Microsoft word - millard on tobacco and lung cancer transcript.doc
Tips and Tools for Smoking Cessation by Dr. Mark Millard, Baylor University
Dr. West: Hello and welcome. My name is Jack West, and I’m a Medical Oncologist in Seattle, Washington and the President and CEO of GRACE, the Global Resource for Advancing Cancer Education. We’ll continue with the second part of our webinar program with Dr. Mark Millard, Medical Director of the Baylor Martha Foster Lung Care Center and Professor of Pulmonology at Baylor University Medical Center in Dallas, Texas. This program, following part one on the history of tobacco and its association with lung cancer, will now cover smoking cessation strategies. Our podcast is co-sponsored with our partner, the LUNGevity Foundation. Following Dr. Millard’s presentation, we have a question and answer session on this topic. Dr. Millard: Now, how do we stop this epidemic of smoking? And I think it was epidemiology that sort of put the relationship between tobacco smoke and lung cancer on the map. And I think if you look at the current modern epidemiology and the way they approach epidemics, it’s useful in terms of instruction about where we are and how do we need to go about stopping this epidemic of tobacco use and encouraging tobacco cessation. And so in the epidemiology model classic that’s published in Epidemiology Journal of Preventative Medicine by Giavino, he applies the epidemiology model of tobacco use. And you always have an agent, what’s the causative thing (and that’s cigarettes). And the host is the person who smokes. And the vector is, well how do we get the agent into the host? And the answer is because of a market strategy. And then finally you have the environment that encourages tobacco smoking. And you have the consequences of tobacco smoking use: addiction, disease, and death. So you have this model. And when you look at this four quadrant model, you can begin to develop strategies that may be able to deal with each aspect. You can understand how the agent has sort of been manipulated and continues to sort of mutate, so to speak, to try to gain more entry. And actually I read the other day that a couple of decades ago, one of the tobacco companies introduced into the market this strain of tobacco that actually had double the dose, double the amount of nicotine per gram of tobacco. And that really jacked up the content of nicotine in each cigarette -- and the FDA actually used that as justification for them beginning to monitor nicotine levels because they said this is deliberate manipulation of the market place. And the cigarette companies were just trying to sell more nicotine and trying to get more people addicted. You can look at the vector market strategy and certainly these are areas that we can prevent transmission by reducing the appeal, by focusing more by getting the marketing removed. You know there are no more cigarette ads on the airwaves; there are no more cigarette ads in TV and radio. And you can also see how the tobacco companies are trying to get around these with direct mailing and retail. The environment and the host finally lots of things. But this is a very instructive model to help us look at the problem and then try to come up with strategies to stop smoking. The US Public Health Service has published this straightforward algorithm for every time the patient is seen in the office -- and the fact is when I go to my internist, I should be asked, every
time, do I smoke, or have I been smoking, or “how much are you smoking these days?” Assume that I smoke. That’s critical that every encounter with a health care professional the question about tobacco use should be added, and if the patient is smoking, then you have to say, “Do you want to quit?”. And that’s very important, because if somebody wants to quit then there are 5As. if somebody doesn’t want to quit and you assess it real quickly; there’s no reason to be beating on them to say “stop smoking; you're stupid!”. I mean you need to find what’s motivation. What sort of receptors are there out there that you can tweak that maybe can bring a person around to that sense of “Wow -- maybe I do need to stop.” And it’s always important if the patient did previously smoke to encourage to continue abstinence and prevent relapse. Now the 5As and 5Rs -- what are they? The 5 As are for people willing to quit, it’s always important to ask about tobacco use, advise the patient to quit, assess willingness to make a quit attempt, assist in the quit attempt, and finally arrange follow up. And if somebody doesn’t want to smoke, and say you’ve got a friend or loved one or somebody who doesn’t want to smoke or a patient, you know. It’s very important that we still sort of talk about that. And one of the things you don’t do is say, “you’re so stupid, I can’t believe you smoke!”