Knowledge and attitudes of french cardiologists about smoking. Olivier Stora, cardiologist, Nantes

Transcription

1 Knowledge and attitudes of french cardiologists about smoking Olivier Stora, cardiologist, Nantes

2 Disclosure Statement of Financial Interest I currently have, or have had over the last two years, an affiliation or financial interests or interests of any order with a company or I receive compensation or fees or research grants with a commercial company : ASTRAZENECA BAYER HEALTH CARE SAS BOEHRINGER INGELHEIM FRANCE BOSTON SCIENTIFIC SAS BOUCHARA RECORDATI BRISTOL-MYERS SQUIBB DAIICHI SANKYO MEDA PHARMA MENARINI FRANCE MERCK SERONO PIERRE FABRE MEDICAMENT PFIZER NOVARTIS PHARMA SAS SERVIER

3 INTERHEART: Association of risk factors with acute MI in women and men Risk factor Current smoking Diabetes Hypertension Abdominal obesity Psychosocial index Fruits/Vegetables Exercise Alcohol ApoB-ApoA1 ratio Gender F M F M F M F M F M F M F M F M F M Adjusted for age, sex, geographic region Note: odds ratio plotted on a doubling scale Odds ratio (99% CI) Yusuf S et al. Lancet. 2004;364:

4 Attitudes of French Cardiologists Towards Smoking TESSIER J.F. (1) ; THOMAS D. (2) ; NEJJARI C. (1) ; BELOUGNE D. (1) ; FREOUR P. (3) ; A postal enquiry performed with the aid of the French Society of Cardiology and the French Federation of Cardiology in cardiologists, 730 replied (34% of the study population). Age 47 +/- 9 years; 84 % men 27 % smokers (14% daily smokers and 13% occasional smokers), 44 % daily smokers tried to stop,16% hoped to stop in 5 years 47% were former smokers and 26% had never smoked (the younger age groups), Young cardiologists were more aware of the cardiovascular and respiratory diseases related to tobacco consumption. Only 64% of cardiologists (54% of daily smokers) systematically warned a smoker patient 47% are underinformed about smoking-cessation management French cardiologists are insufficiently prepared for tabacco cessation

5 Knowledge and management of smoking-cessation strategies among cardiologists in France: a nationwide survey. Aboyans V 1, Pinet P, Lacroix P, Laskar M. Arch Cardiovasc Dis cardiologists, 370 participate in the survey (37% of the study population) 8.1% smokers, 32.4% past smokers Cardiologists routinely assessed active (96.2%) and passive smoking (43%) 85 % advised systematically for smoking cessation 29.2% considered themselves well informed about smoking-cessation management 5.4% of cardiologists followed up their patients 16 % address smokers to their general practitioner 67 % address to smoking-cessation centres and/or quitlines CONCLUSION: French cardiologists are rarely involved in the management of smoking cessation.

6 Survey 2015 Updating of the 1995 and 2005 surveys Diffusion by mailing, to cardiologists adhering to the French Society of Cardiology (SFC) and the French National College of Cardiologists (CNCF) Google form document (open-ended questions, multiple choice, unique choices, free answers, Automatic realization by incrementation of an Excel table cardiologists? = > 210 responses 130 Men, 80 Women (ratio 62% / 38%) Average age 45 years (men 48 years, women 41 years) 50% Hospitals, 50% Liberal or mixed practice

7 44 Questions 10 to 15 minutes - Identity, age, sex, place of work... - Knowledge and training of cardiologists - Priorities for the management of risk factors (Arteritis, Infarction, stroke) - Management of Smoking in Patients - Prescription of smoking cessation substitutes nicotinic, e-cig - Delegation of smoking cessation - Smoker?

8 Evolution of smoking among cardiologists Smokers Past smoker Never smoke

9 Is the cardiologist's smoking status important? 1995 : Personal smoking influences their attitude towards smokers patients Cardiologists who smoked : Ask less about patients' smoking (90% vs 98.2%, p=0.039). Are more passive in offering counselling (23% vs 7%, p=0.011), Referred less frequently to a smoking-cessation center (37% vs 64%, p=0.028).

10 About Patient Smoking Estimated 32% of smokers In your opinion, what is the proportion of patients who can finally stop smoking after a cardiovascular accident (heart attack, stroke,...)? 10 to 90% average 48% => 16 % smokers after a cardiovascular accident

11 EUROASPIRE IV: A European Society of Cardiology survey on the lifestyle, risk factor and therapeutic management of coronary patients from 24 European countries 78 centres from 24 European countries Patients <80 years with coronary interviewed and examined 6 months later. 16,426 medical records were reviewed and 7998 patients (24.4% females) 16.0% of patients smoked cigarettes, and 48.6% were persistent smokers. 25,00% 20,00% 15,00% 20,30% 21,20% 18,20% Smokers 16% 10,00% 5,00% 0,00% EUROASPIRE I II III IV European Journal of Preventive Cardiology February 16, 2015

12 Priorities for the management of risk factors Priorities Coronary disease Arteritis of the lower limbs Stroke Tobacco stop Hight blood pressure Lowering cholesterol Physical exercise Weight reduction 5 5 5

13 Heterogeneous associations between smoking and a wide range of initial presentations of cardiovascular disease in people in England: lifetime risks and implications for risk prediction 1.93 million personnes, age 30 ans, Pas d ATCD de maladies CV, Int J Epidemiol Feb; 44(1):

14 Knowledge and training of cardiologists Training - 30% of cardiologists perform vascular examinations - 19% of cardiologists have received training on tobacco ( 5% formed by a tobacco IUD ) No age difference / training Knowledge % not enough knowledge % consider themselves well informed % well or very well informed, 51% moderately, 19% little or not informed "52% not seeking further training, irrespective of initial training "

