Smoking Cessation: Good News at Last!

Transcription

1 Smoking Cessation: Good News at Last! Andrew L. Pipe, CM, MD The Minto Prevention & Rehabilitation Centre University of Ottawa Heart Institute Ottawa, Ontario. Canada

2 Declaration of Interest In the past I have received research and educational support from, and/or served as a consultant to: PFIZER GSK JOHNSON & JOHNSON

3 Stopping smoking may have a greater effect on reducing the risk of mortality among patients with CHD who smoke than the effect of any other intervention or treatment. Critchley JA, Capewell S JAMA;2003;290:86-97

4 Smoking Cessation The Most Important CVD Intervention! Gaemperli O, et al Curr Pharm Des 2010;16:

5 Our attitudes have changed, but our approaches to cessation are out-dated!

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7 Smokers don t require more information or a lecture. They want help.

8 French Cardiologists: Cessation is a Top Priority for CAD patients! Enquired about active smoking 96.0% Asked about passive smoking 43.0% Advised cessation 85.0% Provided cessation support 5.4% Aboyans V et al. Arch Cardiovasc Dis 2009;102:

9 cardiologists are less committed to assist their patients with smoking cessation when compared with the management of other risk factors. Aboyans V, Thomas D, Lacroix P. Curr Opin Cardiol 2010;25:

10 Smoking diminishes benefit of blood pressure control Hypertensive smokers have a worse cardiovascular risk profile than non-smokers in spite of treatment Blood Pressure 2005;14:

11 Smoking diminishes benefits of statins 61% higher risk of events for smokers compared with nonsmokers treated with statins for secondary prevention Statin Milionis HJ et al. Angiology 2001;52:

12 Cessation & The Hospital Large numbers of smokers Relevance of smoking to admission Increased motivation to quit Availability of staff Opportunity for systematic approach Availability of Pharmacotherapy Treatment of withdrawal Can arrange follow-up Influence community practice

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14 Curr Opin Cardiol 2011; 26:

15 The Ottawa Model Identification Documentation Counseling Pharmacotherapy Long-term follow-up Reid RD, Pipe AL, Quinlan B. Can J Cardiol 2006;22:

16 Smoking Cessation & CVD We can t commence smoking cessation treatment at the time of hospitalization particularly in cardiac patients.

17 Pharmacotherapy 3 Generations NRT bupropion varenicline

18 2 Fundamental Principles Treat smoking cessation in exactly the same way that you would manage any other CVD risk factor. Manage smoking cessation medications in the same way that you would manage other cardiac medications.

19 A Smoke-free Future Sometimes the doorway has to be opened wider, or held open longer

20 Titrate NRT: Dose Duration Combination

21 The Ottawa Model Identification Documentation Counseling Pharmacotherapy Long-term follow-up Reid RD, Pipe AL, Quinlan B. Can J Cardiol 2006;22:

22 Ottawa Model s Automated Telephone Follow-up Interactive Voice Response Technology Patients receive 8 automated telephone calls post-discharge 3, 14, 30; every month x 6 months

23 In-Patient Cessation Programme More than 1,500 smokers identified annually Counseling provided to 1,470 (98%) ~15% increase in mid-term cessation rates 35% ~50% absolute cessation rate

24 Saving bed days Over 450 bed days saved at UOHI in 2009 with a $200,000 investment (ROI = 355%)

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26 Reid RD, Mullen KA, Slovinec D'Angelo ME, Aitken DA, Papadakis S, Haley PM, McLaughlin CA, Pipe AL. Nicotine Tob Res Jan;12(1):11-8

27 Zombie Concepts The safety of nicotine-replacement therapy in cardiovascular disease patients is supported by data from randomized trials, efficacy studies, observational data and physiologic studies. Joseph AM, Fu, Progress in Cardiovascular Diseases 2003;45:

28 NRT and CV Risk The use of NRT is not associated with any increase in the risk of myocardial infarction, stroke, or death. N = 33,247 Hubbard R, Lewis S, et al. Tobacco Control 2005;14:

29 UOHI Smoking Cessation Programme Use of NRT in the Cardiac Setting Smoking Patients NRT Male NRT Female NRT ACS % ACS NRT ,016 (23%) 194 (19%) 149 (20%) 45 (17%) (39%) , (44%) 477 (46%) 180 (41%) (63%) , (60%) 453 (60%) 185 (60%) (70%)

30 Efficacy and Safety of Varenicline for Smoking Cessation in Patients with Cardiovascular Disease: A Randomized Controlled Trial Rigotti NA, Pipe AL, Benowitz NL, Arteaga C, Garza D, Tonstad S. Circulation 2010;121(2):221-9

31 Seven-day Point Prevalence of Tobacco Abstinence Abstinence Point Prevalence (%) Drug Treatment * 54.1 * Follow-up Varenicline (n = 355) Placebo (n = 359) Week * Week 12: OR: 6.05; CI: (p < ); Week 24: OR: 2.98; 95% CI: (p < ); Week 52: OR: 2.10; 95% CI: (p < ) OR = Odds ratio; CI = 95% Confidence intervals

32 It is time for cardiologists to be less passive about their patients smoking cessation Lancet 2009;373(9667):867

33 Physician s Advice Clear Strong Personalized unambiguous and non-judgemental Matched by an institutional commitment to best practice!

34 Canadian Journal of Cardiology 2011;27:

35 The provision of unambiguous, non-judgemental advice regarding the importance of cessation and the offer of specific assistance with the initiation of a smoking cessation attempt should be seen as a fundamental responsibility of any clinicians who see smokers in their practice. The role of the specialist in delivering specific advice in this regard may itself result in enhanced rates of cessation. All cardiovascular specialists should be familiar with the principles and practice of smoking cessation. Canadian Journal of Cardiology 2011;27:

36 Assistance with smoking cessation is a fundamental responsibility of any practitioner who sees patients who are smokers.

37 Transforming Institutional Practices Professional Behaviours Patient Care

38 Nicotine & Tobacco Research 2010;12(1):11-18.

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40 Smoking Cessation Good News at Last!

41 Hospital-based Smoking Cessation: the Ottawa Model

42 Smoking Rates - Canada Daily Current Male: 16% 21% Female: 11% 14% Ottawa Male: 10% 16% Female: 8% 13%

43 Acknowledgements