin 200050147.
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5 Rs of Quitting

• Relevance
• Risks
• Rewards
• Roadblocks
• Repetition

R
R
R
R
R
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Relapse

• Most often in first three months of abstinence,
  with first few days crucial
• Partner support may increase success
• Enhance supportive behaviors, minimize critical
  behaviors

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Smoking Cessation in Special Populations

• 
  

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Special populations

• Pregnant Women
• Smoking cessation interventions during pregnancy
  reduce low birth weight and incidence of pre-term
  birth
• Hospitalized persons
• High-intensity behavioral interventions including
  one month follow up
• Substance abuse treatment or recovery

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Practice Recommendation Clinicians should
encourage women who smoke to quit,since active
smoking increases breast cancer risk whenwomen
stop smoking the risk disappears. EBM Source
Bandolier Does Exposure to Smoke Increase Risk
of Breast Cancer? (Original Citation Reynolds P,
et al. J National Cancer Inst 2004).http//www.jr
2.ox.ac.uk/bandolier/booth/hliving/smobrca.html S
trength of Evidence Study of 116,544 women
(smoking statuses never, former, and current)
who had no diagnosis of breast cancer at the
outset of study follow-up of 5 years
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Intervention Pharmacotherapy

• 
  

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Nicotine replacement therapy

• Gum, dermal patch, inhaler, nasal spray, lozenge
• Doubles chance that quit attempt will be
  successful

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Source Hughes JR. CA Cancer J Clin 200050147.
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NRT

• Effectiveness appears independent of intensity of
  support programs
• No evidence of significant side effects
• Caution with those who had recent MI (in past 2
  weeks)
• Recommended for pregnant women
• Recommended for all who smoke 10 or more
  cigarettes per day.
• Use regimen not ad lib

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• Practice Recommendation
• Healthcare providers should recommend
  nicotine-replacement therapy
• (NRT) to patients who wish to stop smoking, since
  all of the
• commercially-available forms of NRT are effective
  as part of a strategy
• to promote smoking cessation and increase the
  odds of quitting
• approximately 1.5 to 2-fold regardless of
  setting.
• EBM Source Cochrane Database of Systematic
  Reviews Nicotine Replacement
• Therapy for Smoking Cessation (Silagy C, et. al.
  Cochrane Database Syst Rev
• 2004. Issue 3. Article CD000146).
• http//www.cochrane.org/cochrane/revabstr/AB000146
  .htm
• Strength of Evidence
• Results from 103 randomized clinical trials that
  compared NRT to placebo or no
• treatment for a follow-up period of 6 months or
  greater.

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Bupropion

• Doubles odds of cessation as compared to placebo
• Works better in men than women
• Effectiveness undiminished by previous NRT use
• On its own works better than NRT, except nasal
  spray NRT (equal)
• Side effects mild, including insomnia, dry mouth,
  tremor and rash
• Contraindicated for persons using MAOI, with
  seizure disorders, anorexia and bulimia
• Can be used with NRT
• Not contraindicated for pregnant women

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Practice Recommendation Healthcare providers
should recommend bupropion to patients who wish
to stop smoking, since bupropion aids in
long-term smoking cessation and doubles the odds
of quitting relative to alternative
therapies EBM Source Cochrane Database of
Systematic Reviews Antidepressants for Smoking
Cessation (Cochrane Review) Cochrane Database
Syst Rev 2004. http//www.cochrane.org/cochrane/re
vabstr/AB000031.htm Strength of
Evidence Meta-analysis of 25 randomized clinical
trials, each with a follow-up of 6 months or
greater, that compared bupropion to an
alternative therapy for smoking cessation.
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Second line therapies

• Not FDA approved
• Clonidine
• Mecamylamine
• Opioid antagonists
• Anxiolytics
• Antidepressants

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Practice Recommendation Healthcare providers
should recommend individualbehavioral counseling
to smokers who wish to quit, as such counseling
has been shown to assist smokers who are trying
to quit. EBM Source Cochrane Database of
Systematic Reviews Individual Behavioral
Counseling for Smoking Cessation (Cochrane
Review) Cochrane Database Syst Rev 2002.
http//www.cochrane.org/cochrane/revabstr/AB001292
.htm Strength of Evidence Meta-analysis of 18
clinical trials with a follow up of 6 months or
greater.
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Costs and reimbursements

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Costs and reimbursments

• Buproprion 3 to 5 per day
• NRT 5 to 10 per day
• ICD-9 305.1 Tobacco dependence
• Medicare now covers tobacco cessation counseling

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Adult Smoking Cessation Intervention Strategies
for Primary Care Providers
Consensus Recommendations from an Expert Panel