Cease Smoking Today CS2day An EvidenceBased Approach To Treating Tobacco Dependence Focus on the Psy

1
Cease Smoking Today (CS2day)An Evidence-Based
Approach To Treating Tobacco
DependenceFocus on the Psychiatric Patient
Scott M. Strayer, MD, MPH, FAAFP Associate
Professor Departments of Family Medicine and
Public Health Sciences University of Virginia
Health System
2
Question

• Which of the following statements
• regarding tobacco dependence and
• smoking cessation in patients with
• psychiatric disorders is/are correct?

3
Answers

• Rates of smoking are similar to individuals
  without psychiatric illness.
• Because of possible decompensation, smoking
  cessation is discouraged.
• Most psychiatric patients are highly motivated to
  quit smoking.
• Risks of most pharmacologic interventions
  outweigh the benefits.
• Smoking cessation may cause adverse reactions to
  psychiatric medications.

4
Smokers With Psychiatric Disorders

• Consume nearly ½ cigarettes smoked in US
• Spend nearly 40 of income on cigarettes
• Patients seeking tobacco dependence treatment
• 30 60 with past history of depression
• 20 with history of alcohol abuse or dependence

Fiore MC, et al. U.S. DHHS Public Health Service
2008
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Smokers With Psychiatric Disorders

• Chemical dependence
• gt 70 smoke
• Increased mortality from tobacco-related diseases
• 1 study

Fiore MC, et al. U.S. DHHS Public Health Service
2008
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Smokers With Psychiatric Disorders

• May have greater sensitivity to nicotine
  dependence symptoms at lower levels of smoking
• Failing to address nicotine withdrawal may
  compromise psychiatric care for inpatients on
  smoke-free units.

Fiore MC, et al. U.S. DHHS Public Health Service
2008
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Answers

• Rates of smoking are similar to individuals
  without psychiatric illness.
• Because of possible decompensation, smoking
  cessation is discouraged.
• Most psychiatric patients are highly motivated to
  quit smoking.
• Risks of most pharmacologic interventions
  outweigh the benefits.
• Smoking cessation may cause adverse reactions to
  psychiatric medications.

8
Answers

• Rates of smoking are similar to individuals
  without psychiatric illness.
• Because of possible decompensation, smoking
  cessation is discouraged.
• Most psychiatric patients are highly motivated to
  quit smoking.
• Risks of most pharmacologic interventions
  outweigh the benefits.
• Smoking cessation may cause adverse reactions to
  psychiatric medications.

9
Outline

• Assessment
• 5 As
• Interventions
• Counseling
• Pharmacotherapy

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Case

• 22 yo Latino M, psychology student at local
  college, here for medication refill
• History of bipolar disorder
• Currently stable
• Several full blown episodes of mania and
  depression
• Hospitalized at age 19 during manic episode
• Depakote, Lithium

11
Case

• Past medical and surgical history
• Otherwise unremarkable
• Lives in an apartment with his girlfriend who
  smokes and a 2 year-old daughter

12
Case

• Smokes 1 pack/day cigarettes since 16 yo
• Recently increased to 2 packs/day
• Cope with stress at college
• Smokes when he drinks alcohol
• Wants to quit
• Unsure if he can
• Concerned about impact on bipolar disorder

13
Question

• At this time, all of he following interventions
• are recommended EXCEPT
• Decrease cigarette intake by 25 every 1 to 2
  weeks
• Initiate pharmacotherapy
• Follow-up with phone call 1 week after stopping
• Abstain from drinking beer
• Convince wife to stop smoking

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Assessment of Tobacco Use
Patient presents to a healthcare provider
Does patient currently use tobacco?
Yes
No
Is the patient currently willing to quit?
Did the patient previously use tobacco?
Yes
Yes
No
No
Promote motivation to quit (5 Rs)
Provide appropriate treatments (5 As)
Encourage continuedabstinence
Prevent relapse
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The 5 As
For Patients Willing to Quit

