合同协议书

Rx for CHANGE,Clinician-Assisted Tobacco Cessationfor Patients with Cancer,is the chief, single, avoidable cause of death in our society and the most important public health issue of our time.”,C. Everett Koop, M.D., former U.S. Surgeon General,“CIGARETTE SMOKING,TRENDS in ADULT SMOKING, by SEXU.S., 19552006,Trends in cigarette current smoking among persons aged 18 or older,Graph provided by the Centers for Disease Control and Prevention. 1955 Current Population Survey; 19652005 NHIS. Estimates since 1992 include some-day smoking.,Percent,70% want to quit,Male,Female,23.9%,18.0%,20.8% of adults are current smokers,Year,2004 REPORT of the SURGEON GENERAL:HEALTH CONSEQUENCES OF SMOKING,Smoking harms nearly every organ of the body, causing many diseases and reducing the health of smokers in general.Quitting smoking has immediate as well as long-term benefits, reducing risks for diseases caused by smoking and improving health in general.Smoking cigarettes with lower machine-measured yields of tar and nicotine provides no clear benefit to health.The list of diseases caused by smoking has been expanded.,U.S. Department of Health and Human Services. (2004). The Health Consequences of Smoking: A Report of the Surgeon General.,FOUR MAJOR CONCLUSIONS:,HEALTH CONSEQUENCES of SMOKING,CancersAcute myeloid leukemia Bladder and kidneyCervicalEsophagealGastricLaryngealLungOral cavity and pharyngealPancreaticPulmonary diseasesAcute (e.g., pneumonia)Chronic (e.g., COPD),Cardiovascular diseasesAbdominal aortic aneurysmCoronary heart diseaseCerebrovascular diseasePeripheral arterial diseaseReproductive effectsReduced fertility in womenPoor pregnancy outcomes (e.g., low birth weight, preterm delivery)Infant mortalityOther effects: cataract, osteoporosis, periodontitis, poor surgical outcomes,U.S. Department of Health and Human Services. (2004). The Health Consequences of Smoking: A Report of the Surgeon General.,HEALTH CONSEQUENCES of SMOKELESS TOBACCO USE,Periodontal effectsGingival recessionBone attachment lossDental cariesOral leukoplakiaCancerOral cancerPharyngeal cancer,Oral LeukoplakiaImage courtesy of Dr. Sol Silverman - University of California San Francisco,Use of alcohol in combination with moist snuff increases the risk of oral cancers.,ANNUAL U.S. DEATHS ATTRIBUTABLE to SMOKING, 19972001,Centers for Disease Control and Prevention. (2005). MMWR 54:625628.,32%,28%,23%,9%,8%,30 pack-years has been shown to be an independent prognostic factor for both short- and long-term survival ratesTobacco mutagenicity may play a role in the growth and extension of certain cancersPresents further obstacles for survival,Quitting smoking before diagnosis and treatment can positively influence survival.,Smoking after diagnosis negatively impactsOverall quality of life (QOL) Risk for co-morbid diseases, which independently have a negative impact on QOLSymptom distress Higher in persistent smokers, compared to never smokers,EFFECTS of SMOKING on QUALITY OF LIFE in PATIENTS WITH CANCER,HOW DOES SMOKING CESSATION IMPROVE CANCER PROGNOSIS?,Quitting prior to diagnosis and treatment has a positive influence on prognosis and survivalExamplesHead and neck cancerQuitting 12 weeks and 1 yr prior to diagnosis reduces mortality by 40% and 70%, respectivelyNon-small cell lung cancerQuitting at any point prior to lung operation is beneficial to prognosis and long-term survival,WHAT FACTORS POSITIVELY INFLUENCE QUITTING in PATIENTS WITH CANCER?,Patient awareness of the link between smoking and their diagnosed smoking-related cancer Patient concern about recurrent disease and the effects of smoking on treatment successAdvice given in the context of medical care,MORE