Session 12: Smoking and Noncommunicable

Transcription

1 Tobacco Cessation Interventions Lunch and Learn Seminar Series for Physicians, Family Health Teams, and other Health/Allied Health Practitioners Session 12: Smoking and Noncommunicable Disease: A Focus on Cardiovascular Disease Faculty: Dr. Andrew Pipe, CM, MD Lunch & Learn Seminar Series 2012/13 1

2 Housekeeping Please sign-in or send an to if you have attended as a group Please ensure you have completed Learning Assessment 1 A link to Learning Assessment 2 will be sent by Both Learning Assessments are required for the Letter of Completion If you cannot hear audio on your computer, please dial-in via audioconference. You will be automatically muted. Conference #: Participant Code: # The Adobe Connect webinar will remain ON until 1:00 pm Lunch & Learn Seminar Series 2012/13 2

3 Dr. Andrew Pipe, CM, MD Dr. Andrew Pipe is Chief of the Division of Prevention and Rehabilitation at the University of Ottawa Heart Institute and Professor in the Faculty of Medicine at the University of Ottawa. He received his MD from Queen's University in Kingston, Ontario, in Dr. Pipe is Canada's foremost expert on smoking cessation. He was instrumental in the development of the widely adopted Ottawa Model for Smoking Cessation at the Heart Institute. Recognized as one of Canada's leading experts in cardiovascular disease prevention, physical activity and health, and smoking cessation, Dr. Pipe has addressed audiences in over 28 nations and is frequently consulted on issues related to tobacco use and smoking cessation, drug use in sport, and physical activity and health. A former Chair of Physicians for a Smoke-Free Canada, Dr. Pipe is a Life Member of the Canadian Council on Smoking and Health. In addition to his clinical responsibilities, Dr. Pipe has been extensively involved in sports and sport medicine for many years. He is currently President of the Commonwealth Games Association of Canada. He served as a physician at eight Olympic Games and has been Team Physician for Canada's National Men's Basketball Team since He served as Chair of the Canadian Centre for Ethics in Sport from its inception until Dr. Pipe is the recipient of the International Olympic Committee's Award for Sport, Health and Wellbeing, and is a member of the Canadian Olympic Hall of Fame. He has received honourary degrees from Queen's University (LLD); Brock University (DSc) in St. Catharines, Ontario; and the University of Guelph (DSc) in Guelph, Ontario. He is Vice Chair of the Board of Trustees at Queen's University. Lunch & Learn Seminar Series 2012/13 3

4 Disclosures Dr. Andrew Pipe In the past Dr. Pipe has received research and educational support from, and/or served as a consultant to: PFIZER GSK JOHNSON & JOHNSON Lunch & Learn Seminar Series 2012/13 4

5 Disclaimer These materials (and any other materials provided in connection with this presentation) as well as the verbal presentation and any discussions, set out only general principles and approaches to assessment and treatment pertaining to tobacco cessation interventions, but do not constitute clinical or other advice as to any particular situations and do not replace the need for individualized clinical assessment and treatment plans by health care professionals with knowledge of the specific circumstances. Lunch & Learn Seminar Series 2012/13 5

6 TEACH Curriculum Development The TEACH Curriculum and slides were developed and compiled with funding from the Government of Ontario, Ministry of Health and Long Term Care. Content of slides are primarily based on evidence based guidelines including: CAN-ADAPTT Canadian Practice Guidelines Initiative developed in collaboration with national experts in tobacco cessation and health behaviour change ( US Guidelines Treating Tobacco Use and Dependence: Clinical Practice Guideline 2008 Update. US Department of Health and Human Services, Public Health Service Rethinking Stop-Smoking Medications: Treatment Myths and Medical Realities OMA Position Paper, January The development and delivery of the TEACH curriculum is not influenced or funded in any part by tobacco industry. TEACH has not received funding from the tobacco industry. The development of the TEACH curriculum has not been influenced by pharmaceutical industry. TEACH project received a $ unrestricted grant from Pfizer, to develop video vignettes that are used in our training. Information presented on pharmacotherapy refers to generic products only, and recommendations are based on existing research, including the CAN-ADAPTT and US guidelines. An algorithm is provided to help practitioners determine if and which pharmacotherapy is appropriate for a smoker. Lunch & Learn Seminar Series 2012/13 6

7 Session #12: Learning Objectives 1. Offer evidence-based approaches for the treatment of tobacco dependence for patients with cardiovascular disease and/or risk 2. Recommend and/or prescribe evidencebased pharmacotherapies for the treatment of tobacco dependence for patients with cardiovascular disease and/or risk 3. Identify the myths associated with the use of smoking cessation medications for patients with cardiovascular disease and/or risk Lunch & Learn Seminar Series 2012/13 7

8 Smoking Cessation in the Cardiac Setting: A Canadian Experience Andrew L. Pipe, CM, MD The Minto Prevention & Rehabilitation Centre University of Ottawa Heart Institute Ottawa, Ontario. Canada apipe@ottawaheart.ca

9 Acknowledgements

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11 Smoking Stimulates atherogenesis Stimulates endothelial inflammation Impairs flow-mediated arterial dilatation Affects platelet aggregation Decreases fibrinolysis Increases carboxyhemoblobin levels Precipitates acute cardiovascular events!