• ASK about tobacco use
• ADVISE to quit
• ASSESS willingness to make a quit
• attempt
• ASSIST in quit attempt
• ARRANGE for follow-up

Fiore MC, et al. U.S. DHHS Public Health Service
2008
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Ask

• 70 of smokers want to quit
• 81 have tried to quit at least once
• Only 7 to 15 very reluctant to discuss quitting
  smoking
• EVERY patient at EVERY visit

Fiore MC, et al. U.S. DHHS Public Health Service
2008
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Vital Signs Stamp

VITAL SIGNS
Blood Pressure
Pulse
Weight
Temperature
Respiratory Rate
Current Former Never
Tobacco Use
(circle one)
Fiore MC, et al. U.S. DHHS Public Health Service
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AskScreening System
Fiore MC, et al. U.S. DHHS Public Health Service
1996. Meta-analysis (n 3 studies).
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Advise

• Advice should be clear, strong and personalized.

Fiore MC, et al. U.S. DHHS Public Health Service
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Advise

• 37.5 of preventable causes of death are
  tobacco-related
• 1/3 of all tobacco users will have a decreased
  life span
• 13.2 years in men
• 14.5 years in women
• Someone dies from tobacco use every 8 seconds

Fiore MC, et al. U.S. DHHS Public Health Service
2008
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AdviseSmokers With Psychiatric Disorders

• Chemical dependence
• Increased mortality from tobacco-related diseases
  versus other patient populations
• 1 study

Fiore MC, et al. U.S. DHHS Public Health Service
2008
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Advise

• Never too late to quit
• Age 40 gain 9 years
• Age 50 gain 6 years
• Age 60 gain 3 years

Fiore MC, et al. U.S. DHHS Public Health Service
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Assist

• S et a quit date to stop completely
• Ideally within 2 weeks
• T ell family friends
• A nticipate challenges
• R emove tobacco products from environment (home,
  work, car)

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AssistTriggers Challenges

• Where, when, why does patient smoke
• Alcohol
• Other smokers
• Urges and Cues
• Withdrawal symptoms
• Prior quit experience
• Build on success

Fiore MC, et al. U.S. DHHS Public Health Service
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AssistTriggers Challenges

• Concern about weight gain
• Negative affect, stressors
• Mental illness
• Increased risk of relapse
• Lack of support
• Lack of self efficacy
• Lack of knowledge

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Assist

• Counseling behavioral therapies
• Pharmacotherapy

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AssistSmokers With Psychiatric Disorders

• Smoking cessation and/or nicotine withdrawal may
  exacerbate underlying psychiatric condition.
• Consider waiting until psychiatric symptoms
  stabilized before initiating smoking cessation
  interventions.
• Case by case basis

Fiore MC, et al. U.S. DHHS Public Health Service
2008
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Arrange

• Relapse
• Most likely within 1st 3 months
• Especially 1st 2 weeks
• Recommended follow-up
• Ideally within 1st week after quitting
• 2nd contact within 1st month
• Further follow-up based on need

Fiore MC, et al. U.S. DHHS Public Health Service
2008
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ArrangeSmokers With Psychiatric Disorders

• Increased risk of relapse

Fiore MC, et al. U.S. DHHS Public Health Service
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The 5 As Model 2008 Update

• Ask about tobacco use.
• Advise to quit.
• Assess willingness to make a quit attempt.
• Assist in quit attempt. For patients unwilling to
  quit at the time, provide motivational
  interventions designed to increase future quit
  attempts.
• Arrange follow-up. For patients unwilling to make
  a quit attempt at the time, address tobacco
  dependence and willingness to quit at next clinic
  visit.

Fiore MC, et al. U.S. DHHS Public Health Service
2008
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Question

• At this time, all of he following interventions
• are recommended EXCEPT
• Decrease cigarette intake by 25 every 1 to 2
  weeks
• Initiate pharmacotherapy
• Follow-up with phone call 1 week after stopping
• Abstain from drinking beer
• Convince wife to stop smoking

33
Question

• At this time, all of he following interventions
• are recommended EXCEPT
• Decrease cigarette intake by 25 every 1 to 2
  weeks
• Initiate pharmacotherapy
• Follow-up with phone call 1 week after stopping
• Abstain from drinking beer
• Convince wife to stop smoking

34
Question

• Of the following statements
• regarding the non-pharmacologic
• treatment of this patients tobacco
• dependence, which is correct?

