Challenges Facing Clinicians Treating Tobacco Use Christopher S Holaway, Pharm.D Adjunct Clinical Assistant Professor
ACKNOWLEDGMENT
Permission to utilize slides from UCSF RX for Change
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Learning Objectives Define the prevalence of smoking Review mortality associated with smoking Describe the psychiatric populations and disparities as they relate to smoking Review the mechanism of nicotine addiction and positive feedback Compare and contrast pharmacotherapy for smoking cessation Smoking cessation action plan
To stop smoking all you have to do is: Give up something you enjoy Give up something that helps get you through the day Give up something that helps motivate you Give up something that makes you feel good Give up something that you look forward to in life when you just lost everything Give up the one thing you can afford now
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Prevalence According to the WHO, more than 1 billion people smoke tobacco worldwide and estimates that this number will exceed 1.6 billion by 2025. Nahoopii R, Said Q, Dirani R, Brixner D. An employer-based cost-benefit analysis of a novel pharmacotherapy agent for smoking cessation. J. Occup. Environ. Med. 2007;49(4):453–460.
WORLDWIDE ADULT TOBACCO USE PREVALENCE (Men/Women) Canada 24/17
Russian Federation 59/24
France 36/27 Greece 63/41
China 51/2 USA 21/15 Mexico 24/8
UK/ Northern Ireland 25/23
Japan 42/12 Philippines 47/10 Iran 26/2
Brazil 22/13
South Africa 36/10
Kiribati 71/43
India 26/4 Papua New Guinea 58/31
Australia 22/19
World Health Organization Report on the Global Tobacco Epidemic (2011). U.S. updates from: Centers for Disease Control and Prevention (CDC). (2014). MMWR 63:1108-
TRENDS in ADULT SMOKING, by SEX—U.S., 1955–2007 Trends in cigarette current smoking among persons aged 18 or older
19.4% of adults are current smokers
Percent
Male
21.9%
Female
17.1%
Year
70% want to quit Graph provided by the Centers for Disease Control and Prevention. 1955 Current Population Survey; 1965–2007 NHIS. Estimates since 1992 include some-day smoking.
PREVALENCE of ADULT SMOKING, by EDUCATION—U.S., 2013 24.2%
No high school diploma
41.4%
GED diploma 22.0%
High school graduate
20.9%
Some college Undergraduate degree Graduate degree
9.1% 5.6%
Percent Centers for Disease Control and Prevention (CDC). (2014). MMWR 63:1108–1112.
PREVALENCE of SMOKING by INSURANCE STATUS U.S. ADULTS AGE 18-64, 2007 17% Privately insured
33% Medicaid
26% Other
32% Uninsured
Centers for Disease Control and Prevention. 2007. NHIS.
PREVALENCE of ADULT SMOKING, by RACE/ETHNICITY—U.S., 2013 26.8%
Multiple race
26.1%
American Indian/Alaska Native White
19.4%
Black Hispanic Asian
18.3% 12.1% 9.6%
Percent Centers for Disease Control and Prevention (CDC). (2014). MMWR 63:1108–1112.
WHY ADDRESS TOBACCO USE in PSYCHIATRIC POPULATIONS?
