Smoking Cessation

1
Smoking Cessation

• 45 Million americans smoke
• 35 Million want to quit smoking

2
Smoking Cessation

• It's not hard to quit smoking, I've quit
  thousands of times.
• Mark Twain

3
Smoking Cessation

• Why are people addicted to cigarettes?
• Nicotine
• Nicotine is a naturally occurring chemical in
  tobacco. It is a stimulant, insecticide, it not
  a food, it is an accident
• Nicotine is a poisonous alkaloid, C10H14N2
• NICOTINE DOES NOT CAUSE CANCER
• Nicotine binds the nAcetylcholine receptor and
  triggers dopamine and other neurotransmitter
  release, identified as pleasure and calm feeling.
  Rats will press a button for more nicotine,
  choosing it over food in a lab setting.

4
SMOKING CESSATION

• Smoking causes cancer
• Radon causes cancer
• Inhaling asbestos and other particles causes
  cancer
• Cigarette smoke has 4,000 different chemicals, 69
  carcinogens such as Nitrosamine and benzopyrene
• Combining cigarettes with other inhalants
  increases the chances of cancer.
• Smoking cigarettes increases the chances of lung
  cancer, and cancers of the pancreas, bladder,
  kidney, stomach and colon.

5
Smoking Cessation

• Smoking cigarettes started in the the 1500s
• 1610 Smoking may be dangerous
• 1632 Illegal to smoke in Massachusetts
• 1760 First Tobacco Company in New York
• 1826 Pure form of Nicotine refined
• 1836 Samuel Green Discovers Nicotine can kill
  a man if too much is taken It causes rapid
  heart rate and constriction of the arteries.
• 1847 Phillip Morris established
• 1902 Marlboro brand
• 1913 Camel brand

6
Smoking Cessation

• The link to cancer first noted by a German Doctor
  Fritz Lickint. Prior to 1900 the diagnosis of
  lung cancer at autopsy was rare. Dr. Lickint
  noted an increase in lung cancers and noted the
  association with smoking.
• During WWII cigarettes were given out in soldiers
  rations.
• 1952-1956 Kent brand contains asbestos in the
  filters
• 1953 Study proves that tar from cigarettes causes
  cancer in mice
• 1960 Warnings about the hazards of smoking

7
(No Transcript)
8
(No Transcript)
9
(No Transcript)
10
(No Transcript)
11
Smoking Cessation

• What methods are available
• Will power---- long term success 3
• Nicotine replacement products over the counter 6
• Physicians counseling and NRT 10
• Bupropion (Wellbutrin/Zyban-- 13
• Bupropion 150mg twice a day and Transdermal
  Nicotine patch 21mg/day had a 35 success

12
(No Transcript)
13
Smoking Cessation

• What methods are available
• Varenicline (Chantix) a new partial agonist of
  nicotinic acetylcholine receptor at one milligram
  twice a day had a 44 continuous abstinence rate
• Hypnotherapy in hospitalized patients 50 quit
  rate at 6 months.
• Smoking cessation clinic combining all methods, 6
  one hour sessions 65 quit rate at completion

14
Smoking Cessation

• Nicotine Replacement Products
• Nicotine Patch dose varies, 21mg/day to 7mg/day
• Easy to use, helps with morning cravings, no rx
• FREE from New York State 1-866 NY QUIT
• Calculating the dose, of cigarettes/day closest
  to multiple of 7,14 or 21 OK to use 2 patches,
  rotate sites, cannot smoke while on patch
• NICOTINE GUM 2mg and 4mg
• Easy to control dose, prevents over eating, no
  prescription
• Nicotine spray/inhalerFast relief for cravings,
  easy to adjust dose. Disadvantage requires
  prescription

15
Smoking Cessation

• Buproprion (Zyban and Wellbutrin
• Blocks reuptake of dopamine and norepinephrine
  and has a direct competitive inhibitory effect on
  the nicotine Ach receptor
• Anti-depressant that boosts chemicals that
  elevate mood. It also decreases cravings for
  food and alcohol
• Requires a Doctor visit and prescription
• Contraindications include history of seizure
  disorder, head trauma, eating disorder, side
  effects, insomnia
• Dr Pillsbury, I don't know if I was depressed
  and therefore I smoked, or if I smoked and was so
  angry at myself I was depressed-- but taking
  Wellbutrin I am so happyI don't smoke!