35
Answers

• Quit lines alone are effective in achieving
  abstinence.
• The addition of counseling to medications does
  not increase abstinence rates.
• Physicians are much more effective than
  non-physician clinicians at delivering treatment.
• Individual counseling alone is ineffective in
  achieving abstinence.
• Teaching problem solving and skills training
  alone is ineffective in achieving abstinence.

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Counseling

• Strong dose-response relationship

Fiore MC, et al. U.S. DHHS Public Health Service
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CounselingIntensity of Clinical Interventions
Fiore MC, et al. U.S. DHHS Public Health Service
2000. Meta-analysis (n 43 studies).
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Estimating Likelihood of Abstinence
Fiore MC, et al. U.S. DHHS Public Health Service
2008
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Smokers With Psychiatric Disorders

• May have greater sensitivity to nicotine
  dependence symptoms at lower levels of smoking
• Increased risk of relapse

Fiore MC, et al. U.S. DHHS Public Health Service
2008
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Counseling Components of Intensive Treatment

• Population
• Program clinicians
• Program intensity
• Program format
• Type of counseling and behavioral therapies
• Medication

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Counseling Components of Intensive Treatment

• Population
• All tobacco users willing to participate in such
  efforts
• Optimizes likelihood of abstinence

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2008
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Counseling Components of Intensive Treatment

• Program clinicians
• Physicians and non-physician clinicians equally
  effective
• 2 clinician types optimal

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2008
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Counseling Components of Intensive Treatment

• One counseling strategy
• Physician
• Delivers strong message to quit
• Discusses health benefits of quitting
• Prescribes medications
• Non-physician clinician
• Delivers additional counseling behavioral
  interventions

Fiore MC, et al. U.S. DHHS Public Health Service
2008
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Counseling Components of Intensive Treatment

• Program intensity
• Session length
• gt 10 minutes
• Number of sessions
• 4 sessions
• Total contact time
• 30 90 minutes

Fiore MC, et al. U.S. DHHS Public Health Service
2008
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Counseling Components of Intensive Treatment

• Program format
• Effective
• Individual or group counseling
• Proactive telephone counseling, including Quit
  lines
• 1 800 QUIT NOW

Fiore MC, et al. U.S. DHHS Public Health Service
2008
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Counseling Components of Intensive Treatment

• Program format
• Optional
• Self help materials and cessation Web sites
• Multiple formats optimal, with use of 3 4
  types especially effective

Fiore MC, et al. U.S. DHHS Public Health Service
2008
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Counseling Components of Intensive Treatment

• Type of counseling behavioral therapy
• Practical counseling
• Problem solving/skills training/stress management
• Intra-treatment social support
• Direct contact with clinician

Fiore MC, et al. U.S. DHHS Public Health Service
2008
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Counseling Components of Intensive Treatment

• Types of counseling behavioral therapies
  recommended by 2000 but not 2008 guideline
• Extra-treatment social support
• Smokers environment
• Aversive smoking procedures
• Rapid smoking, rapid puffing, other smoking
  exposure

Fiore MC, et al. U.S. DHHS Public Health Service
2008
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Type of Counseling Behavioral Therapy
Fiore MC, et al. U.S. DHHS Public Health Service
2000. Meta-analysis (n 43 studies).
50
Practical Counseling Problem
Solving/Skills Training
Fiore MC, et al. U.S. DHHS Public Health Service
2008
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Counseling
Intra-treatment Supportive Treatment
Fiore MC, et al. U.S. DHHS Public Health Service
2008
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Combination of Counseling and Medication Superior
to Either Treatment Alone
Fiore MC, et al. DHHS Public Health Service 2008.
Meta-analysis, Combination vs medication alone (n
18 studies) and vs counseling alone (n 9
studies).
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Answers

• Quit lines alone are effective in achieving
  abstinence.
• The addition of counseling to medications does
  not increase abstinence rates.
• Physicians are much more effective than
  non-physician clinicians at delivering treatment.
• Individual counseling alone is ineffective in
  achieving abstinence.
• Teaching problem solving and skills training
  alone is ineffective in achieving abstinence.

