Great American Smokeout (2), 2009

Tomorrow (November 19th, 2009) is the Great American Smokeout 2009 – a day on which smokers across the country are encouraged to try to go the whole day without using any tobacco - and then to consider staying that way. The American Cancer Society have produced a series of tips on quitting smoking, which can be accessed at:
http://www.cancer.org/docroot/subsite/greatamericans/content/Help_Is_Available.asp

If there is a specific topic you want to know more about then I'd recommend using the search box at the right to find it.

There is usually a reasonable amount of media activity encouraging people to quit smoking and there is a national peak in quit attempts on this day. It is therefore an excellent day for smokers who have been contemplating quitting to have a go. If you are a regular reader of this blog, you’ll know that we’ve previously given a lot of advice on methods for stopping smoking.
Best of luck.

Some of the links are provided here to help you recap:

How bad is smoking for your health? 2/18/07
http://www.healthline.com/blogs/smoking_cessation/2007/02/how-bad-is-smoking-for-health.html

Ten tips for coping with nicotine withdrawal. 3/7/07
http://www.healthline.com/blogs/smoking_cessation/2007/03/ten-tips-on-coping-with-tobacco.html

Nicotine addiction: how it can trick you into “absent-minded” smoking. 4/13/07
http://www.healthline.com/blogs/smoking_cessation/2007/04/nicotine-addiction-how-it-can-trick.html

How to tell if a smoking cessation aid works. 4/29/07
http://www.healthline.com/blogs/smoking_cessation/2007_04_01_smoking_cessation_archive.html

Get rid of all your tobacco. 6/16/07
http://www.healthline.com/blogs/smoking_cessation/2007/06/get-rid-of-all-your-tobacco.html

Is nicotine replacement therapy effective in the “real world”? 6/21/07
http://www.healthline.com/blogs/smoking_cessation/2007/06/is-nicotine-replacement-therapy.html

When is the best time to quit smoking? 6/29/07
http://www.healthline.com/blogs/smoking_cessation/2007/06/when-is-best-time-to-quit-smoking.html

A year of smoking takes 3 months off your life. 7/9/07
http://www.healthline.com/blogs/smoking_cessation/2007/07/last-friday-july-6th-new-paper-was.html

Labels: GASO, Great American Smokeout 2009, jonathan foulds

Permalink | 0 Comments| Email Post

Post your comment

Great American Smokeout: a great day for clinicians to help patients quit.

This Thursday, November 19th is the 2009 “Great American Smokeout”. This is a day that has been set up by the American cancer Society as one day each year for all smokers to try to quit, and to make it last for at least the whole day. Of course, the idea is that once the smoker is off to a good start they will try to keep it going for another day, and another. So if you are a smoker, this is an ideal day to have a go at quitting, and I hope you can find some useful advice on this blog. If you are interested in specific topics or smoking cessation aids, you will probably be able to find a blog post on it by using the “Search Health Experts” search box on the right.

But today I’d like to add a slightly different angle to Great American Smokeout. For over 20 years we have been encouraging clinicians to intervene with all of their smoking patients. Very simple mnemonics were developed to try to remind doctors to assess and treat tobacco dependence in their patients. We had the “4 As” then the “5 As”, and now some have realized that the last few A’s (Assist and Arrange) are usually not happening and so are pushing “2 As and an R” which basically means “Ask the patient if they use tobacco, Assess dependence and motivation and Refer to a specialist service”. There are many reasons why the 5As (Ask, Advise, Assess, Assist, Arrange) are only rarely implemented. These include lack of training, lack of financial reimbursement and lack of confidence in effectiveness. So my suggestion is that all clinicians make Great American Smokeout the one day of the year when they make a serious attempt to implement the 5 As with all their patients and try to help their smoking patients to quit.

Some colleagues and I recently wrote a short paper that is designed to remind clinicians to treat tobacco dependence like any other serious modifiable risk factor for disease. It points out that smoking is a unique risk factor in that it is causally related to diseases affecting every organ system, but also that we have relatively effective treatments. The paper is freely available online from today, and I hope it might encourage more clinicians to help their patients to quit, particularly on Great American Smokeout.

Reference
Foulds J, Schmelzer AC, Steinberg MB. Treating tobacco dependence as a chronic illness and a key modifiable predictor of disease. International Journal of Clinical Practice. (In press).

