Tobacco Cessation: Curb the Deadliest Epidemic Keith Bradley, MD Director, 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

Small Cell Carcinoma 20% of all lung cancers highly aggressive, metastasizing early.

Small Cell Carcinoma 20% of all lung cancers highly aggressive, metastasizing early. only 1% of cases occur in non-smokers

Small Cell Carcinoma 20% of all lung cancers highly aggressive, metastasizing early. only 1% of cases occur in non-smokers incurable by surgery

Small Cell Carcinoma 90% of small cell carcinomas begin in central airways

Small Cell Carcinoma 90% of small cell carcinomas begin in central airways –consistent with smoking association

Small Cell Carcinoma 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 Carcinoma 90% of small cell carcinomas begin in central airways –consistent with smoking association Small cell staged as limited or extensive (spread outside chest) –70% are extensive at diagnosis

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 About 40% of lung cancer cases in the US The most common lung cancer among women –number of new cases is increasing

Adenocarcinoma About 40% of lung cancer cases in the US The most common lung cancer among women –number of new cases is increasing Usually starts near the outer edges of the lungs

Adenocarcinoma About 40% of lung cancer cases in the US The most common lung cancer among women, –number of new cases is increasing Usually starts near the outer edges of the lungs Often metastasized at diagnosis

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 25-30% of lung cancer cases in the US Occurs most frequently in men and the elderly Usually starts in one of the larger breathing tubes

Squamous Carcinoma 25-30% of lung cancer cases in the US Occurs most frequently in men and the elderly Usually starts in one of the larger breathing tubes Tends to grow relatively slowly

Squamous Carcinoma 25-30% of lung cancer cases in the US Occurs most frequently in men and the elderly Usually starts in one of the larger breathing tubes Tends to grow relatively slowly Tends to remain localized in the chest longer than other types of lung cancer

Squamous Carcinoma 25-30% of lung cancer cases in the US Occurs most frequently in men and the elderly Usually starts in one of the larger breathing 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

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

Large Cell Carcinoma “Other” –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

Large Cell Carcinoma “Other” –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

Large Cell Carcinoma “Other” –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 % of lung cancer cases in the US Usually starts in the smaller breathing tubes

Large Cell Carcinoma “Other” –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 Usually starts in the smaller breathing tubes May occur in any part of the lung

Large Cell Carcinoma “Other” –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 % 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

Large Cell Carcinoma “Other” –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 % 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)

Large Cell Carcinoma “Other” –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 % 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

Psychoactive

Nicotine Addiction Psychoactive –dose-related changes in mood and feeling

Nicotine Addiction Psychoactive –dose-related changes in mood and feeling –transient

Nicotine Addiction Psychoactive –dose-related changes in mood and feeling –transient Euphoriant

Nicotine Addiction Psychoactive –dose-related changes in mood and feeling –transient Euphoriant –dose-related increases in scores on standard measures of euphoria.

Nicotine Addiction Psychoactive –dose-related changes in mood and feeling –transient Euphoriant –dose-related increases in scores on standard measures of euphoria. Reinforcer

Nicotine Addiction Psychoactive –dose-related changes in mood and feeling –transient Euphoriant –dose-related increases in scores on standard measures of euphoria. Reinforcer Neuroadaptation

Nicotine Addiction Psychoactive –dose-related changes in mood and feeling –transient Euphoriant –dose-related increases in scores on standard 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

Treating Tobacco Use and Dependence. U.S. Public Health Service. kesum.htm kesum.htm Guideline, Treating Tobacco Use and Dependence –based on the literature review and expert panel opinion

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

Brief Tobacco Dependence Tx should be: –effective –offered to every patient who uses tobacco

Brief Tobacco Dependence Tx should be: –effective –offered to every patient who uses tobacco Quitlines

Brief Tobacco Dependence Tx should be: –effective –offered to every patient who uses tobacco Quitlines: –mandated by tobacco company settlements

Brief Tobacco Dependence Tx should be: –effective –offered to every patient who uses tobacco Quitlines: –mandated by tobacco company settlements –about 30-40% effective

Tx Dose-Response Relationship

strong relationship between intensity of tobacco dependence counseling and its effectiveness

Tx Dose-Response Relationship strong relationship between intensity of tobacco dependence counseling and its effectiveness person-to-person treatments (individual, group, or telephone counseling)

Tx Dose-Response Relationship strong relationship between intensity of tobacco dependence counseling and its effectiveness person-to-person treatments (individual, group, or telephone counseling): –consistently effective

Tx Dose-Response Relationship strong relationship between intensity of tobacco dependence counseling and its effectiveness 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)

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)

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

Pharmacotherapies

Reliably increase long-term smoking abstinence

Pharmacotherapies Reliably increase long-term smoking abstinence Nicotine –gum –inhaler –nasal spray –patch

Pharmacotherapies Reliably increase long-term smoking abstinence Nicotine –gum –inhaler –nasal spray –patch “ Over-the-counter nicotine patches are effective relative to placebo, and their use should be encouraged.”

Pharmacotherapies Reliably increase long-term smoking abstinence Nicotine –gum –inhaler –nasal spray –patch “ 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.

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Insurers should include as a reimbursed benefit:

$ ? Insurers should include as a reimbursed benefit: counseling and pharmacotherapeutic treatments identified as effective in this guideline.

$ ? Insurers should include as a reimbursed benefit: 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.

Clinicians and Tobacco Cessation 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.

Clinicians and Tobacco Cessation One recent study reported: only 15 percent of smokers who saw a physician in the past year were offered assistance with quitting

Clinicians and Tobacco Cessation 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 Line These evidence-based guidelines reveal:

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

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

Bottom Line These evidence-based guidelines reveal: 1.multiple efficacious tobacco cessation tx exist 2.these tx can double or triple the likelihood of long- term cessation 3.many cessation tx are appropriate for the primary care setting

Bottom Line These evidence-based guidelines reveal: 1.multiple efficacious tobacco cessation tx exist 2.these tx can double or triple the likelihood of long- term cessation 3.many cessation tx are appropriate for the primary care setting 4.cessation tx are more cost-effective than many other reimbursed clinical interventions

Bottom Line These evidence-based guidelines reveal: 1.multiple efficacious tobacco cessation tx exist 2.these tx can double or triple the likelihood of long- term cessation 3.many cessation tx are appropriate for the primary care setting 4.cessation tx are more cost-effective than many other reimbursed clinical interventions 5.utilization and impact of cessation treatments can be increased by supportive health system policies (e.g., coverage through insurance)

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