Smoking Lecture -SE.pdf

SMOKING AND HEALTH The University of Sydney Page 3  Tobacco – Tobacco smoke > 7,000 chemicals. – At least 70 of the chemicals are known to cause cancer in people or animals. – Cigarettes, water pipes, cigars, chewed tobacco – Water pipe/shisha Tobacco + molasses...

SMOKING AND HEALTH The University of Sydney Page 3  Tobacco – Tobacco smoke > 7,000 chemicals. – At least 70 of the chemicals are known to cause cancer in people or animals. – Cigarettes, water pipes, cigars, chewed tobacco – Water pipe/shisha Tobacco + molasses + fruit flavor → nicotine, carbon monoxide, tar and other toxins Toxins are not removed by water Even if tobacco-free, the smoke from wood/charcoal → carbon monoxide, toxins, chemicals 45 mins of shisha = 100 cigarettes Communicable disease transmission? WHO Study Group on Tobacco Product Reguation. (2005). Advisory Note. Waterpipe tobacco smoking: health effects, research needs and recommended actions by regulators. Retrieved from Geneva: http://www.who.int/tobacco/global_interaction/tobreg/Waterpipe%20recommendation_Final.pdf Water pipe factsheet: https://www.health.nsw.gov.au/tobacco/Factsheets/water-pipe-smoking.pdf WHO Report on the Global Tobacco Epidemic, 2008: The MPOWER package. Geneva, World Health Organization, 2008 The University of Sydney Centers for Disease Control and Prevention. (2017). Lung Cancer. Retrieved from https://www.cdc.gov/cancer/lung/basic_info/risk_factors.htm Page 4 WHO Report on the Global Tobacco Epidemic, 2008: The MPOWER package. Geneva, World Health Organization, 2008  Mpower - WHO – WHO has introduced the MPOWER package of six proven policies: The University of Sydney WHO Report on the Global Tobacco Epidemic, 2019: Offer help to quit tobacco use.. Geneva, World Health Organization, 2020. Page 7 WHO Report on the Global Tobacco Epidemic, 2008: The MPOWER package. Geneva, World Health Organization, 2008  Smoking in Australia – Tobacco – Leading cause of cancer – Contributes to 44% of cancer burden – Daily smokers – 24% in 1991 – 12.2% in 2016 – 11% in 2019 BUT 19.6% in remote/very remote areas Men smoke daily more than women – 63% of Australians 14 years and over have never smoked – Some populations are more likely to smoke daily than the general Australian population (people living with mental illness, Indigenous Australians) The University of Sydney Australian Institute of Health and Welfare 2022. Alcohol, tobacco and other drugs in Australia. Available from: Page 10 https://www.aihw.gov.au/reports/alcohol/alcohol-tobacco-other-drugs-australia/contents/drug-types/tobacco  Smoking in Australia – Main reasons for quitting – Cost – Affecting health – Indigenous people = 2-3 x more likely to smoke daily – People with mental health conditions or high psychological distress are twice as likely to smoke daily as people without mental health conditions and those with low distress Australian Institute of Health and Welfare 2020. Alcohol, tobacco and other drugs in Australia. Available from: https://www.aihw.gov.au/reports/alcohol/alcohol-tobacco-other-drugs-australia/contents/drug-types/tobacco The University of Sydney Australian Institute of Health and Welfare 2017. National Drug Strategy Household Survey 2016: Page 14 detailed findings. Drug Statistics series no. 31. Cat. no. PHE 214. Canberra: AIHW.  E-cigarettes – Electronic cigarettes aka e-cigarettes/electronic nicotine delivery systems/personal vaporisers – deliver nicotine and/or other chemicals via an aerosol vapour – Inhaled – contain a battery, a liquid cartridge and a vaporisation system → simulates smoking – Different to heated tobacco products which ‘heat tobacco leaf to produce an inhaled aerosol’. – Contain Formaldehyde (lung damage) Acrolein Formaldehyde (lung damage) propylene glycol Glycerol Flavourings Nicotine (sometimes) ABS – Smoking 2022: https://www.abs.gov.au/statistics/health/health-conditions-and-risks/smoking/latest-release AIHW – Alcohol, tobacco and other drugs in Australia 2022: https://www.aihw.gov.au/reports/alcohol/alcohol-tobacco-other-drugs-australia/contents/drug-types/tobacco The University of Sydney https://www.cdc.gov/tobacco/basic_information/e-cigarettes/Quick-Facts-on-the-Risks-of-E-cigarettes-for-Kids-Teens-and-Young- Page 