. And one of the things is encourage patients to think of the relevance of quitting smoking. Why is it important? How much money would I save? I mean would my health insurance get less? And you know my healthcare system, Baylor Healthcare System, has recently introduced a policy where they will not hire tobacco users. New hires -- if you get a urine test for nicotine and it’s in your blood stream- it’s in your urine, you're not going to be hired. And old hires, current employees aren’t going to be fired if they use it, but if you are a tobacco user then you have to pay a higher healthcare premium -- about $600 bucks a year or more. So, again there’s an economic issue. We assist patients in identifying the risks of smoking. In terms of what are the issues? What are the health-related problems? And what are the rewards of smoking cessation. And it’s important to discuss road blocks or barriers to attempted cessation. And again, every time a healthcare professional sees a patient again, motivational intervention is very, very important. Okay let’s see if I can go. The American College of Physicians in 2007 came up with this sort of paradigm of smoking cessations. What kind of interventions do we have? Do we do telethon? Do we do individual therapy? Do we do group therapy? Do we do self-help? And they identified resources that can be used in the community for the purposes of smoking cessation. And again to reiterate -- it’s not just lung cancer. Smoking touches so many organ systems. The diseases of tobacco related in terms of increased cardiovascular disease, heart attacks, stroke, cancer, COPD, emphysema, worsening asthma -- all these things. There’s global reason to stop smoking. I mean you can almost talk an organ system and I can tell you a complication that tobacco smoke can bring on it. So how do we get somebody to stop smoking, more practically? We do the 5As and we assess, yeah they want to stop smoking. Okay so what do we do? And this is from a recently published article in one of the journals. You ask the patient do you want to stop smoking. And if they do, you talk about do you want to just try and stop on your own? Or do you want to try medication? And you have three general sort of bins of different general medicine strategies. One is stuff that’s over the counter -- nicotine replacement therapy. This can be effective; nicotine replacement patch, gum inhaler, lozenge, nasal spray recently the e-cigarette, which is often made in China, believe it or not, and there are some quality control issues about what’s in it, but certainly it does
deliver nicotine. People feel like they’re getting nicotine replacement. Is that the way they want to try it? And I often personally will encourage somebody first, if they have never used it before, to go into nicotine replacement therapy. Because the addictive substance in tobacco is nicotine -- no question. I mean there’s a certain amount of behavioral stuff involved with it, you know the cup of coffee and cigarette in the morning. But usually it’s because you need that nicotine to feel good. And nicotine binds to receptors in the brain and certain parts of the brain that are associated with pleasure. What nicotine does when you smoke a cigarette it’s kind of like when you solve a problem or when something good happens and you say” Yes!” well that’s the same neurotransmitter- the same receptor that makes you say “Yes!” “Great!” “touchdown pass” or whatever. That is a nicotine receptor that’s being fired off. Now it’s not with nicotine it’s with another substance but it hits that same kind of neurotransmitter; it’s that same kind of feeling. And the same kind of sensation that you get with a puff of tobacco. And one of the things that the brain learned about real quickly was nicotine sticks around longer than does briefly released neurotransmitters that happen when something good happens -- when you solve a problem and something great happens, when you win the lottery or whatever. And so the brain after a while thinks if I have more of this tobacco stuff, this nicotine, it lasts longer. And so that’s one of the reasons why nicotine is…I mean that’s the stuff of addiction…and so providing that without the behavior of smoking, or without the tar and all the other volatiles there, certainly can cut down on a lot of diseases. Nicotine per se doesn’t cause cancer. Nicotine per se doesn’t cause emphysema. It does have vasoactive and neurotransmitter issues, but it doesn’t cause lung cancer, and nicotine doesn’t cause COPD. So that’s one option. Or we have the Bupropion. The trade name is Zyban , or Wellbutrin. And bupropion was initially developed as an anti-depressant, and it was observed by the investigators that a lot of the patients who are taking this medicine also stopped smoking at the same time. And so they looked at that and they said “wow!” this is sort of an unintentional side effect that it stops smoking, and nobody was sure why. But bupropion was one of the first medical treatments of smoking, and it is clearly more effective than nicotine replacement or behavior counseling alone. The primary sort of contraindication is people who have had previous seizures. There are other medicines that have had this same sort of side line benefit such that it becomes almost the primary reason for using it. Psychiatry still uses a little bit of bupropion but it used more for smoking cessation than anything else. I think that the medicine that’s the most famous medicine for which a side effect became the primary reason for using it was actually