Assisting Adolescents and Adults to Stop Smoking TAFP C. Frank Webber Lectureship Austin, Texas Friday – April 5, 2019 9:45 – 11:15 a.m. Clare Hawkins, MD, MSc, FAAFP – Regional Medical Officer – Aspire Healthcare
Speaker Disclosure • Dr. Hawkins has disclosed that he has no actual or potential conflict of interest in relation to this topic.
AdobeStock license # 105397772 Smoking Cessation Objectives By completing this educational activity, the participant should be better able to: 1. Recognize the impact of tobacco use on health. 2. Discuss the evidence for e‐cigarettes and vaping on patient’s health. 3. Make office system changes to increase cessation rates. 4. Practice counseling with stages of change approach for smoking cessation and vaping. 5. Prepare an action plan to reach health goals.
Epidemiology in Adults • 2017 record low to 14% U.S. Adults smoking • Estimated 480,000 deaths annually attributed to tobacco • 40% of smokers make an average of 2 quit attempts annually Rostron BL, Chang CM, Pechacek TF. Estimation of cigarette smoking‐attributable morbidity in the United States. JAMA Intern Med . 2014 Dec;174(12):1922‐8. Anthonisen NR, Skeans MA, Wise RA, Manfreda J, Kanner RE, Connett JE. Lung Health Study Research Group. The effects of a smoking cessation intervention on 14.5‐year mortality: a randomized clinical trial. Ann Intern Med . 2005;142(4):233‐239.
Epidemiology in Children and Adolescents • 24.2% High School (3.69 million students) in 2011 and 27.1% in 2018 • 4.04 million students • From 2017 to 2018 middle school students increased from 5.6% to 7.2% CDC 2018 & Surgeon General
History • Late recognition of connection between smoking and cancer • Long battle with tobacco manufacturers (see The Emperor of All Maladies: A History of Cancer, Siddhartha Mukherjee) • Tobacco Settlement $$ (funding quit lines… and highways) • Master Settlement Agreement, 1998 • Resurgence of aggressive techniques to recruit youth smokers • International tobacco promotion
Physiology • Inhalation of tobacco smoke and is rapidly absorbed in pulmonary venous circulation then enters arterial circulation to travel directly to the brain • Strongly felt rush (highly efficient route of delivery) • Smoking process and rapid reinforcement allows for precise dosing • Can achieve desired effect without toxicity • Smoking improves concentration, reaction time, and performance of certain tasks • Activation of alpha4Beta2 neuronal nicotinic acetylcholine receptors Benowitz NL, Nicotine Addiction. N Engl J Med . 2010 June 17 362(24): 2292‐2303.
DOPAMINE! • Activation results in Dopamine release signaling • Pleasurable experience resulting in reinforcing smoking • Mesolimbic area, corpus striatum, and frontal cortex • Ventral tegmental area of midbrain and shell of nucleus accumbens • Glutamine release facilitating both Dopamine and GABA which inhibits dopamine though long‐term exposure results in GABA desensitization leaving dopamine unbalanced • Hypocretins, neuropeptides in the lateral hypothalamus also regulate the stimulatory effects of nicotine on reward centers
MAOI, Tolerance and Withdrawal • Acetaldehyde in cigarette smoke inhibit monoamine oxidase , (MAO A and B) contributing to the addictiveness of smoking by reducing the metabolism of dopamine • Neuroadaptation (tolerance) develops by increasing binding sites in brain, and desensitization (closure of the receptor) plays a role in tolerance and dependence: With craving and withdrawal beginning earlier • With near complete saturation of alpha4Beta2 , smokers are probably attempting to avoid withdrawal symptoms by regularly smoking • Withdrawal: Anxiety, stress, craving, irritability, depressed mood, restlessness, Anhedonia. (Cascade of corticotropin releasing factor, CRF which precipitates relapse)
AdobeStock license # 194770801 Conditioning • Conditioning: Urge to resume smoking long after withdrawal symptoms dissipate • Cues can trigger relapse • After a meal, with a cup of coffee, or an alcoholic drink • Smoking with friends • Manipulation of smoking materials • Taste, smell and feel of smoke in the throat • Light smokers (<5/d) and occasional smokers have difficulty quitting • Dependence with different pharmacodynamics from heavier smokers
Genetics • High degree of heritability of cigarette smoking (>50%) • Candidate genes coding for nicotine‐ receptor subtypes, dopamine receptors, and dopamine transporters, GABA r eceptors, opiate and cannabinoid receptors . (Also coding for cell adhesion and extracellular matrix molecules common with other addiction) AdobeStock License #91249577 • Genome‐wide association alpha5/alpha3/Beta4 nicotinic cholinergic receptor gene complex on chromosome 15 • Neural plasticity and learning are key determinants of individual differences in vulnerability
Nicotine Addiction, Youth and Mental Health • 80% of smokers begin smoking by 18 years of age • 2/3 of young people try cigarette smoking and only 20‐25% of them become dependent daily smokers • Peer and parental influences • Behavioral problems, (poor school performance) • Personality characteristics (rebelliousness, risk taking, depression and anxiety) • Highly prevalent in persons with mental illness or other substance‐use disorders • Likely a shared genetic predisposition including capacity for nicotine to relieve psychiatric symptoms Lynch, BS, Bonnie RJ, Growing up tobacco free – preventing nicotine addiction in children and youths. Washington, DC: National Academy Press; 1994. The nature of nicotine addiction; p.28‐68.