15 Adults.html https://lungfoundation.com.au/lung-health/protecting-your-lungs/e-cigarettes-and-vaping/  E-cigarettes – In Australia: – Lifetime use of e-cigarettes increased significantly from 8.8% in 2016 to 11.3% in 2019 – Similarly, among smokers, lifetime use of e-cigarettes has increased significantly between 2016 (31%) and 2019 (39%) – 54% tried them due to curiosity (54%) – 23% use e-cigarettes because they think they are less harmful than regular cigarettes – Evidence in this area is still emerging, BUT – Some of the ingredients in e-cigarette aerosol could also be harmful to the lungs in the long-term. – Some e-cigarette flavorings may be safe to eat but not to inhale because the gut can process more substances than the lungs. – Defective e-cigarette batteries have caused some fires and explosions, a few of which have resulted in serious injuries. – The use of any tobacco product, including e-cigarettes, is unsafe for young people. The University of Sydney Page 16 ABS – Smoking 2022: https://www.abs.gov.au/statistics/health/health-conditions-and-risks/smoking/latest-release AIHW – Alcohol, tobacco and other drugs in Australia 2022: https://www.aihw.gov.au/reports/alcohol/alcohol-tobacco-other-drugs-australia/contents/drug-types/tobacco https://www.cdc.gov/tobacco/basic_information/e-cigarettes/Quick-Facts-on-the-Risks-of-E-cigarettes-for-Kids-Teens-and-Young-Adults.html  DEPENDENCE AND WITHDRAWAL The University of Sydney Page 19  Tobacco withdrawal – DSM 5 Diagnostic Criteria – Daily use of tobacco for at least several weeks. – Abrupt cessation of tobacco use, or reduction in the amount of tobacco used, followed within 24 hours by four (or more) of the following signs or symptoms: – Irritability, frustration, or anger. – Anxiety. – Difficulty concentrating. – Increased appetite. – Restlessness. – Depressed mood. – Insomnia. cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. not attributed to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-V Retrieved from http://dsm.psychiatryonline.org.ezproxy1.library.usyd.edu.au/doi/book/10.1176/appi.books.9780890425 596 The University of Sydney Page 21  RACGP - Nicotine dependence1,2 – Assessment of nicotine dependence: – ‘How soon after waking do you have your first cigarette?’ – ‘How many cigarettes do you smoke each day?’ – ‘Have you had cravings for a cigarette, or urges to smoke and withdrawal symptoms when you have tried to quit? – Indicators of nicotine dependence: – Smoking within 30 minutes of waking – Smoking more than 10 cigarettes per day – History of withdrawal symptoms in previous attempts to quit – Time to first cigarette = most reliable indicator of nicotine dependence. 1. Baker TB, Piper ME, McCarthy DE, et al. Time to first cigarette in the morning as an index of ability to quit smoking: implications for nicotine dependence. Nicotine Tob Res 2007;9 Suppl 4:S55570. 2. The Royal Australian College of General Practitioners. Clinical Guidelines. Supporting smoking cessation: a guide for health professionals. Retrieved from Melbourne, VIC: https://www.racgp.org.au/guidelines/smokingcessation The University of Sydney Page 22  Genetics and smoking – Research shows a high degree of heritability of cigarette smoking (50–70%). – Genetic factors have a role in: Nicotine withdrawal symptoms Taking up smoking Ability to quit Response to smoking cessation therapies – How to target treatment based on genetics is not known, yet. 1. Vink JM, Willemsen G, Boomsma DI. Heritability of smoking initiation and nicotine dependence. Behav Genet 2005;35:397–406. Search PubMed 2. Ho MK, Goldman D, Heinz A, et al. Breaking barriers in the genomics and pharmacogenetics of drug addiction. Clinical Pharmacol Ther 2010;88(6):779−9 3. Royal College of Physicians. Harm reduction in nicotine addiction: helping people who can’t quit. A report by the Tobacco Advisory Group of the Royal College of Physicians. London: RCP, 2007. 