a medicine called sildenafil. And sildenafil was a medicine that was being developed for hypertension. And it’s a nitric oxide inhibitor, and so they tried it in this group of people to see if it worked on hypertension. Yeah, it was okay but it wasn’t as good as others. But when they tried to get the medicine turned in they couldn’t get any of the men to turn back in the sildenafil. The placebos always came in, but the real ones weren’t there. The real ones weren’t being turned in. They said “well why in the world?!” and so they finally were able to figure out “oh there’s something about this stuff”. And the fact is sildenafil is Viagra and, it’s a bad hypertensive but sure is good for erectile dysfunction. And so bupropion is okay as an antidepressant and still used but its side effect is that it’s a non-specific blocker of nicotine in the brain and so it’s useful. It’s been shown it helps people stop smoking. They are not addicted, so they don’t have the withdrawal from nicotine. And now most recently you have this designer drug varenicline, called Chantix. Chantix is a sort of specifically engineered to hit that nicotine receptor in the brain and bind to it. You get a little bit
of the feel good from the nicotine, but not too much. The other pernicious thing about Varenicline in a good way, if you can use that term “in a good way” is that it may block feel-good feelings when you smoke a cigarette. In other words you smoke a cigarette in the morning when you wake up. “Oh I gotta have a cup of coffee and my cigarette”, and you have the cup of coffee and that’s good, and you light up the cigarette, you take a puff and nothing happens. And that’s because the Chantix has blocked the effect of the nicotine. Now there is an FDA caution. I think there are some slides left down the road that we’ll talk about, but the fact that varenicline is probably the most effective pharmacotherapy right now to get people to stop smoking. And you can choose monotherapy. Some people will have more recently added nicotine replacement to varenicline – it doesn’t work as well, obviously -- or to Bupropion. There are lots of ways to do it, the key thing is there are specific things we can do to get our patients to stop smoking. Chantix costs about a hundred bucks a month give or take. The world can’t afford that. We have trouble with funding Medicare much less funding all these smoking things, and the world has much less money than we do. And there is the need for a low cost nicotine antagonist. As it turns out cytosine is fairly effective. And when you look at just cytosine versus placebo in terms of abstinence for 12 months, you find that there is almost a three- or four-fold increase in the ability of people to stop smoking. And this is cheap -- apparently it’s like water, almost. So it’s very inexpensive and we hope that this at some point will be introduced into the marketplace, which would really make it a lot cheaper to get people to stop smoking. Now I want to move briefly into the clinic. This is the American College of Physicians proprietary smoking cessation clinic. This comes directly from the American College of Physicians, and it’s a great summary that’s worth looking at. We should consider the type of smoker who should be considered for smoking cessation, people who can’t quit after behavioral interventions, heavy smokers. If somebody asks for it, in terms of “Doc I need to stop, I can’t stop on my own.” That’s important, and also smokers who are high risk for adverse health effects; certainly, patients with established lung disease, heart disease, and somebody who is thinking of getting pregnant. Very important, because none of these studies, neither in varenicline or bupropion, have been studied in pregnant women. That’s a population you stay away from. You’re not supposed to -- so nobody knows what happens in pregnancy. The safety’s unknown, and in terms of seizures, eating disorders you really don’t want to use bupropion. With renal disease, since varenicline is cleared by the kidneys, you might want to hold that, and bupropion can have some problem with hypertension and of course, cardiovascular disease. If you use nicotine replacement that can increase blood pressure. Now nicotine replacement clearly leaves withdrawal symptoms. There’s always a thing about people -- a couple would come into my office, and I’d say well are you interested in stopping smoking and the wife looks at me and says “No he’s not, because I can’t take it anymore. You know I can’t take it, he’s a bear.” or the guy says “you know, this lady, she becomes a witch of the west when she stops smoking”. I mean clearly with smoking cessation attempts, there’s a lot of emotion associated with it. So nicotine replacement sort of helps that, and all forms clearly help, in motivated patients -- all forms of nicotine replacement increase quit rate. In a typical dosing, I think you’re at your leisure in terms of the way you give it. Do you give the gum? the patch? the spray? the inhaler? the lozenge? the e-cigarette? (it’s not on here -- it’s not approved). But it’s all these things you dose for satisfaction and then you back off over time. And you really try to back off.