Women • Smoking behavior in women is more strongly influenced by conditioned cues and negative affect • Men are more likely to smoke in response to pharmacologic cues, regulating intake of nicotine more precisely than women • Women metabolize nicotine more quickly • Increased susceptibility to addiction and more difficulty quitting AdobeStock License # 216674078
FIVE As Ask Advise Assess Assist Arrange https://www.aafp.org/patient‐care/public‐health/tobacco‐nicotine/toolkit.html. AdobeStock license 197026886
1. Ask • Office systems should ensure that all tobacco users are identified • Smoking status should be documented at every visit • Promoting cessation appears to increase patients’ satisfaction with their visit, even among smokers not yet motivated to quit • Including it as a vital sign may remind the physician • “Have you ever been a smoker or used other tobacco products? Do you use tobacco now? How much?” AdobeStock license 130474067
2. Advise • Unambiguous support for smoking cessation should be expressed by the physician, and the benefits of quitting should be discussed • Advice to patients should be clear (direct expression of the need for smoking cessation) • Strong: Highlighting the importance of cessation • Personalized: Linking the patients health goals to cessation AdobeStock License 211760591
Teachable Moments • New patient visits • Annual physicals • Well‐child visits (e.g., discuss smoking in the home and car) • Women’s wellness exams • OV for tobacco influenced diseases: i.e., upper respiratory conditions, diabetes, hypertension, asthma • Follow‐up visits after hospitalization for a tobacco‐related illness or the birth of a child • A recent health scare AdobeStock. License 65454027
How Bad are Your Lungs? Tell Them Their “Lung Age”? • 52 yo patient with Spirometry showing FEV1 value at the level of a nonsmoking 75 year old • Discussion of “lung age” prompted higher quit rate at one year even if lung age not reduced • 13.6 vs. 6.4 in the control group who only received a number Parkes G, Greenhalgh T, Griffin M, Dent R. Effect on smoking quit rate of telling patients their lung age: the Step2quit randomized controlled trial. BMJ . 2008;336(7644):598‐600.
But I’m Going to Gain Weight? • Weight gain is a major concern (or rationalization) of those who are contemplative • Modest weight gain carries less risk than ongoing smoking • Bupropion, fluoxetine, NRT and varenicline reduce post cessation weight gain while using the medication. Although this effect was not maintained one year after stopping smoking, the evidence is insufficient to exclude a modest long‐term effect. Farley AC et al. Interventions for pre‐venting weight gain after smoking cessation. Cochrane Database Syst Rev . 2012 Jan 18;1:CD006219.
Drug Interactions • Induction of cytochrome P450 (CYP) 1A1, CYP1A2 and possibly CYP2E1, CYP1A1 • Caffeine, tacrine, imipramine, haloperidol, pentazocine, propranolol, flecainide and estradiol. Cigarette smoking results in faster clearance of heparin • Lesser magnitude of blood pressure and heart rate lowering during treatment with beta‐blockers • Less sedation from benzodiazepines and less analgesia from some opioids Zevin S, Benowitz, NL. Drug interactions with tobacco smoking. An update. Clin Pharmacokinet . 1999;36(6):425‐38. Kroon LA. Drug interactions with smoking. Am J Health System Pharm . 2007;64(18):1917‐21.
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