54
Answers

• Quit lines alone are effective in achieving
  abstinence.
• The addition of counseling to medications does
  not increase abstinence rates.
• Physicians are much more effective than
  non-physician clinicians at delivering treatment.
• Individual counseling alone is ineffective in
  achieving abstinence.
• Teaching problem solving and skills training
  alone is ineffective in achieving abstinence.

55
Question

• Of the following pharmacologic
• treatment options for this patients
• tobacco dependence, which would
• you choose?

56
Question

• Nicotine patch (21 mg)
• Nicotine gum (4 mg)
• Bupropion SR 150 mg bid
• Sertraline 100 mg once a day
• Nortriptyline 50 mg qhs
• Varenicline 1 mg bid
• Clonidine 0.2 mg patch/24 hrs

57
Question

• Of the following statements
• regarding the pharmacologic
• treatment of this patients tobacco
• dependence, which is correct?

58
Question

• 2nd line agents are contraindicated because of
  drug-drug interactions.
• Varenicline is contraindicated because of the
  risk of suicide.
• Bupropion SR may cause mood destabilization.
• Pharmacotherapy should be initiated at lower than
  usual doses.
• Pharmacotherapy tailored to the psychiatric
  disorder is superior to standard therapy.

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Pharmacotherapy

• 1st line agents
• Nicotine replacement therapy (NRT)
• Patch, gum, nasal spray, inhaler, lozenge
• Sustained-release bupropion (Zyban)
• Varenicline (Chantix)
• 2nd line agents

Fiore MC, et al. U.S. DHHS Public Health Service
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Pharmacotherapy

• 2nd line agents
• Nortriptyline, Clonidine
• Contraindications to, failure of 1st line agents
• Not FDA approved
• Concern about potential side effects

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Not Recommended

• Other antidepressants
• SSRIs
• Anxiolytics
• Benzodiazepines
• Beta blockers
• Opioid antagonists/naltrexone
• Silver acetate
• Mecamylamine

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Candidates for Pharmacotherapy

• All smokers trying to quit except
• When contraindicated
• Pregnant women
• Smokeless tobacco users
• Adolescent smokers
• Patients smoking lt10 cigarettes/day
• If prescribe NRT, ½ usual dose

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Pharmacotherapy

• Summary of results
• 6 month abstinence rate
• 19.0 to 33.2
• Odds Ratio
• 1.5 to 3.1

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Meta-analysis of Abstinence Rates for
Monotherapies Compared to Placebo at 6-Months
Postquit
( 95 CI)
80
5
4
4
6
3
6
3
26
32
10
5
15
Fiore MC, et al. Treating Tobacco Use and
Dependence 2008 Update. Rockville, MD U.S.
Department of Health and Human Services. Public
Health Service. 2008.


Number of study arms indicated within
the bar. This information concerns a use that has
not been approved by the US Food and Drug
Administration.
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Pharmacotherapy

• Recommended combination therapy
• Long term nicotine patch (gt 14 weeks) ad
  libitum nicotine gum or spray
• OR 1.9 (95 CI 1.3 2.7)
• Nicotine patch Bupropion SR
• OR 1.3 (95 CI 1.0 1.8)
• Nicotine patch inhaler
• OR 1.1 (95 CI 0.7 1.9)

Fiore MC, et al. U.S. DHHS Public Health Service
2008
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Meta-analysis of Abstinence Rates for Combination
Therapies Compared to Placebo at 6-Months Postquit
( 95 CI)
80
3
3
2
2
3
Fiore MC, et al. Treating Tobacco Use and
Dependence 2008 Update. Rockville, MD U.S.
Department of Health and Human Services. Public
Health Service. 2008.