Now bupropion was the first medication approved for smoking cessation that was non nicotine. And it clearly worked when compared with a nicotine replacement. There’s an article in the New England Journal of Medicine that showed that bupropion did help, but there are not a whole lot of articles out there – there’s one, at least. There are studies that clearly show there’s improvement in the quit rate about twice that seen with nicotine replacement. So there’s no question that wellbutrin (Zyban, trade name) or the bupropion needs to be the sustained release, bupropian sustained release or the extra length or whatever it is you take, 150 milligrams twice a day. And that’s the sustained release formula, and that works. And you use it as long as you need it, frankly. If you need it forever take it forever. Because let me tell you, going back to smoking is fine, but obviously at some point you try to back off you try to stop it and see whether or not the patient can then sustain quitting. In terms of the varenicline, is designed specifically for smoking cessation. It binds the nicotine receptor and has an improvement in quit rate. Now the issue with varenicline is you can smoke and take it. Since one of the major side effects is nausea and vivid dreams, you start out on a low dose. First once a day, and then twice a day and then you double the dose and it says for 12 weeks, and the fact is you can take it for a long time. There’s additional studies that were just released that suggest that you may need to take it for longer to keep down the recidivist rate. And obviously if you have somebody with kidney failure you’ve got to dose-adjust, and there’s no studies in pregnant women. I should say one more thing about Chantix, and that’s that there’s been a lot in the media about suicide, and the depressive events recently. The FDA, I think it was in October of this year, released a statement. They had looked at two studies that were done looking at nicotine replacement versus Chantix in smokers, and they found that there was no increase in psychiatric hospitalization, or serious psychiatric events, when you compare Chantix to nicotine replacement. So clearly you have to educate your patients to say if you start feeling crazy, or if you start having problems, or you start saying stupid things – if you feel bad, or different, or funny and were not talking about funny ha-ha -- stop the drug and call me. I mean very clearly you don’t give it P.R.N. (as needed) refills and never see them back. You have to monitor it, and it’s very important. So other therapies - clonidine, alprazolam, I’ve never used silver acetate, I don’t even know how I’d get it. But you know this this is part of the ACP module, and there are some other nicotine antagonists, which means that you don’t get any effect at all if not some bad effects. Are the problems with quitting? Yes, weight gain -- weight gain uh is one of them, that clearly people weigh more and women gain on average five kilograms, which is 12+ pounds more. And the issue is do I want to die fat and happy, or do I want to die thin and miserably? I think that the weight gain really when you consider it is not the issue as much as it is the diseases that are not prevented or delayed that don’t happen when you stop smoking. Nicotine gum and bupropion may be shown to delay but don’t prevent the weight gain. I’ve not used any naltrexone, so I can’t speak to the anti opiate use of it in terms of patients concern about gaining weight. I just know that any way we can get our patients to stop smoking that doesn’t put them or us in jail is worth it. So let’s see -- depression. People who stop smoking may develop depressive symptoms. Again we all know about the smoking rage when they stop smoking, what happens, and this is a real issue. Perhaps bupropion might be a good choice for those in whom depression happens worse and that has to be looked at, and you have to monitor it.
So the good news and bad news: The good news of stopping smoking is right away you reduce the risk of cardiovascular complications and neoplasia. It takes about ten years for the risk of lung cancer and other malignancies to come down to its lowest level; it never becomes that of a non- smoker, but it becomes just a smidgen above. But after ten years you can sort of like breathe a little bit of a sigh and say “I’ve made it down ten years”. Reduce exacerbations of asthma or progression of COPD -- no question we wouldn’t see COPD, were it not for tobacco. Cost savings: This is getting very expensive, and I think it its curious that that there are some medicines that actually are influenced by tobacco in terms of the metabolism and the liver. Medicines like theophylline we don’t use that anymore but we do use clozapine occasionally, which is a psychiatric drug and some other medicines, So it’s important that we need to recognize that there’s no action without reaction and look at the pharmacopeia of medicines and ask do we need to adjust doses if somebody really is successful stopping smoking. In the COPD world we used to use theophylline a lot. And in that situation, when people stop smoking we had to drop the dose off, or else they’d become theophylline toxic. Fortunately we don’t need to use that much anymore. So I think -- this is my last slide -- and it’s the currently proposed new package labeling for tobacco. And the tobacco companies have sued, and it’s going to the Supreme Court, and there’s a lot of issues on this. Does this violate free speech? Should the tobacco companies abide putting this kind of very graphic slide on the package of tobacco, and this is going to be something that is decided by the courts. But clearly – thank you for not smoking -- there’s no question we need to do everything we can to cure this epidemic of tobacco use in this country and in the world as well. So I think that’s my last slide and I appreciate the opportunity to present this information. I hope it’s been helpful, and hopefully that this is an encouragement to everybody to keep working on stopping smoking today, tomorrow, and in the days to come. Dr. West: Thank you very much. That was a remarkable presentation and very complete. I really appreciate it, and I know many of our viewers and listeners will as well. I wanted to cover a couple of questions and one is about the concept of who should be doing smoking cessation counseling. And you know you made the very good point that every medical encounter is an opportune time to intervene. At the same time there are a lot of agents here and a lot of approaches that seem both time consuming and complex, and so I would ask in your experience are most primary care physicians, most pulmonologists, equipped with the skill and time to do this well? Or is this something that in your mind most institutions should have a person or a clinic dedicated to smoking cessation that the primary care front line or maybe any doctor and healthcare professional should be screening patients for their candidacy to pursue? Dr. Millard: Well, you know, that’s a great question, and there are a number of sort of colliding issues with that question. First of all, 20% of the country smokes. So there’s no way we can have one employee per hospital, or one employee per hospital system or two or three to deal with 20% of people, so I think there is a role for the dedicated tobacco counselor.