INTENSIVE or TAILORED INTERVENTIONS MAY BE NEEDED,Patients with cancer tend to have:Higher levels of nicotine dependenceHigher levels of psychiatric co-morbidityHigher need for treatment supportHigh percentage of household smokers Poorer general health and physical functioningMore stress and emotional distressCancer disease-related issues need to be taken into account in treatment decisions and patient monitoringImpact of smoking on surgery, radiation, and chemotherapySystematic advice (from multiple providers), with stepped-care approach for patients experiencing difficulty with quitting,RELAPSE in PATIENTS WITH CANCER,Up to one third or one half of patients will either continue to smoke after diagnosis or relapse after an initial quit attemptRelapse is often delayed in patients with cancer, compared to healthy patientsFollow-up and monitoring is neededIn relapsers: Encourage a subsequent quit attempt, to avoid additional post-diagnosis risk due to smoking,SUMMARY: REASONS TO QUIT for PATIENTS WITH CANCER,Reduced risk for complications related to cancer therapy and surgeryImproved survivalImproved quality of lifeReduced risk of second primary tumor(s),TOBACCO CESSATION is an essential component of treatment for patients with cancer.,TREATING TOBACCO USE and DEPENDENCE: MEDICATIONS for QUITTING,HANDOUT,TOBACCO DEPENDENCE:A 2-PART PROBLEM,Tobacco Dependence,Treatment should address the physiological and the behavioral aspects of dependence.,Physiological,Behavioral,PHARMACOLOGIC METHODS: FIRST-LINE THERAPIES,Three general classes of FDA-approved drugs for smoking cessation:Nicotine replacement therapy (NRT)Nicotine gum, patch, lozenge, nasal spray, inhalerPsychotropicsSustained-release bupropionPartial nicotinic receptor agonistVarenicline,PHARMACOTHERAPY,Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.,Medications significantly improve success rates.,* Includes pregnant women, smokeless tobacco users, light smokers, and adolescents.,“Clinicians should encourage all patients attempting to quit to use effective medications for tobacco dependence treatment, except where contraindicated or for specific populations* for which there is insufficient evidence of effectiveness.”,PHARMACOTHERAPY: USE in PREGNANCY,The Clinical Practice Guideline makes no recommendation regarding use of medications in pregnant smokersInsufficient evidence of effectivenessCategory C: varenicline, bupropion SRCategory D: prescription formulations of NRT,“Because of the serious risks of smoking to the pregnant smoker and the fetus, whenever possible pregnant smokers should be offered person-to-person psychosocial interventions that exceed minimal advice to quit.” (p. 165),Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.,PHARMACOTHERAPY: OTHER SPECIAL POPULATIONS,Pharmacotherapy is not recommended for:Smokeless tobacco usersNo FDA indication for smokeless tobacco cessation Individuals smoking fewer than 10 cigarettes per dayAdolescentsNonprescription sales (patch, gum, lozenge) are restricted to adults 18 years of ageNRT use in minors requires a prescription,Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.,Recommended treatment is behavioral counseling.,NRT: RATIONALE for USE,Reduces physical withdrawal from nicotineEliminates the immediate, reinforcing effects of nicotine that is rapidly absorbed via tobacco smokeAllows patient to focus on behavioral and psychological aspects of tobacco cessation,NRT products approximately doubles quit rates.,Polacrilex gumNicorette (OTC)Generic nicotine gum (OTC)LozengeCommit (OTC)Generic nicotine lozenge (OTC)Transdermal patchNicoDerm CQ (OTC)Generic nicotine patches (OTC, Rx),Nasal sprayNicotrol