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Transcript of Smoking Cessation
for not smoking
Aug 21st 2013
20 yo man - "forms"
Military service physical
Dyslexic, mild hearing loss
2 PPD since age 9
(20-9)*2 = 22 pack years
Frequent binge alcohol use
No other concerns
*May not be historically accurate
The 5 "A"s of Smoking Cessation
if the patient smokes
for behavioural change
You raise the issue of smoking cessation. The patient says "quitting is for squares" grabs the paperwork from you, and rides off on his motorcycle.
And he doesn't pay the document fee.
Tools and Strategies
- Smoking is the leading cause of preventable death
- 1B people will die worldwide in the 21st C.
- Smokers lose at least 10 yrs. life expectancy
Increased risk of:
2011 Canadian Tobacco Use Monitoring Survey
Quitting smoking is the single greatest thing a smoker can do for his or her health
68% of current smokers want to quit
70% of smokers see a physician annually
2-5 min of advice boosts quit rate 1-3%
Benefits of quitting are immediate!
A custom loathsome to the eye, hateful to the nose, harmful to the brain, dangerous to the lungs, and in the black, stinking fume thereof, nearest resembling the horrible Stygian smoke of the pit that is bottomless.
King James I on tobacco use, 1604
- In the 1900s, physicans often promoted smoking
- CMA warns of the dangers of smoking, 1954
- US Surgeon General's report on smoking and health, 1964
Public attitudes have shifted, health hazards of smoking are now widely recognized, but the allure of cigarettes and the addictive properties of nicotine have kept the custom alive.
- Coronary heart disease - Stroke
- Several types of cancer - Infertility
- Stillbirth - Osteoporosis
- Premature skin aging - Lung Disease
- Sudden infant death syndrome (SIDS)
- 17% of the population currently smokes (lowest since 1965)
- Average is 14.4 cigarettes per day
- Highest prevalence in age 20-24 (21%)
- Males > females (20% to 15%)
- Smokeless tobacco use <1% in last 30 days
26% of Canadian
Most long-term former smokers make 3-6 attempts over 7-10 years before successful cessation
*Of current smokers,
But less than half received advice to quit in the last year.
- Smoking habits
- Previous quit attempts
- Results (and analysis)
- Comorbid drug/alcohol use
- Psychiatric disorders
Let's talk strategy...
Review "5 Rs"
Elicit, clarify, and resolve ambivalence
The 2-3 Pattern of Withdrawal
PEAK of cravings
et quit date
emove tobacco products
Phone- or web-based
The Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment CAN-ADAPTT
First-line strategy for those with contraindications to pharmacological therapy. (e.g. pregnant women)
Combined approach is much more successful than either on its own.
Partial agonist and partial competitive antagonist at nicotine receptor
Reduces cravings and pleasure from smoking
Depression, suicidal thoughts and actions
Caution with pre-existing psych disorders.
N/V, constip., HA, dream d/o, insomnia, psychosis
More effective than either bupropion or NRT (odds ratios 1.40 and 1.54 respectively)
One week loading dose, quit date, 12 weeks (+/- 12 more)
2009 meta-analysis of 101 studies done by Pfizer
2011 FDA Safety Announcement
2012 BMJ meta analysis
2012 BMJ cohort study
"small, increased risk of certain cardiovascular AEs in patients who have cardiovascular disease"
- All double-blind RCTs of varenicline vs. placebo
- No significant increase in cardiovascular serious adverse events associated with varenicline use
- Negligible variation in the evidence over 22 independent trials with 9,232 subjects
- 36k Danish smokers on bupropion or varenicline
- No sig. differences in cardiovascular events by drug
DNRI, nicotine receptor antagonist
Reduces cravings and withdrawal symptoms
Contraindicated in: seizure d/o, MAOI use within 2wk, eating d/o
Insomnia, dry mouth, lowered sz threshold
More effective than NRT or placebo
3 day AM loading dose of 150mg, then BID x7-12 weeks.
Quit date 1-2 weeks from start. Maintenance: up to 6 months
21% abstinent at 12 months vs. 8% placebo (OR 2.73)
Agonist at nicotine receptor
Reduces cravings and withdrawal symptoms
Variable by route - mucosal irritation, insomnia
More effective than placebo!
Many different forms (gum, patch, inhaler), equal efficacy.
Useful as additive to previous therapies.
Evidence for dual NRT - patch plus rapid delivery
(Cochrane Review 2008)
19.7% abstinent at 12 months vs. 11.5% placebo
Weight gain (average 4.5kg)
Focus on relapses as "slips" rather than failures.
What about our patient?
At age 48 he presents with a persistent cough, having failed multiple courses of antibiotics given to him by a walk-in clinic.
You decide to order a chest XR.
A percutaneous biopsy reveals malignant mesothelioma.
Likely secondary to multiple asbestos exposures while in the marines, on the movie sound-stage and in his flame-retardant racing suits.
Cigarette smoking is a substantial risk factor for this uniformly fatal disease.
Unaccepting of his terminal diagnosis, he travels to Ciudad Juárez, Mexico,
where receives coffee enemas, frequent shampoos, injection of live cells from cows and sheep, massage and "laetrile" therapy.
He dies of an MI 24h after radical resection of multiple head, neck and liver metastases,
less than a year after diagnosis.
King of Cool
1930 - 1980
Hunt P. Motivating Change. NUlSing Standard 2001; 16(2):45-52, 54-55.
Janz, NK. Am J Pub Health. 1987
Mnemonics: Toronto Notes
Anxiety, depression, feelings of restlessness or frustration, headaches, an increase in appetite and difficulty concentrating
>10 minutes >4x with 6-12 month followup improves results
14% abstinent with counselling vs. 10% without counselling
Canadian Tobacco Use Monitoring Survey 2011.
Toronto Notes 2012.
Drug monographs for NRT, bupropion, varenicline.
Hall, Hariet. Smoking: The Good News and the Bad News. www.sciencebasedmedicine.org
CAN-ADAPTT - Canadian Smoking Cessation Guidelines
Benowitz, Neal. "Basic and Clinical Pharmacology of Varenicline". CA Tobacco-Related Disease Research Program. Retrieved 3 March 2013.
Wikipedia commons (Images).
quitnow.ca (Canadian Lung Association)
Diane Staines - SMHC Pharmacist
Smoking Treatment for Ontario Patients (STOP) Program