You can access the free preview version of the paper online at:
http://www3.interscience.wiley.com/journal/122685385/abstract

Labels: 5As, ACS, American Cancer Society, GASO, great american smokeout, jonathan foulds

Permalink | 0 Comments| Email Post

Post your comment

Nicotine receptors take over a month to normalize after quitting

Nicotine withdrawal symptoms typically peak in the first week of abstinence and return to normal at around 3-4 weeks. It has long been known that certain nicotinic receptors (particularly the beta-2 subtype) are closely involved in nicotine addiction, and that smokers have a larger number of nicotine receptors in their brains than non-smokers. When the smoker quits, this large number of vacant, unstimulated receptors is believed to be involved in the resulting craving and distressing withdrawal (irritability, restlessness, depression, anxiety, poor concentration etc). Earlier this year, a study published by Drs Kelly Cosgrove, Julie Staley and colleagues at Yale University, provided evidence on the time course of normalization of these receptors after quitting smoking.

In the study, 19 heavy smokers and 20 non-smokers underwent brain scans using single photon emission topography (SPECT) which can measure the density of beta-2 nicotine receptors. The smokers were also scanned at various time-points after quitting smoking. During the first 4 weeks after quitting, the ex-smokers had 20-30% more nicotine receptors, but the number had normalized to that of never-smokers by weeks 6-12. The time-course of these changes is similar (though not identical) to that consistently found for studies of nicotine withdrawal symptom severity, and may reflect a readjustment process in the brain.

Studies like this one are technically difficult and expensive to do, as brain-scanning itself is an expensive business, and some of the methods for assessing specific nicotine receptor numbers have only recently been developed. But the evidence from this and similar studies supports the idea that nicotine withdrawal is related to the number of vacant nicotine receptors, and that it takes just over a month after quitting for these to normalize.

Of course, this doesn’t mean that nicotine addiction is all over six weeks after the last cigarette. It just means that the acute nicotine withdrawal phase is largely gone within that time frame.

A nice summary of the study with a picture of the brain scans can be found at:
http://www.nida.nih.gov/NIDA_notes/NNvol22N4/Abstinent.html


Reference
Cosgrove KP, Batis J, Bois F, Maciejewski PK, Esterlis I, Kloczynski T, Stiklus S, Krishnan-Sarin S, O'Malley S, Perry E, Tamagnan G, Seibyl JP, Staley JK. Beta-2 nicotinic acetylcholine receptor availability during cute and prolonged abstinence from tobacco smoking. Arch Gen Psychiatry. 2009 Jun;66(6):666-76

Labels: brain imaging, jonathan foulds, nicotine, nicotine withdrawal, receptors, SPECT

Permalink | 0 Comments| Email Post

Post your comment

Make Yours A Smoke-free Home (2)

A new report was published today from the Centers for Disease Control and Prevention (CDC), showing wide variability in exposure to secondhand smoke and cigarette smoking prevalence across the United States, but overall things are moving in the right direction.

Around 8% of the adult population report exposure to tobacco smoke while at work, and a similar number report it at home. 45% of smokers live in a household with an indoor smoking ban, as do 85% of non-smokers, giving an overall average of around 78%(note these figures are from surveys covering 11 states).

The report also gave state-by-state figures for cigarette smoking prevalence from a state-based survey carried out in 2008 (BRFSS). This found a median smoking rate of 18.4% (20.4% for men and 16.7% for women). But there continue to be wide differences in smoking rates across states, from 9% in Utah to 27% in West Virginia. I was pleased to see New Jersey again doing well with the third lowest cigarette smoking prevalence in the country (14.8%), catching up on California at 14%. New Jersey is now one of 6 or 7 states with a lower male cigarette smoking prevalence than California and New Jersey is the state with the highest proportion of ex-smokers. For a summary of why New Jersey has done so well at reducing smoking, check out my posting of June 30th:
http://www.healthline.com/blogs/smoking_cessation/2009/06/why-have-so-many-new-jersey-smokers.html

West Virginia, in addition to having the highest smoking rate overall (26.6%), is the only state in which more women (27.1%) smoke than men (26.1%). I’d be interested in hearing your views on why cigarette smoking rates remain so high in West Virginia, particularly among women.

West Virginia has a relatively low state cigarette tax rate (55 cents per pack). Rhode Island has the highest state cigarette tax ($3.46 per pack). West Virginia has not passed legislation protecting all workers from exposure to secondhand tobacco smoke.

