Treating Treating tobacco tobacco dependence dependence Terry Terry A. A. Rustin, Rustin, MD MD
Tobacco sales in Iceland 2
Changing behavior • • •
Logic Emotion Humor and sarcasm
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Tobacco kills •
•
Over 5,000,000 people worldwide die every year from diseases caused by tobacco Equivalent to the entire population of Iceland, every three weeks
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Tobacco kills Icelanders, too
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That’s the equivalent of two of Icelandair’s new Boeing 757 aircraft, fully loaded with passengers and crew, crashing and burning and killing everyone on board, every hour of every day 6
Iceland 24 26
7 ESPAD (European School Project on Alcohol and Drugs) 1999 report
Iceland 26 30
8 ESPAD (European School Project on Alcohol and Drugs) 1999 report
Iceland 25 28
9 ESPAD (European School Project on Alcohol and Drugs) 1999 report
Tobacco kills •
More people die from the effects of tobacco than from alcohol, cocaine, heroin, AIDS, suicides, murders, fires, drownings, airplane crashes, car crashes, and terrorism…
combined! 10
4,000 chemicals in tobacco smoke • • • • • •
hydrogen cyanide carbon monoxide formaldehyde acetaldehyde benzene nitrosamines
• • • • • •
pyrethrins cadmium lead arsenic radon polonium-210 11
Smoking kills Icelanders •
Familial Risk of Lung Carcinoma in the Icelandic Population Jonsson et al. JAMA.2004; 292: 2977-2983.
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DSM-IV criteria • • • •
Tolerance Withdrawal Denial Compulsive use
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Tolerance • • • •
Better term: “Neuroadaptation” Over time, more and more of the drug is required to produce the same effect Neuroadaptation to nicotine occurs faster than to most other drugs (10 min) Neuroadaptation to the various effects of nicotine occurs at different rates 17
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Withdrawal •
• •
The set of signs and symptoms that occur when the drug is decreased or stopped, and which are alleviated when the drug is started again Specific to the drug, not the individual Nicotine: irritability, agitation, anxiety, difficulty concentrating, bradycardia, insomnia, hunger, labile mood 20
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Fagerström Test for Nicotine Dependence •
•
How soon after you wake up do you smoke your first cigarette? • 30 cigarettes = 3 points • 21-30 cigarettes = 2 points • 11-20 cigarettes = 1 point 22
Fagerström Test for Nicotine Dependence •
Is it hard to refrain from smoking in situation where you should not smoke? •
•
First one = 1 point
Any other = 0 points
Do you smoke more in AM? •
•
No = 0 points
Which cigarette do you value the most? •
•
Yes = 1 point
Yes = 1 point
No = 0 points
Do you smoke if you are ill? •
Yes = 1 point
No = 0 points
Heatherton et al (1991). British Journal of Addictions 86:1119-1127 23
Craving •
A drive state in which obtaining the chemical seems essential to survival
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Denial •
The unconscious resistance to accepting the truth • •
The observation is true The conclusion is false
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Mind- and mood-altering • • • • •
Pharmacologically active alkaloid High potency (10 mg nicotine in the tobacco; 1-2 mg delivered per cigarette) Short half-life (100 minutes) Releases dopamine, growth hormone, epinephrine, cortisol Effects similar to cocaine, amphetamine 26
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Compulsive use • • • •
Compulsion: “I’m just going to step outside for a breath of fresh air.” Consequences: “These things happen.” Control: “I didn’t realize I smoked that much.” Cut down: “I tried to cut down and couldn’t do it.” 28
Drug-seeking behavior • • • •
Smoke is aversive but nicotine is reinforcing Intense drive (compulsion) to smoke triggered by internal or external cues Smokers continue to smoke despite consequences Average age of smoking initiation = 14 29
Consider not only the drug, but the set (expectations, experience, emotions) and the setting (place, time, 30 associates) as factors in addictive disorders
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Summary: Nicotine is highly addictive • • • • • •
Addiction occurs soon after initiation Neuroadaptation develops rapidly Withdrawal and craving occur Use continues despite consequences Compulsive use and denial are prominent clinical features Quitting is difficult; relapse is frequent 32
Smoking cessation treatment in 2 minutes • • • • •
Should I quit now or later? Can I just switch brands? Can I just cut down? Medication or no medication? Is there any counseling a clinician can do in 2 minutes that will be effective?