4. The Royal Australian College of General Practitioners. Clinical Guidelines. Supporting smoking cessation: a guide for health professionals. Retrieved from Melbourne, VIC: https://www.racgp.org.au/guidelines/smokingcessation The University of Sydney Page 24  The role of pharmacists – Strong evidence that advice from health professionals (including pharmacists) encourages smoking cessation. – Offer every smoker at least a brief intervention for smoking cessation, including: – simple opportunistic advice to consider quitting – an assessment of the smoker’s commitment to quit – offer of pharmacotherapy and/or behavioural support – self-help material – referral to more intensive, proactive support such as Quitline (13 7848), a tobacco treatment specialist or cessation program. 1. Stead LF, Bergson G, Lancaster T. Physician advice for smoking cessation. Cochrane Database Syst Rev 2008, Issue 2. Art. no. CD000165. 2. Sinclair HK, Bond CM, Stead LF. Community pharmacy personnel interventions for smoking cessation. Cochrane Database Syst Rev 2004, Issue 1. Art. no. CD003698. 3. Carr A, Ebbert J. Interventions for tobacco cessation in the dental setting. Cochrane Database Syst Rev 2006, Issue 1. Art. no. CD005084. 4. Rice VH, Stead LF. Nursing interventions for smoking cessation. Cochrane Database Syst Rev 2008, Issue 1. Art. no. CD001188. 5. Litt J, Ling M-Y, McAvoy B. How to help your patients quit: practice based strategies for smoking cessation. Asia Pac Fam Med 2003;2:175–9. 6. Joyce AW, Sunderland VB, Burrows S, McManus A, Howat P, Maycock B. Community pharmacy’s role in promoting health behaviours. J Pharmacy Prac Res 2007;37:42–4. 7. National Institute for Health and Clinical Excellence. Public health guidance 10. Smoking cessation services in primary care, pharmacies, local authorities and workplaces, particularly for manual working groups, pregnant women and hard to reach communities. NICE, February 2008 8. Dent, L.A., Harris, K.J. and Noonan, C.W. (2007), Tobacco Interventions Delivered by Pharmacists: A Summary and Systematic Review. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy, 27: 1040-1051. https://doi.org/10.1592/phco.27.7.1040 The University of Sydney Page 26  Stages of Change https://www.nysmokefree.com/CME/PageView.aspx?P=50&P1=5025 https://www1.health.gov.au/internet/publications/publishing.nsf/Content/drugtreat-pubs-front9-wk-toc~drugtreat-pubs-front9-wk- secb~drugtreat-pubs-front9-wk-secb-3~drugtreat-pubs-front9-wk-secb-3-3 The University of Sydney Prochaska, J.O., DiClemente, C.C., & Norcross, J.C. (1992). In search of how people change: Applications to the addictive Page 27 behaviors. American Psychologist, 47, 1102-1114. PMID: 1329589.  Remember! – Lapse = a slip up with a quick return to action or maintenance – Relapse = a fullblown return to the original problem behaviour. – Offer assistance to smokers at all stages – The stages are not necessarily “sequential” – Smokers are in different stages of readiness at different times – Tailor your approach to ensure it is relevant to the smoker at that encounter – Re-evaluate readiness at every opportunity The Royal Australian College of General Practitioners. Clinical Guidelines. Supporting smoking cessation: a guide for health professionals. Retrieved from Melbourne, VIC: https://www.racgp.org.au/guidelines/smokingcessation Australian Government, Department of Health. The Stages of Changes Model. https://www1.health.gov.au/internet/publications/publishing.nsf/Content/drugtr The University of Sydney eat-pubs-front9-wk-toc~drugtreat-pubs-front9-wk-secb~drugtreat-pubs-front9- Page 28 wk-secb-3~drugtreat-pubs-front9-wk-secb-3-3  5As The University of Sydney Page 29 The Royal Australian College of General Practitioners. Clinical Guidelines. Supporting smoking cessation: a guide for health professionals. Retrieved from Melbourne, VIC: https://www.racgp.org.au/guidelines/smokingcessation  Antipsychotics and smoking – Read the following two articles: – https://www.nps.org.au/australian-prescriber/articles/clozapine-in-primary-care – https://www.nps.org.au/australian-prescriber/articles/smoking-and-drug-interactions – CYP1A2 activity is significantly higher in heavy smokers (>20 cigarettes/day) than in non-smokers → increase in drug clearance among heavy smokers – 5 cigarettes may be enough for enzyme induction – Polycyclic aromatic hydrocarbons (Tar, NOT Nicotine) → induction of CYP1A2 activity → affects metabolism of