tobacco cessation: curb the deadliest epidemic

Tobacco Cessation:Curb the Deadliest Epidemic

Keith Bradley, MDDirector,

Research Associates Program at St. Vincent’s National Alliance of Research Associates Programs

(NARAP)

Nicotine-Related Pathology

• coronary artery • peripheral vascular disease• hypertension • peptic ulcer disease• fetal mortality and morbidity• cancer

Lung Cancer

All lung cancers begin as small focus of

uncontrolled cell division

→ thickening/piling up of bronchial mucosa.

Lung Cancer

• Small cell

• Adenocarcinoma

• Squamous carcinoma

• Large cell carcinoma

Small Cell Carcinoma


• 20% of all lung cancers



• highly aggressive, metastasizing early.




• only 1% of cases occur in non-smokers




• only 1% of cases occur in non-smokers

• incurable by surgery


• 90% of small cell carcinomas begin in central airways


• 90% of small cell carcinomas begin in central airways– consistent with smoking association



• Small cell staged as limited or extensive (spread outside chest)



• Small cell staged as limited or extensive (spread outside chest) – 70% are extensive at diagnosis

Adenocarcinoma

Adenocarcinoma

• About 40% of lung cancer cases in the US

Adenocarcinoma

• About 40% of lung cancer cases in the US • The most common lung cancer among

women

Adenocarcinoma


women– number of new cases is increasing

Adenocarcinoma


women– number of new cases is increasing

• Usually starts near the outer edges of the lungs

Adenocarcinoma


women, – number of new cases is increasing

• Usually starts near the outer edges of the lungs

• Often metastasized at diagnosis

Squamous Carcinoma

Squamous Carcinoma

• 25-30% of lung cancer cases in the US

Squamous Carcinoma

• 25-30% of lung cancer cases in the US • Occurs most frequently in men and the

elderly

Squamous Carcinoma


elderly • Usually starts in one of the larger breathing

tubes

Squamous Carcinoma



tubes • Tends to grow relatively slowly

Squamous Carcinoma



tubes • Tends to grow relatively slowly • Tends to remain localized in the chest longer

than other types of lung cancer

Squamous Carcinoma



tubes • Tends to grow relatively slowly • Tends to remain localized in the chest longer

than other types of lung cancer • Does not metastasize early

Large Cell Carcinoma

Large Cell Carcinoma• “Other”

– tend to have larger cells than other types of lung cancer


– tend to have larger cells than other types of lung cancer • Incidence appears to be decreasing

– may be due to improvements in determining the types of lung cancer




• 10-15% of lung cancer cases in the US



– may be due to improvements in determining the types of lung cancer.

• 10-15% of lung cancer cases in the US • Usually starts in the smaller breathing tubes




• 10-15% of lung cancer cases in the US • Usually starts in the smaller breathing tubes • May occur in any part of the lung




• 10-15% of lung cancer cases in the US • Usually starts in the smaller breathing tubes • May occur in any part of the lung • Tumors are usually large at diagnosis




• 10-15% of lung cancer cases in the US • Usually starts in the smaller breathing tubes • May occur in any part of the lung • Tumors are usually large at diagnosis• Tends to invade the mediastinum

(chest area behind the breastbone)




• 10-15% of lung cancer cases in the US • Usually starts in the smaller breathing tubes • May occur in any part of the lung • Tumors are usually large at diagnosis• Tends to invade the mediastinum

(chest area behind the breastbone)• Metastasizes to the central nervous system

Nicotine Addiction

Nicotine Addiction• Psychoactive


– dose-related changes in mood and feeling


– dose-related changes in mood and feeling – transient



• Euphoriant



• Euphoriant – dose-related increases in scores on standard

measures of euphoria. •




measures of euphoria. • Reinforcer




measures of euphoria. • Reinforcer• Neuroadaptation




measures of euphoria. • Reinforcer• Neuroadaptation

– leading to tolerance and physiologic dependence.

Nicotine Addiction

nicotine from the use of tobacco has≈ physical addiction potential as morphine

Nicotine Addiction

nicotine from the use of tobacco has≈ physical addiction potential as morphine≈ psychic dependence as cocaine

Smokeless Tobacco

• pharmacokietics of nicotine

(i.e., absorption, distribution, and elimination)

from smoking and from smokeless tobacco

→ magnitude of nicotine exposure similar

Tobacco Cessation

Tobacco Cessation

• Treating Tobacco Use and Dependence. U.S. Public Health Service. http://www.surgeongeneral.gov/tobacco/smokesum.htm

• Guideline, Treating Tobacco Use and Dependence– based on the literature review and expert panel

opinion

http://www.surgeongeneral.gov/tobacco/smokesum.htm

http://www.surgeongeneral.gov/tobacco/smokesum.htm

Which Smokers Offered Cessation ?