Number of study arms indicated within
the bar. This information concerns a use that has
not been approved by the US Food and Drug
Administration.
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Tobacco Dependence TreatmentImpact on Concurrent
Medications

• Nicotine
• Metabolized by CYP2A6
• Does not induce liver enzymes
• Nicotine replacement therapy does not impact drug
  metabolism

Fiore MC, et al. U.S. DHHS Public Health Service
2008
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Tobacco Dependence TreatmentImpact on Concurrent
Medications

• Nicotine
• Activates sympathetic nervous system
• Decreases sedative effects of benzodiazepines,
  opioid analgesia, effect of beta blockers,
  subcutaneous absorption of insulin
• NRT not contraindicated in patients with
  cardiovascular disease

Fiore MC, et al. U.S. DHHS Public Health Service
2008
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Tobacco Dependence TreatmentImpact on Concurrent
Medications

• Polycyclic aromatic hydrocarbons in cigarette
  smoke
• Induce isoforms of CYP450
• Metabolizes
• Fluvoxamine, olanzapine, clozapine
• Caffeine, theophylline

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2008
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Tobacco Dependence TreatmentImpact on Concurrent
Medications

• Bupropion SR
• Metabolized by CYP2B6
• Inhibits CYP2D6
• Metabolizes tricyclic antidepressants,
  antipsychotics
• Contraindications
• MAO inhibitor last 14 days
• History of seizures, eating disorder

Fiore MC, et al. U.S. DHHS Public Health Service
2008
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Tobacco Dependence TreatmentImpact on Concurrent
Medications

• Varenicline
• Eliminated unchanged in urine
• No drug-drug interactions
• Caution with creatinine clearance lt 30 ml/min
• Consider 1 mg/day

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2008
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PharmacotherapyFactors to Consider

• Contraindications/precautions/warnings/ side
  effects/drug-drug interactions
• Patient preference
• Prior effectiveness?
• Clinician familiarity, experience
• Adherence
• Patch gt gum gt nasal spray, vapor inhaler

Fiore MC, et al. U.S. DHHS Public Health Service
2008
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PharmacotherapyFactors to Consider

• Highly dependent/severe withdrawal symptoms
• Nicotine replacement therapy
• 4 mg gum lozenge
• 21 mg patch
• Combination therapy

Fiore MC, et al. U.S. DHHS Public Health Service
2008
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Clues to Nicotine Addiction

• Smokes gt 1 pack per day
• 1st cigarette within ½ hour of awakening
• Symptoms of withdrawal with previous quit
  attempts
• Anxiety, irritability, restlessness, difficulty
  concentrating, insomnia, depression, craving,
  hunger

Fiore MC, et al. U.S. DHHS Public Health Service
2008
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PharmacotherapyFactors to Consider

• Concerned about weight gain
• Bupropion SR
• 4mg gum lozenge
• Varenicline
• Woman
• Nicotine replacement therapy may be less
  effective

Fiore MC, et al. U.S. DHHS Public Health Service
2008
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PharmacotherapyFactors to Consider

• Cardiovascular disease
• Hospitalized patients
• Nicotine replacement therapy, especially patch,
  safe
• ? ICU patients

Fiore MC, et al. U.S. DHHS Public Health Service
2008
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PharmacotherapyFactors to Consider

• History of depression
• Bupropion SR, Nortriptyline
• Cardiovascular disease, hospitalized patients
• Nicotine replacement therapy, especially patch,
  safe
• ? ICU patients

Fiore MC, et al. U.S. DHHS Public Health Service
2008
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PharmacotherapyFactors to Consider

• Long term use
• 6 months OK
• Preferred to continued smoking
• Pragmatic
• Dentures with gum
• Dermatitis with patches
• Insurance coverage
• Cost

Fiore MC, et al. U.S. DHHS Public Health Service
2008
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Smokers With Psychiatric Disorders