NS (Rx)InhalerNicotrol (Rx),NRT: PRODUCTS,Patients should stop using all forms of tobacco upon initiation of the NRT regimen.,PLASMA NICOTINE CONCENTRATIONS for NICOTINE-CONTAINING PRODUCTS,0 10 20 30 40 50 60,Time (minutes),Cigarette,Moist snuff,NRT: PRECAUTIONS,Patients with underlying cardiovascular diseaseRecent myocardial infarction (within past 2 weeks)Serious arrhythmiasSerious or worsening angina,NRT products may be appropriate for these patients if they are under medical supervision.,NICOTINE GUMNicorette (GlaxoSmithKline); generics,Resin complexNicotine PolacrilinSugar-free chewing gum baseContains buffering agents to enhance buccal absorption of nicotineAvailable: 2 mg, 4 mg; original, cinnamon, fruit, mint (various), and orange flavors,NICOTINE GUM: DOSING,Dosage based on current smoking patterns:,NICOTINE GUM: DOSING (contd),NICOTINE GUM: CHEWING TECHNIQUE SUMMARY,Park between cheek & gum,Stop chewing at first sign of peppery taste or tingling sensation,Chew slowly,Chew again when peppery taste or tingle fades,NICOTINE LOZENGECommit (GlaxoSmithKline); generics,Nicotine polacrilex formulationDelivers 25% more nicotine than equivalent gum doseSugar-free mint (various), cappuccino or cherry flavorContains buffering agents to enhance buccal absorption of nicotineAvailable: 2 mg, 4 mg,NICOTINE LOZENGE: DOSING,Dosage is based on the “time to first cigarette” (TTFC) as an indicator of nicotine addiction,Use Commit Lozenge 2 mg:If you smoke your first cigarette more than 30 minutes after waking up,Use Commit Lozenge 4 mg:If you smoke your first cigarette of the day within 30 minutes of waking up,NICOTINE LOZENGE: DOSING (contd),NICOTINE LOZENGE: DIRECTIONS for USE,Use according to recommended dosing schedulePlace in mouth and allow to dissolve slowly (nicotine release may cause warm, tingling sensation)Do not chew or swallow lozenge.Occasionally rotate to different areas of the mouth.Lozenge will dissolve completely in about 2030 minutes.,Do NOT eat or drink for 15 minutes BEFORE or while using the nicotine lozenge.,TRANSDERMAL NICOTINE PATCHNicoDerm CQ (GlaxoSmithKline); generic,Nicotine is well absorbed across the skinDelivery to systemic circulation avoids hepatic first-pass metabolismPlasma nicotine levels are lower and fluctuate less than with smoking,TRANSDERMAL NICOTINE PATCH:PREPARATION COMPARISON,TRANSDERMAL NICOTINE PATCH: DOSING,TRANSDERMAL NICOTINE PATCH:DIRECTIONS for USE,Choose an area of skin on the upper body or upper outer part of the armMake sure skin is clean, dry, hairless, and not irritatedApply patch to different area each dayDo not use same area again for at least 1 week,TRANSDERMAL NICOTINE PATCH:ADDITIONAL PATIENT EDUCATION,Water will not harm the nicotine patch if it is applied correctly; patients may bathe, swim, shower, or exercise while wearing the patch,Do not cut patches to adjust dose Nicotine may evaporate from cut edges Patch may be less effectiveKeep new and used patches out of the reach of children and petsRemove patch before MRI procedures,NICOTINE NASAL SPRAYNicotrol NS (Pfizer),Aqueous solution of nicotine in a 10-ml spray bottleEach metered dose actuation delivers50 mcL spray0.5 mg nicotine100 doses/bottleRapid absorption across nasal mucosa,NICOTINE INHALERNicotrol Inhaler (Pfizer),Nicotine inhalation system consists of:MouthpieceCartridge with porous plug containing 10 mg nicotine and 1 mg mentholDelivers 4 mg nicotine vapor, absorbed across buccal mucosa,BUPROPION SR Zyban (GlaxoSmithKline); generic,Nonnicotine cessation aidSustained-release antidepressantOral formulation,BUPROPION:MECHANISM of ACTION,Atypical antidepressant thought to affect levels of various brain neurotransmi