Prevent Death Improve Health Optimize Psychiatric Medication Effects Reduce Isolation Patient $ Savings
Tobacco Industry Profits Interest groups/politicians supported by Tobacco Industry Tax revenues
TOBACCO KILLS PEOPLE with MENTAL ILLNESS ■
Dying, on average, 25 years prematurely (Colton & Manderscheid, 2006)
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At greater risk of dying from CVD, respiratory illnesses, and cancer, than people without mental illness (e.g., Dalton et al., 2002; Himelhoch et al., 2004; Lichtermann et al., 2001)
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Tobacco use predicts future suicidal behavior ■
independent of depressive symptoms, prior suicidal acts, and other substance use (Breslau et al., 2005; Oquendo et al., 2004)
SMOKING RATE by PSYCHIATRIC HISTORY
41.0% Overall
Active
National Comorbidity Survey 1991-1992 Source: Lasser et al., 2000 JAMA
TOBACCO USE in PSYCHIATRIC POPULATIONS ■
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Nicotine dependence – most prevalent substance use disorder among psychiatric patients ■ Smoking rates are 2 to 4 x’s that of the general population (Hughes, 1993; Poirier, 2002) Persons with mental illness comprise 44% to 46% of the US tobacco market (Lasser et al., 2000; Grant et al., 2004) ■
175 billion cigarettes and $39 billion in annual sales (USDA, 2004)
“90% of Schizophrenics Smoke” A meta-analysis of 42 studies on tobacco smoking among schizophrenia subjects found an average smoking prevalence of 62% (range=14-88%)
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Studies reporting higher smoking rates were more commonly cited in the research literature
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A 10% increase in reported smoking prevalence was associated with a 61% increase in citation rate
This bias was mirrored on the Internet Chapman et al. (2009) Australian & New Zealand Journal of Psychiatry
TREATING SMOKERS with SCHIZOPHRENIA ■
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Treatments tailored for smokers with schizophrenia no more effective than standard programs (George et al., 2000) Atypical antipsychotics associated with greater cessation than typical antipsychotics
TWO RCTS of TOBACCO TREATMENT in PATIENTS with SCHIZOPHRENIA
VARENICLINE USE with INDIVIDUALS with SCHIZOPHRENIA ■
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Evins et al. (2008): Open-label case series reported 13 of 19 patients (68%) with schizophrenia quit smoking at the end of treatment Two RCTs in process of varenicline use in individuals with schizophrenia (Pfizer & NIDA)
MORTALITY
Smoking cessation before age of 40 would reduce mortality rate by 90%.
Jha P, et al. 21st-Century Hazards of Smoking and Benefits of Cessation in the United States. N Engl J Med. 2013. 368(4); 341-50
ANNUAL SMOKING-ATTRIBUTABLE ECONOMIC COSTS—U.S., 1995–2001 Prescription drugs, $6.4 billion
Medical expenditures (1998)
Ambulatory care, Hospital care, $27.2 billion $17.1 billion
Other care, $5.4 billion
Nursing home, $19.4 billion
Societal costs: $7.65 per pack Annual lost productivity costs (1997–2001)
Men, $61.9 billion
Women, $30.5 billion
Billions of dollars CDC. MMWR 2002;51:300–303 and MMWR 2005;54:625-628.
ANNUAL SMOKING-ATTRIBUTABLE ECONOMIC COSTS Health-care expenditures
Lost productivity costs due to premature mortality
$132.5 billion
$156.4 billion
Total economic burden of smoking, per year
$288.9 billion
Billions of US dollars
Societal costs: $19.16 per pack of cigarettes smoked U.S. Department of Health and Human Services (USDHHS). (2014). The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General.
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BUPROPION SR ADVANTAGES ■
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Bupropion SR is easy to use. Bupropion SR can be used with NRT. Bupropion SR may be beneficial in patients with depression.
DISADVANTAGES ■
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Bupropion SR should be avoided in patients with an increased risk for seizures Side effect profile: ■
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Common: dry mouth, anxiety, insomnia (avoid bedtime dosing) Less Common: tremor, skin rash
Effective for treating smoking regardless of depression history (Cox, 2004) and may decrease the negative symptoms in schizophrenia (George 2002, Evins 2005).
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VARENICLINE: SUMMARY ADVANTAGES ■
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Varenicline is an oral formulation with twice-aday dosing.
DISADVANTAGES ■
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Varenicline offers a new mechanism of action for persons who previously failed using other medications. ■
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Early industry-sponsored trials suggest this agent is superior to bupropion SR.
Common side effects: Nausea (in up to 33% of pts) Sleep disturbances (insomnia, abnormal dreams)
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Constipation
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Flatulence
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Vomiting
Post-marketing surveillance data indicate potential for neuropsychiatric symptoms.
ACTIVE FEEDBACK LOOPS Outcome s
Community
Clinic
EQUITY IN OUTCOMES Person level (barriers)
Practice level (adherence)
Community level (mortality)
SYSTEM
PATIEN T COORDINATED CARE
QUALITY