In the state of Texas, where I practice in and live, about ten years ago some money from the tobacco settlements that came to the states filtered into our healthcare system for tobacco education and for two years we had a great tobacco cessation program. The program ran out of money, and no insurance company paid us for tobacco cessation. I think the problem with putting it on the backs of the primary care doctors is the time. They may have the skill and primary care docs are the Doctor Welbys of the world. They’re the ones that are supposed to know everything about the person because that’s why they’re called the primary. We all know what that really means is that their primary job is to refer to different sub-specialties because they don’t have time. And what’s happening in a sense, is that spending time with patients has become a casualty of changing reimbursements and what we all have to do is try to figure out a way to carve out time and carve out that moment where we can say something to a patient or where we can say something to a family member or whatever…wherever we are in the hierarchy of life. And the position is that we need to spend a little bit of time at least to assess the readiness or willingness to quit. Because if somebody is willing to quit then you have a golden opportunity as a healthcare provider to give them the means to quit. If somebody isn’t willing to quit you don’t need to waste your time. You just need to give them some information - we need to talk come back in six months, we’ll talk some more about this. Consider this or that and then move on. I think the primary care is the best way to do it because they understand the whole patient. They’re the only one that has the list hopefully of all the medicines the patient is taking. We all should have it, but it’s often only in the primary care chart. I think it’s the primary care job. I think that’s where the offers are. Unfortunately right now they’re not paid enough to do anything much less extensive tobacco counseling. Dr. West: Thanks. I also I wanted to bring up a topic that was actually the subject of a recent article in the Journal of Thoracic Oncology, and that was an analysis of costs. And the potential benefit in terms of dollars per quality adjusted life here of CT screening for lung cancer. And this is based on the national lung screening trial that got a lot of publicity, justifiably, and was published in The New England Journal of Medicine. But despite the trial that showed a very significant both statistically and clinically significant survival benefit for CT screening, that hasn’t yet become wide spread practice. And part of the question is the financial feasibility of implementing a broad CT screening program for people in the age range of 55-74 who were in that trial and who have a smoking history. The article did a lot of data based modeling and calculated that the impact of smoking cessation at the time of CT screening would really be associated with a remarkable impact on the cost effectiveness if patients were counseled at a teachable moment to quit smoking even if they were found to have dodged a bullet and not have a cancer. If that led to the increase in the rate of smoking cessation then smoking cessation itself was a remarkably cost efficient way to improve survival. But on the other hand if patients might have felt exonerated to continue to smoke after a negative scan, and it leads to a decrease in smoking cessation rates then it became remarkably expensive to see a survival benefit with screening. So, I’m sorry for the long winded question, but really I wanted to ask your impression of how smoking cessation might be integrated into CT screening for lung cancer and if you have any experience of whether this leads to accelerated rates of smoking cessation or do people, feeling justified, continue to smoke if they’ve managed to come out with a negative scan.
Dr. Millard: I think that the tapestry is really very thickly woven with different colors, and there are a lot of different threads in that question. For one, I think the point needs to be made that lung cancer screening was for people who were smokers and who were at risk for smoking. So if you never smoked or if you stopped smoking probably ten years ago, which is I think where most of us feel the risk factor goes back to very little, you don’t need screening. It would be a novel approach to be able to tie reimbursement for a screening CT with completion of a tobacco course for patients who are active smokers. And I think the problem is if you’re not an active smoker then then you don’t need to do that. So then are we discriminating against active smokers? But I think that that would be very clearly the fear factor of getting people saying –“Oh, I think I have lung cancer. I’m gonna stop smoking because oh wow I just dodged a bullet by having a negative CT scan.” That very quickly is overcome by the next need of the nicotine fix. The fear factor has been operative…I mean we all know patients for whom the last cigarette they smoked was when they saw a spot on their lung on a chest X-ray and they thought “maybe I have lung cancer” but that’s the exception more than the rule in my clinical opinion. And I think that by tying smoking cessation to CT scan I think you can model it. Of course you can prove anything you want to with models depending on the weight on the variables. But that certainly would be a requirement to me is that if you want to get this thing paid for by insurance you’ve got to go through smoking cessation if you’re an active smoker. Dr. West:
Thanks to Dr. Millard for his excellent presentation and to the LUNGevity Foundation who worked in partnership with GRACE to make this program possible. We hope it’s helpful.
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