Michael B. Steinberg, MD, MPH, assistant professor in the Department of Medicine at UMDNJ-Robert Wood Johnson Medical School and medical director of the Tobacco Dependence Clinic at UMDNJ-School of Public Health
Time to get tough on tobacco dependence
Across the world, tobacco kills one person every 8 seconds. Tobacco is highly addictive as evidenced by the more than 50% of smokers who continue to smoke after suffering a heart attack or being diagnosed with cancer. Numerous studies show that these smokers will have much better outcomes if they stop smoking, yet they are unable to do so. Some smokers fear it is too difficult or futile, while others are not offered appropriate treatment. Regardless of the reason, these smokers are most at risk because of their continued smoking and need to be treated as aggressively as possible to improve the quality of their lives. By demonstrating effective ways to help smokers with medical illnesses quit successfully, we hope to change the way that they receive tobacco dependence treatment.
Imagine opening the newspaper every morning and reading the front-page headline “Three 747s crash, killing all on board.” This is the burden of death for tobacco use in the U.S.; 1,200 smokers die each and every day. Tobacco dependence is an addiction stronger than heroin or cocaine. Stopping smoking can add 14 years of life and prevent the suffering of numerous diseases— an impact that few other interventions can offer.
|Figure 1: Abstinence rates by medication use; UMDNJ-Tobacco Dependence Clinic; 2001-3
As a physician, after years of hearing “smoking is just a bad habit,” I knew there was much work to be done. The irony is that those smokers who most need to quit, those with existing tobacco-caused illnesses, are not getting adequate treatment. More than half of smokers with heart disease, lung disease, and cancer continue to smoke, and the morbidity and mortality from these conditions rise with every puff. Despite this, there is a hesitancy to provide these smokers with the tools they need to successfully quit.
There are myths in the medical community and among the general public that are entirely unfounded regarding cessation medications, especially that in combination, they can cause heart attacks, strokes, and other untoward effects. These false beliefs result in many highly dependent smokers receiving inadequate doses of medication, and ultimately failing in their attempts to quit. What is missing is the appreciation of the “life or death” circumstance that continuing to smoke represents. We would not withhold life-saving chemotherapy from a cancer patient for the fear of side effects. These misperceptions contribute to a lack of understanding of how important it is to aggressively treat these smokers.
Data from our experience with nearly 3,000 smokers treated at the UMDNJ-Tobacco Dependence Clinic demonstrate that smokers who use more cessation medications tend to be more successful in remaining abstinent (see Figure 1).
However, there are only limited studies demonstrating the benefit of combining medications in a controlled trial fashion, and no study to date has tested a 3-drug combination. To help provide data regarding the benefit of treating smokers with medical illnesses, we are currently conducting a randomized clinical trial of combination medications (nicotine patch, nicotine inhaler, and bupropion) versus patch alone. This study, funded through The Cancer Institute of New Jersey, the UMDNJ-Robert Wood Johnson Medical School (RWJMS) Department of Medicine, and the UMDNJ Foundation, will enroll 130 smokers with known tobacco-related disease who are interested in quitting. Subjects will randomly receive either patch alone or the 3-medication combination, and will only receive brief behavioral information in order to simulate a primary care-type setting. They will be followed up at monthly intervals for 6 months. At each visit, expired carbon monoxide levels will be measured to validate abstinence rates, with the primary outcome being 7-day point abstinence. Data will also be collected regarding changes in motivation, withdrawal symptoms, and adverse medication effects.
Another important setting in which to treat medically-ill smokers is the hospital. Smokers who are hospitalized are at the highest risk of continued tobacco-caused morbidity. They are placed in a setting of forced abstinence and are feeling especially vulnerable during hospitalization, thus creating a “teachable moment.” The clinical effects of tobacco withdrawal during acute medical illness are unknown. Also, relieving physical withdrawal symptoms is a benefit to the patient by improving comfort, and building confidence and familiarity in using these medications in the hospital may increase utilization following discharge. Finally, allowing our patients to continue to smoke during their hospitalization goes against our institutional mission. For many reasons, the hospital is an important setting for intervention, yet previous studies looking at the effect of hospital interventions for smokers have shown mixed results.
To evaluate the benefit of a comprehensive hospital-based tobacco treatment intervention utilizing a new cessation medication called varenicline, we will be conducting a study funded through the Robert Wood Johnson Foundation Physician Faculty Scholars Program. Based on recently published clinical trials, varenicline (an a4b2 nicotinic receptor partial agonist/antagonist) has the potential to deliver high rates of abstinence. Via its mechanisms of action, varenicline may be uniquely suited for treating hospitalized smokers. By stimulating a partial dopamine release in the nucleus accumbens (partial agonist), this medication reduces cravings and withdrawal symptoms in abstinent smokers, thus alleviating withdrawal during the forced abstinence in the hospital. In addition, through its antagonistic actions, this medication can reduce the rewarding effects of smoking, thus preventing a “slip” after discharge from becoming a full relapse. Varenicline could be critical in preventing the greater than 50% of hospitalized smokers who were abstinent during their hospitalization from relapsing to smoking following discharge. We will determine whether this type of intervention can reduce relapse and improve clinical outcomes. Recruitment will include 250 current smokers admitted to Robert Wood Johnson University Hospital with various diagnoses who will receive either an intensive intervention including active varenicline, or usual care with placebo medication. Outcomes will include 7-day point abstinence at 6 months, changes in motivation to quit and withdrawal symptoms, and adverse clinical events during this period. We will gather data demonstrating that quitting smoking during this critical time of an acute medical event may impact on longer term medical outcomes.
The results of these studies will help shape the way we treat smokers with medical illness. We hope to demonstrate that these smokers need to be treated with appropriate intensity and pharmacotherapy that is in line with the risk of their continued tobacco use. If we can show that hospitalized smokers can have better clinical outcomes if they remain smoke-free following discharge, this will have a profound impact on the way we set policy in treating smokers in the hospital setting. We can begin to get tougher on treating tobacco dependence for these smokers who need our help the most.
Michael B. Steinberg, MD, MPH, is an assistant professor in the Division of General Internal Medicine at UMDNJ-Robert Wood Johnson Medical School and medical director of the Tobacco Dependence Clinic at the UMDNJ-School of Public Health. Dr. Steinberg graduated from RWJMS with a combined MD/MPH degree, and completed his internal medicine residency at Thomas Jefferson University Hospital in Philadelphia. He has received numerous teaching awards as a resident and faculty member, as well as being elected junior year AOA while graduating first in his medical school class. He has published numerous articles on various aspects of tobacco control, including novel pharmacotherapies for cessation, improving tobacco dependence treatment by physicians, and predictors of success in treating smokers. These articles and other resources can be found at www.tobaccoprogram.org.