clozapine, olanzapine, fluvoxamine… – Smoking also induces CYP2B6 (substrates include: bupropion, clopidogrel, methadone) The University of Sydney NSW Health. Clozapine and smoking cessation. Available from: https://www.health.nsw.gov.au/tobacco/Publications/tool-03-clozapine-smoking-cessation.pdf Page 31 Winckel K, Siskind D. Clozapine in primary care. Aust Prescr 2017;40:231-6.https://doi.org/10.18773/austprescr.2017.067 Lucas C, Martin J. Smoking and drug interactions. Aust Prescr 2013;36:102-4.https://doi.org/10.18773/austprescr.2013.037  Antipsychotics and smoking – Smoking cessation → rapid exponential decrease in CYP450 activity → clozapine blood levels can increase → toxic effects – A new steady state is reached in approx. 1 week – Under medical supervision: – immediate decrease of clozapine dose on cessation of smoking (about 10 per cent dose reduction daily; up to 50% reduction as per AMH) PLUS TDM (individual variations) PLUS Blood and clinical monitoring for up to 6 months. Australian Medicines Handbook 2023 (online). Available from: https://amhonline.amh.net.au/ The University of Sydney NSW Health. Clozapine and smoking cessation. Available from: https://www.health.nsw.gov.au/tobacco/Publications/tool-03-clozapine-smoking-cessation.pdf Page 32 Winckel K, Siskind D. Clozapine in primary care. Aust Prescr 2017;40:231-6.https://doi.org/10.18773/austprescr.2017.067 Lucas C, Martin J. Smoking and drug interactions. Aust Prescr 2013;36:102-4.https://doi.org/10.18773/austprescr.2013.037  Pharmacotherapy – smoking cessation – Nicotine Replacement Therapy (NRT) – Varenicline – Bupropion The University of Sydney Page 33  Pharmacotherapy treatment algorithm The University of Sydney Page 34 The Royal Australian College of General Practitioners. Clinical Guidelines. Supporting smoking cessation: a guide for health professionals. Retrieved from Melbourne, VIC: https://www.racgp.org.au/guidelines/smokingcessation The University of Sydney Page 35 The Royal Australian College of General Practitioners. Clinical Guidelines. Supporting smoking cessation: a guide for health professionals. Retrieved from Melbourne, VIC: https://www.racgp.org.au/guidelines/smokingcessation  Types of NRT – initial dosages See eTG for dosing regimens The University of Sydney Page 36 The Royal Australian College of General Practitioners. Clinical Guidelines. Supporting smoking cessation: a guide for health professionals. Retrieved from Melbourne, VIC: https://www.racgp.org.au/guidelines/smokingcessation  AMH 2023 The University of Sydney Page 37 Australian Medicines Handbook 2023 (online). Available from: https://amhonline.amh.net.au/  Common adverse effects and management - NPS The University of Sydney https://www.nps.org.au/australian-prescriber/articles/optimal-use-of-smoking-cessation-pharmacotherapy Page 38  Varenicline – Partial agonist at a subtype of neuronal nicotinic acetylcholine receptors. – Blocks nicotine by binding to receptors, preventing the pleasurable effects of smoking. – Partial agonist activity reduces symptoms of nicotine withdrawal. – Precautions: – History of seizures—use cautiously – Avoid in pregnancy (no human data) – No human data in BF – Common side effects: nausea, vomiting, dyspepsia, constipation, flatulence, abdominal pain, increased appetite, weight increase, headache, taste disturbance, insomnia, abnormal dreams, sleep disorder – Nausea is dose-related (affects 30% on usual dose, 10% on placebo) – Nausea is generally mild-to-moderate and transient but may persist throughout treatment. The University of Sydney Page 39 Australian Medicines Handbook 2023 (online). Available from: https://amhonline.amh.net.au/  Dosage – Varenicline – Start at least 7 days before stopping smoking. Takes 1 week to become effective – If nausea is intolerable, consider reducing the dose (1mg once daily). Food may help with nausea – 0.5 mg once daily for 3 days, then 0.5 mg twice daily for 4 days, then 1 mg twice daily for 11–23 weeks, as tolerated. Dose titration to reduce incidence of nausea The University of Sydney https://www.champix.co.nz/giving-up-smoking-with-champix Page 40 Australian Medicines Handbook 2023 (online). Available from: https://amhonline.amh.net.au/  Varenicline - counselling – Can affect driving/operating machinery due to side effects (e.g. dizziness, sleepiness) – Swallow tablets whole. – You may feel nauseous when taking this medicine. Contact your doctor if this is severe, because it may improve with dose reduction. initial dose titration aims to reduce the incidence of nausea – During and after finishing treatment: fast-acting product (e.g. film, inhaler, lozenge, spray) is particularly helpful when strong cigarette cravings occur Australian Medicines Handbook 2023 (online). Available The University of Sydney from: https://amhonline.amh.net.au/ Page 41  Varenicline - summary – Partial agonist for nicotinic receptor – >2x chances of long-term quitting – More effective than bupropion and NRT monotherapy – More effective when combined with NRT – Similar effectiveness to combination NRT – Advise patients to report unusual mood changes, depression, behaviour disturbance and suicidal thoughts – May have to stop using the medicine. – The target quit day is in the second week of treatment. Australian Medicines Handbook 2022 (online). Available The University of Sydney from: https://amhonline.amh.net.au/ Page 43 The Royal Australian College of General Practitioners. Clinical Guidelines. Supporting smoking cessation: a guide for health professionals. Retrieved from Melbourne, VIC: https://www.racgp.org.au/guidelines/smokingcessation  Bupropion – Non-nicotine oral therapy – Originally developed as an antidepressant. – Significantly increases cessation rates compared with placebo. – Effective for smokers with depression, cardiac disease and respiratory diseases, including COPD. – Shown to improve short-term abstinence rates for people with schizophrenia. – Less effective than varenicline and combination NRT The University of Sydney Page 45 The Royal Australian College of General Practitioners. Clinical Guidelines. Supporting smoking cessation: a guide for health professionals. Retrieved from Melbourne, VIC: https://www.racgp.org.au/guidelines/smokingcessation  Bupropion – Unknown MOA – inhibition of neuronal reuptake of dopamine and noradrenaline? – Contraindications: – Treatment with a MAOI in the previous 14 days – Seizures – Precautions: Bipolar disorder – Antidepressant effects may precipitate mania – Avoid in pregnancy; can be considered in breastfeeding if non- pharmacological and NRT are inadequate. – Common side effects: insomnia, nightmares, dizziness, concentration difficulties, agitation, anxiety, tremor, headache, fever, rash, itch, urticaria, anorexia, nausea, dry mouth, constipation Australian Medicines Handbook 2023 (online). Available from: https://amhonline.amh.net.au/ The University of Sydney Wilkes, S. The use of bupropion SR in cigarette smoking cessation. 2008:3(1) Pages 45—53. Page 46  Bupropion – dose – Start bupropion at least 7 days before stopping smoking. – Initially 150 mg once daily in the morning for 3 days, then 150 mg twice daily (doses at least 8 hours apart) for 7–9 weeks. The University of Sydney Page 47 Australian Medicines Handbook 2021 (online). Available from: https://amhonline.amh.net.au/  Bupropion - Counselling – Swallow tablets whole – Rash, swelling of lips/mouth, breathing difficulty → contact doctor and stop taking bupropion. – Drink only small quantities of alcohol – can increase the risk of fits and other side effects. – Side effects may affect ability to drive and operate machinery – Avoid these activities until you know how bupropion affects you. – Assess progress throughout treatment – Stop drug if there is no marked reduction in smoking – Use with NRT improves effectiveness – Fast-acting product when strong cigarette craving occurs – Bupropion causes false-positive results (amphetamines) with some urine drug screens; confirm positive results using a more specific assay Australian Medicines Handbook 2021 (online). Available The University of Sydney from: https://amhonline.amh.net.au/ Page 48  Pharmacotherapy key points The University of Sydney Page 49 The Royal Australian College of General Practitioners. Clinical Guidelines. Supporting smoking cessation: a guide for health professionals. Retrieved from Melbourne, VIC: https://www.racgp.org.au/guidelines/smokingcessation