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Smoking cessation treatment in 2 minutes • • • • •
Should I quit now or later? Can I just switch brands? Can I just cut down? Medication or no medication? Is there any counseling a clinician can do in 2 minutes that will be effective?
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Set a Quit Day: • The patient must select the date, not the clinician • Two weeks or more in the future • Choose a date with significance • Develop a plan to be successful on the Quit Day
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Smoking cessation treatment in 2 minutes • • • • •
Should I quit now or later? Can I just switch brands? Can I just cut down? Medication or no medication? Is there any counseling a clinician can do in 2 minutes that will be effective?
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Neal37 Benowitz
Smoking cessation treatment in 2 minutes • • • • •
Should I quit now or later? Can I just switch brands? Can I just cut down? Medication or no medication? Is there any counseling a clinician can do in 2 minutes that will be effective?
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Heavy smokers cut down using the nicotine inhaler. Carbon monoxide levels remained constant. Hurt et al (2000) Nicotine and Tobacco Research
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Heavy smokers cut down using the nicotine inhaler. Thiocyanate levels (measure of carcinogenesis) stayed constant. Hurt et al (2000) Nicotine and Tobacco Research
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Smoking cessation treatment in 2 minutes • • • • •
Should I quit now or later? Can I just switch brands? Can I just cut down? Medication or no medication? Is there any counseling a clinician can do in 2 minutes that will be effective?
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Medications for treating nicotine dependence •
Nicotine replacement therapy (patch, gum, spray, inhaler, lozenge) •
•
Treats nicotine withdrawal
Bupropion •
Treats both nicotine withdrawal and nicotine craving 42
Medications for treating nicotine dependence • • • • • •
Start with patients in Preparation stage For most patients: Set a Quit Date 1-2 weeks in the future Start bupropion 1-2 weeks before Quit Day Initial dose: 150 mg daily Maintenance dose: 150 mg BID Continue treatment at least 7 weeks 43
Medications for treating nicotine dependence •
• • • •
Apply nicotine patch the night prior to the Quit Day (so the patient has an adequate nicotine level in the AM) New patch daily Continue patch for 3-6 weeks Reduce patch dose if desired Use gum, lozenge, nasal spray to supplement nicotine 44
Effective combinations • • • • •
Nicotine patch plus nicotine gum Nicotine patch plus nicotine nasal spray Bupropion plus nicotine gum Bupropion plus nicotine patch Bupropion plus nicotine nasal spray
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Smoking cessation treatment in 2 minutes • • • • •
Should I quit now or later? Can I just switch brands? Can I just cut down? Medication or no medication? Is there any counseling a clinician can do in 2 minutes that will be effective?
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Health prediction • •
“Your cough is going to get a lot better after you quit smoking.” “Your exercise tolerance is going to improve a lot after the second week without a cigarette.”
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Reduce fears about quitting •
Ask •
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Acknowledge the affect •
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“Those are reasonable concerns. “
Clarify the issue •
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“What are your thoughts and feelings about quitting smoking?”
“Explain more about your concerns to me.”
Intervention: The example of one •
“Let me tell you about another patient of mine…” 48
Focus on the future •
Ask •
•
Acknowledge the affect •
•
“Wouldn’t that be great?”
Clarify the issue •
•
“How will your life be better after you have quit smoking?”
“Tell me more about that.”
Intervention: Obtain a commitment to change • •
“Shall we set a quit date?” “Not quite ready? How about we set a date, to set a quit date?” 49
Community resources for smoking cessation •
QuitNet •
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American Cancer Society QuitLine •
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www.QuitNet.com www.cancer.org
American Lung Association Freedom From Smoking •
Online at http://www.ffsonline.org
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