• Increased risk of relapse
• Insufficient evidence that treatment tailored to
  psychiatric diagnoses/symptoms is superior to
  traditional treatment

Fiore MC, et al. U.S. DHHS Public Health Service
2008
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Smokers With Psychiatric Disorders

• Past history of depression
• Bupropion SR nortriptyline vs placebo
• OR 3.42 (95 CI 1.70 6.84)
• Bipolar disorder
• Antidepressants may cause mood destabilization

Fiore MC, et al. U.S. DHHS Public Health Service
2008
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Smokers With Psychiatric Disorders

• Patients being treated for non-nicotine chemical
  dependence
• Pharmacotherapy and counseling for nicotine
  dependence are effective
• Treating concurrently does not interfere with
  outcomes
• Except possibly alcohol abstinence outcome (1
  study)

Fiore MC, et al. U.S. DHHS Public Health Service
2008
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Smokers With Psychiatric Disorders

• Schizophrenia
• Bupropion SR and NRT may be effective
• May improve negative and depressive symptoms
• Patients on atypical antipsychotics may be more
  responsive to Bupropion SR than those on standard
  antipsychotics

Fiore MC, et al. U.S. DHHS Public Health Service
2008
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Smokers With Psychiatric Disorders

• Varenicline
• NOT contraindicated
• Reports of depressed mood, agitation, changes in
  behavior, suicidal ideation, suicide
• FDA recommendation
• Elicit psychiatric history
• Monitor for changes in mood, behavior

Fiore MC, et al. U.S. DHHS Public Health Service
2008
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Question

• 2nd line agents are contraindicated because of
  drug-drug interactions.
• Varenicline is contraindicated because of the
  risk of suicide.
• Bupropion SR may cause mood destabilization.
• Pharmacotherapy should be initiated at lower than
  usual doses.
• Pharmacotherapy tailored to the psychiatric
  disorder is superior to standard therapy.

85
Question

• 2nd line agents are contraindicated because of
  drug-drug interactions.
• Varenicline is contraindicated because of the
  risk of suicide.
• Bupropion SR may cause mood destabilization.
• Pharmacotherapy should be initiated at lower than
  usual doses.
• Pharmacotherapy tailored to the psychiatric
  disorder is superior to standard therapy.

86
Question

• Nicotine patch (21 mg)
• Nicotine gum (4 mg)
• Bupropion SR 150 mg bid
• Sertraline 100 mg once a day
• Nortriptyline 50 mg qhs
• Varenicline 1 mg bid
• Clonidine 0.2 mg patch/24 hrs

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Question

• Nicotine patch (21 mg)
• Nicotine gum (4 mg)
• Bupropion SR 150 mg bid
• Sertraline 100 mg once a day
• Nortriptyline 50 mg qhs
• Varenicline 1 mg bid
• Clonidine 0.2 mg patch/24 hrs

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Obtaining the 2008 Guideline

• The full text of the 2008 Guideline,
  www.ahrq.gov/path/tobacco.htmclinic
• To order the 2008 Guideline and the various
  supplemental materials go to www.ahrq.gov/clinic/t
  obacco/order.htm
• UW-CTRI
• www.ctri.wisc.edu
• CS2day
• www.ceasesmoking2day.org

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Patient Unwilling to QuitMotivational
Interviewing
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Patient Unwilling to QuitMotivational
Interviewing
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Patient Unwilling to QuitMotivational
Interviewing
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The 5 Rs
To Motivate Patients Unwilling to Quit at This
Time

• RELEVANCE tailor advice and discussion
• to each patient
• RISKS outline risks of continued smoking
• REWARDS outline the benefits of quitting
• ROADBLOCKS identify barriers to
• quitting
• REPETITION reinforce the motivational
• message at every visit

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Patient Unwilling to Quit (The 5Rs)
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Patient Unwilling to Quit (The 5Rs)
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Patient Unwilling to Quit (The 5Rs)
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Patient Who Has Recently Quit
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Patient Who Has Recently Quit
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Patient Who Has Recently Quit
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