15 Minimum advice: Do you smoke? Do you want to stop? 57% say they know the minimum advice 18% cite it correctly. In the other answers, we find advice, information, injunctions, or a proposal for help... In 2005: 39% declared that they knew the minimum advice, 7% describe it correctly

16 Brief opportunistic advice Brief advice from a primary care physician during a routine consultation is effective in increasing the number of smokers stopping for at least 6 months. Intervention Target population Effect size 1 95% CI Brief opportunistic advice from a physician to stop Smokers attending GP surgeries or outpatient clinics 2% 1%-3% 1 The difference in >6 month abstinence rate between intervention and control/placebo in studies reported West R, McNeill A, Raw M. Thorax. 2000; 55: Stead LF, Buitrago D, Preciado N, Sanchez G, Hartmann-Boyce J, Lancaster T. Physician advice for smoking cessation. Cochrane Database of Systematic Reviews 2013, 5.

17 Analysis of infarcts in smoking patients: Search for a weaning or brochure delivery advice Mortality 30 days : 2% vs 3% RR = 0.81 (p = 0.04) Comparison of smokers' mortality rates Mortality 2 years: 25 % vs 30 % RR = 0.92 (p = 0.006) recommended vs. unsuitable smokers (A uni then multivariate): No research on efficacy in smoking cessation Houston TK et al; Am J Med 2005; 118 :

18 Prescription of nicotine substitutes Nicotine substitutes, 33 % regularly prescribe 37 % sometimes 19 % rarely 11 % never Evaluation of the dosage of nicotinic substitutes 57% Number of Daily Cigarettes 15% use the Fagerström test (18% in 2005 )

19 Varénicline : 77% never prescribe it, Lack of experience or information, risk of side effects, especially psychiatric, bupropion : 83%, never prescribe it, Lack of practice, knowledge, fear of side effects.

20 Meta-analyzes: efficacy (OR) and abstinence rate (%) estimated for different drugs and drug combinations vs placebo at 6 months (83 studies - USDPHHS, 2008) PLACEBO 80 1,0 13,8 Monothérapies Nicotine Gum (6-14 weeks) 15 1,5 (1,2 1,7) 19,0 (16,5 21,9) Nicotine Nasal Spray 4 2,3 (1,7 3,0) 26,7 (21,5 32,7) High-Dose Nicotine Patch (>25 mg) (These included both standard or long-term duration) 4 2,3 (1,7-3,0) 26,5 (21,3-32) Long-Term Nicotine Gum (> 14 weeks) 6 2,2 (1,5 3,2) 26,1 (19,7 33,6) Varenicline (1 mg/day) 3 2,1 (1,5 3,0) 25,4 (19,6 32,2) Nicotine Inhaler 6 2,1 (1,5 2,9) 24,8 (19,1 31,6) Clonidine 3 2,1 (1,2 3,7) 25,0 (15,7 37,3) Bupropion SR 26 2,0 (1,8 2,2) 24,2 (22,2 26,4) Nicotine Patch (6-14 weeks) 32 1,9 (1,7 2,2) 23,4 (21,3 25,8) Long-Term Nicotine Patch (> 14 weeks) 10 1,9 (1,7 2,3) 23,7 (21,0 26,6) Nortriptyline 5 1,8 (1,3 2,6) 22,5 (16,8 29,4) Varenicline (2 mg/day) 5 3,1 (2,5-3,8) 33,2 (28,9 37,8) Patch (long-term ; > 14 weeks) + ad lib NRT (oral or spray) Combinaison thérapies 3 3,6 (2,5-5,2) 36,5 (28,6 45,3) Patch + Bupropion SR 3 2,5 (1,9-3,4) 28,9 (23,5 35,1) Patch + Nortriptyline 2 2,3 (1,3-4,2) 27,3 (17,2 40,4) Patch + Inhaler 2 2,2 (1,3-3,6) 25,8 (17,4 36,5) Patch + Second génération antidepressants (paroxetine, venlafaxine) 3 2,0 (1,2-3,4) 24,3 (16,1 35,0)

21 Electronic cigarette : The opinion is generally favorable 93% of cardiologists are in favor or neutral, - the dangers are limited compared to conventional cigarettes - they can be useful help in smoking cessation - 15% think that it Is less harmful, but makes it as dependent as the conventional cigarette. - 7% as harmful as the traditional cigarette and discourage its use as a precaution. Electronic cigarette is an intermediate step towards a definitive withdrawal 20% "totally replace cigarettes" cases, sometimes in combination with nicotine substitutes. 25% " to reduce the number of conventional cigarettes" 20% never proposed (Precautionary principle, lack of validation and scientific evidence, absence of studies proving the safety and / or efficacy of Electronic cigarette for smoking cessation)

22 Delegation of smoking cessation? Access to tobacologist. 63% of cardiologists knows a tobacco specialist, 37% have no access to this service. No difference between liberal exercise, hospital or clinic. No difference between Paris, Île de France, cities with more than inhabitants, cities with fewer than inhabitants and other geographical areas, 35% smokers are addressed to the tobacco specialist, according to patient's motivation (In 2005, 32% never refer a patient to a tobacco specialist and 25% do not know a tobacco specialist)

23 Experience feedback from the tobacco consultation. 22% have no opinion, 28% noted rather unfavorable or disappointing results, 49% mentioned rather favorable or very favorable results 22% 49% 28%

24 Does the training of cardiologists influence care? 100% 90% 80% 70% 60% % 40% 30% 20% 10% % Trained ask for trained Know minimal advise Prescription Nicot S Prescription bupropion Prescription varénicline Know a tobacco specialist

25 Conclusions Cardiologists are aware of the issues, but... Untrained or poorly trained Insufficient motivation Low support However, they Know how to delegate Little change for 20 years!!