• Because effective tobacco dependence treatments are available, every patient who uses tobacco should be offered at least one of these treatments:– Patients willing to try to quit tobacco use should

be provided treatments identified as effective in this guideline.

– Patients unwilling to try to quit tobacco use should be provided a brief intervention designed to increase their motivation to quit.

Which Smokers Offered Cessation ?

“It is essential that clinicians and

health care delivery systems …

institutionalize the consistent

identification, documentation, and

treatment

of every tobacco user seen in a health

care setting.”

Brief Tobacco Dependence Tx


• should be: – effective


• should be: – effective– offered to every patient who uses tobacco



• Quitlines



• Quitlines:– mandated by tobacco company settlements



• Quitlines:– mandated by tobacco company settlements– about 30-40% effective

Tx Dose-Response Relationship

Tx Dose-Response Relationship• strong relationship between

intensity of tobacco dependence counseling and its effectiveness



• person-to-person treatments (individual, group, or telephone counseling)



• person-to-person treatments (individual, group, or telephone counseling):– consistently effective



• person-to-person treatments (individual, group, or telephone counseling):– consistently effective– effectiveness increases with treatment intensity

(e.g., minutes of contact)

Types of Counseling and Behavioral Tx


1. Provision of practical counseling (problem solving/skills training)



2. Provision of social support as part of tx (intra-treatment social support)



2. Provision of social support as part of tx (intra-treatment social support)

3. Help in securing social support outside of tx (extra-treatment social support)

Pharmacotherapies

Pharmacotherapies

Reliably increase long-term smoking abstinence

Pharmacotherapies

Reliably increase long-term smoking abstinence• Nicotine

– gum– inhaler – nasal spray– patch

Pharmacotherapies



“Over-the-counter nicotine patches are effective relative to placebo, and their use should be encouraged.”

Pharmacotherapies



“Over-the-counter nicotine patches are effective relative to placebo, and their use should be encouraged.”

• Bupropion (Wellbutrin) SR • Other anti-depressants

Effective Pharmacotherapies

Except in the presence of contraindications,

these should be used with all patients

attempting to quit smoking.

$ ?

Insurers should include as a reimbursedbenefit:

$ ?

Insurers should include as a reimbursedbenefit:• counseling and pharmacotherapeutic

treatments identified as effective in this guideline.

$ ?

Insurers should include as a reimbursedbenefit:• counseling and pharmacotherapeutic

treatments identified as effective in this guideline.

• clinicians for providing tobacco dependence treatment just as they are reimbursed for treating other chronic conditions.

Clinicians and Tobacco Cessation

• About 20 years ago, data indicated that clinicians too frequently failed to intervene with their patients who smoke.


• About 20 years ago, data indicated that clinicians too frequently failed to intervene with their patients who smoke.

• Recent data confirm this has not changed markedly over the past two decades.


One recent study reported: • only 15 percent of smokers who saw a

physician in the past year were offered assistance with quitting


One recent study reported: • only 15 percent of smokers who saw a

physician in the past year were offered assistance with quitting

• only 3 percent were given a follow-up appointment to address this topic.

Bottom LineThese evidence-based guidelines reveal:

Bottom LineThese evidence-based guidelines reveal: 1. multiple efficacious tobacco cessation tx exist

Bottom LineThese evidence-based guidelines reveal: 1. multiple efficacious tobacco cessation tx exist 2. these tx can double or triple the likelihood of long-

term cessation


term cessation 3. many cessation tx are appropriate for the

primary care setting



primary care setting4. cessation tx are more cost-effective than many

other reimbursed clinical interventions



primary care setting4. cessation tx are more cost-effective than many

other reimbursed clinical interventions5. utilization and impact of cessation treatments can

be increased by supportive health system policies (e.g., coverage through insurance)

tobacco cessation: curb the deadliest epidemic

Documents

lung cancer cases

common lung cancer

chest small cell carcinoma90

surgery small cell carcinoma90

us squamous carcinoma25

us adenocarcinomaabout

womennumber of new cases

elderly squamous carcinoma25