The data for 2008 presented in this new report were collected prior to the $1 increase in federal cigarette taxes, and so there is every reason to believe that this will help continue the trend towards less smoking in 2009 and 2010. However, there is a greater need to provide assistance to smokers who want to quit but find that they are addicted. The head of CDC, Dr Tom Frieden pointed out in an interview that various state and local governments across the country collect $25 billion per year from tobacco settlements and taxes, but spend only 3% of that on tobacco control. It would be far better to invest more of that money in prevention.
The new CDC report can be found at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5844a3.htm

For a previous post on smoke-free homes:
http://www.healthline.com/blogs/smoking_cessation/2007/08/make-yours-smoke-free-home.html

Labels: CDC, cigarette smoking, jonathan foulds, prevalence, secondhand smoke, smoke-free home

Permalink | 0 Comments| Email Post

Post your comment

Combination NRT gets higher quit rates: new study

A new study published this month in the journal “Archives of General Psychiatry” aimed to compare the effectiveness of some of the main medicines for stopping smoking and their combinations. The study, by Dr Megan Piper and colleagues at University of Wisconsin, recruited just over 1500 smokers seeking help to quit, and randomly allocated them to use either, placebo nicotine replacement, the nicotine patch, nicotine lozenge, bupropion tablets, buproion plus nicotine lozenges ,or the patch plus nicotine lozenges.

This was one of the biggest and most ambitious placebo-controlled trials of smoking cessation medicines ever published. Each participant was provided with medication to last a normal course of treatment, as indicated on the product label, plus 6 brief face-to-face counseling sessions. The key questions were:
1. Do each of the individual medicines (patch, lozenge, bupropion) produce higher quit rates than placebo?
2. Do combination medicines produced higher quit rates then individual medicines?


This was a “double-blind” study, meaning that both the participants and the researchers didn’t know who had active medicine and who had placebo, until the study was completed. Most of the medicines were provided for 8 weeks, but the lozenge could be used for 12 weeks after the planned quit date (as is normal according the labeling).

The researchers looked at the proportions of smokers who were quit (no smoking in previous week) at 2 and 6 months after the target quit rate. The quit rates at the 2 month follow-up were as follows:

Placebo : 30%
Patch: 45%
Lozenge: 40%
Bupropion : 40%
Bupropion plus lozenge: 50%
Patch plus lozenge: 54%

At 6 month follow-up the quit rates were:
Placebo : 22%
Patch: 34%
Lozenge: 34%
Bupropion : 32%
Buoropion plus lozenge: 33%
Patch plus lozenge: 40%

Each of the individual medicines achieved higher quit rates than placebo, but the patch plus lozenge combination had higher quit rate again. So these results add to the growing evidence suggesting that combining the nicotine patch plus another NRT is significantly better than either medicine alone.

This study was embedded in a larger 3-year study of factors influencing health, and this may explain the unusually high quit rate in the placebo group. To get into this study all the participants had to be willing to attend numerous appointments over a 3 year period, implying that they were (a) very highly motivated to improve their health and (b) relatively confident in the stability of their life over the coming 3 years.

One other noteworthy aspect of these results was that they appear to confirm the recent trend of results finding bupropion to be equivalent to but no better than NRT for smoking cessation. In the early bupropion trials it looked like bupropion may get slightly higher quit rates than the patch, but more recent studies (including this one) have found bupropion to give very similar outcomes to NRT. Perhaps the most disappointing result in this study was that of bupropion plus lozenge (no better than lozenge alone at 6 months). However, I suspect that this was a fluke poor outcome, caused by a few more participants relapsing after coming off their meds. Although the trial overall is relatively large, each “arm” has only around 250 participants, and so the quit rate is substantially influenced by just a few more people quitting or relapsing.

So this study confirms that the nicotine patch remains a pretty good basic smoking cessation aid, but that adding on another NRT on top of the patch helps more smokers to quit. Other studies suggest that quit rates could be boosted even further by (a) allowing participants to use the patch for a few weeks prior to their target quit date and (b) encouraging those doing well at two months to continue using their NRT for up to 6 months (or as log as needed). This trial did not provide a direct comparison with varenicline (Chantix/Champix) but other studies suggest that varenicline produces quit rates in the same ball park as patch plus another NRT.

We have now been consistently seeing research studies showing that combination NRT is more effective than single NRT for over a decade, and yet the labeling on all of these NRT products continues to warn patients not to combine them. Maybe its time the labeling on these medicines was changed so as not to warn smokers away from using them in the most effective way?

Reference:
Piper ME, Smith SS, Schlam TR, Fiore MC, Jorenby DE, Fraser D, Baker TB. A randomized placebo-controlled clinical trial of 5 smoking cessation pharmacotherapies.Arch Gen Psychiatry. 2009 Nov;66(11):1253-62.

This link should take you to the full report on the study:
http://archpsyc.ama-assn.org/cgi/content/full/66/11/1253

Labels: bupropion, combination, jonathan foulds, lozenge, Megan Piper, nicotine patch, nicotine replacement therapy, NRT, Smoking, smoking cessation, trial

Permalink | 1 Comments| Email Post

Post your comment