16
Smoking Cessation

• Varenicline (Chantix)
• New type of medication that partially blocks the
  action of nicotine and partially stimulates the
  nicotine receptor in the brain so there are not
  severe nicotine withdrawal symptoms
• Blocks the euphoria associated with smoking
• Causes mild nausea
• Minimal weight gain
• Does not interact with Digoxin,
  warfarin(coumadin), or metformin (glucophage)
• Cons
• Requires a prescription and office visit, there
  are reports of stable psychiatric patients having
  severe mood changes, use with caution if there is
  a history of a mood disorder.

17
Smoking Cessation

• The Future
• There will be more partial agonists drugs similar
  to Varenicline. The rate of smoking in the world
  is increasing, there is an explosion is basic
  research on selective receptor modulators
  involved in mood/addiction
• Nicotine Vaccine (NicVax)
• Nicotine is bound to a protein and injected to
  produce an antibody response. The antibody binds
  to Nicotine and prevents it from crossing the
  blood vessels into the brain. It is a 5 shot
  series over one year. Not yet available
• Quit rate after one year of study 16
• Long term safety not known
• Groups that should not have this done, not known
• Has not been combined with other stop smoking
  techniques

18
Smoking Cessation

• Social Factors
• Its very important that teenagers do not start
  smoking.
• 18 year olds have a 80 chance of continuing to
  smoke once they start and almost all recently
  surveyed (20yrs) wished they did not smoke
• Explaining the money saved to younger patients is
  very effective. Two effective behavior techniques
  that work well in the young
• deposit 4 into a jar every day that they do not
  smoke.
• Exercise vigorously for 10 minutes before
  smoking, the urge to smoke will often pass after
  exercise.

19
Smoking Cessation

• Social Factors
• The lowest rates of smoking in the country are in
  the state of Utah. Many counties there have a
  smoking rate less than 10. The main factor is
  religious.
• Hawaii has a very low smoking rate 12 in some
  surveys, Asians have a very low rate of smoking.
  The state of Hawaii also spends significantly on
  stop smoking education
• The State of New York sponsors free patches, web
  site, and selected stop smoking clinics including
  a very successful program on Long Island at the
  Center for Smoking Cessation at Long Island
  Jewish Hospital in Great Neck, New York

20
Smoking Cessation

• Research
• Clinicaltrials.gov
• There are many trials combining new drugs and
  comparing different methods to help people become
  non-smokers
• There are several new types of drugs being
  studied that modulate the subsets of nicotine
  receptors in the research phase.
• If you smoke, talk to your Doctor and keep trying
  to quit. Try hypnotherapy, try Chantix

21
Smoking Cessation

• In the 1950s close to 45 of American adults
  smoked cigarettes.
• In 2005 the percent has dropped to close to 20

22
Smoking Cessation

• Smoking is an Addiction
• The 5 As
• Ask, at every visit
• Advise, age based advise
• Assess, are they ready to quit
• Assist, websites, quit lines, programs
• Arrange, follow up visit discuss more option

23
Smoking Cessation

• Behavioral Advice
• The 5 Ds, Cravings will pass
• Delay
• Drink Water
• Do something else, distraction
• Deep Breath
• Discuss

24
Smoking Cessation

• Relapse, The 5 Rs Relapsing x 5 is not unusual
• There has never been any program with gt50
  success at one year. The programs that have
  combined all techniques including Chantix have
  less than 40 success at the one year mark.
• Addressing the Why? The other 5 Rs
• Patients will tell you if you ask.
• Relevance
• Risks
• Rewards
• Roadblocks
• Repetition, teachable moments

25

• The MKMG/NWHC Smoking Cessation Program
• Break the habit 666-1182 MKMG.com,
  NWHC.com
• Four consecutive one hour sessions from 7-8pm
• Goal is to combine all techniques, support group,
  peer group enrollment, behavior modification,
  education, nutrition, hypnotherapy, aroma
  therapy, exercise instruction, nicotine
  replacement and information on Zyban and Chantix,
  RXs must come from primary MD. The program is
  seeking MD volunteers, 2 hours during weeks 1
  and 2
• Week 1, support group, behavior and MD
  information
• Week 2 , Nutrition information, discussion,
  support
• Week 3, Intro to hypnotherapy
• Week 4, Alternative approaches, aroma therapy, etc