12 INTERHEART: Odds of MI & Smoking Rate. Lancet. 2004;364:937-52

13 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

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

15 People who quit smoking after a heart attack or cardiac surgery reduce their risk of death by 36% Cochrane Database of Systematic Reviews 2003;4:CD003041

16 Admission & Readmission Each year large numbers of smokers are admitted to Canadian hospitals most commonly, no attempt is made to assist them with smoking cessation during the course of their hospital stay... and re-admission rates are high.

17 Effect of intensive smoking cessation treatment on hospital admissions Mohiuddin, S. M. et al. Chest 2007;131:

18 overall 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:

19 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:

20 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:

21 Among smokers with HF Smoking cessation is as effective or more effective at reducing mortality as beta-blockers or ACE inhibitors J Am Coll Cardiol 2001;37:

22 The rapidity and potency of risk reduction, as well as the other healthenhancing effects associated with smoking cessation, argue for the prioritization of smoking cessation in any program of secondary prevention of coronary disease. American College of Cardiology

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

24 FOREBRAIN Dopamine BRAIN STEM α 4 ß 2 receptors

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26 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:

27 Pharmacotherapy All smokers trying to quit, except in the presence of special circumstances, should receive pharmacotherapy for smoking cessation. 3 Generations NRT bupropion varenicline

28 Nicotine Replacement Therapy Rationale Products The Patch Chewing Pieces Lozenges Nicotine Inhaler Advantages Shortcomings

29 Zombies are everywhere!

30 Pharmacodynamics The dose-response to HR acceleration and BP elevation is flat Thus there is little increased risk attributable to nicotine therapy Slow delivery systems produce less intense effects e.g. no psychoactive effects for NRT

31 Pharmacokinetics Nicotine is absorbed rapidly from cigarette smoke Venous nicotine levels are several fold lower Nicotine metabolized to cotinine Fetal nicotine metabolism occurs at a much lower rate than in the mother

32 Never Make Assumptions NRT Blood Pressure and HR safe to use NRT in hypertensives NRT Coronary Vasoconstriction no increase in ischaemia NRT Arrhythmias no effect on arrhythmias NRT Atherosclerosis HDL & LDL levels improve while on NRT NRT Thrombosis aggregability indices improve Joseph AM, Fu SS Progress in Cardiovascular Diseases 2003;45:

33 You can t use NRT in cardiac patients.

34 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:

35 NRT and CV Risk Clinical trials of NRT in patients with underlying, stable cardiovascular disease suggest that nicotine does not increase cardiovascular risk. Benowitz NL, Gourlay SG. J Am Coll Cardiol 1997;29:

36 NRT and CV Risk The use of nicotine patches did not cause aggravation of myocardial ischemia or arrhythmia in coronary patients and therefore can be used as a method to promote smoking cessation in this high-risk group. Tzivoni D, Keren A, Meyler et al. Cardiovasc Drugs Ther 1998;12:

37 NRT and CV Risk High-dose nicotine treatment, even with concomitant smoking, caused no short-term adverse effects on the cardiovascular system. Zevin S, Peyton J, Benowitz NL. Clin Pharmacol Ther 1998;64:87-95.

38 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:

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

40 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%)

41 We found evidence that all forms of NRT made it more likely that a person s attempt to quit smoking would succeed. The chances of stopping smoking were increased by 50% to 70%. NRT works with or without additional counselling, and does not need to be prescribed by a doctor. Heavier smokers may need higher doses of NRT. There is no evidence that NRT increases the risk of heart attacks.

42 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.

43 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

44 10 Best Practices for Smoking Cessation 1. Tobacco use queried and documented at all admissions 2. Training for tobacco-dependence treatment offered to hospital staff 3. Designated staff responsible for smoking cessation programme 4. Tobacco treatment included on clinical pathways, care maps etc. 5. Self-help materials readily available to patients, family members, and staff 6. Links to community resources readily available 7. Pharmacotherapy available through hospital formulary 8. Processes to follow up tobacco users for at least 1 month post discharge 9. Processes to evaluate healthcare providers performance 10. Processes to provide performance feedback to health care providers

45 Can J Cardiol 2006;22(9):

46 Hospital-based Smoking Cessation: the Ottawa Model

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

48 Standard Orders 1 pack a day 21 mg + and Inhaler 2 packs a day 42 mg + and Inhaler 3 packs a day further titration prn In every case recognize the need for titration

49 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

50 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

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

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

53 Curr Opin Cardiol 2011; 26:

54 N α4ß2 receptor

55 N NICOTINE α4ß2 receptor

56 N Varenicline α4ß2 receptor

57 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

58 Abstinence Point Prevalence (%) Seven-day Point Prevalence of Tobacco Abstinence 60 Drug Treatment * Follow-up Varenicline (n = 355) Placebo (n = 359) * OR = Odds ratio; CI = 95% Confidence intervals Week * Week 12: OR: 6.05; CI: (p < ); Week 24: OR: 2.98; 95% CI: (p < ); Week 52: OR: 2.10; 95% CI: (p < )

59 Varenicline causes CV problems* * This zombie was first sighted in Canada

60 Placebo Varenicline Risk of CV Events: 0.82% 1.06%

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62 Limitations of the Meta-Analysis -- Identified by authors: Our estimates are imprecise owing to the low event rates. The trials enrolled different populations, evaluated different doses of varenicline and had different lengths of follow-up and proportions lost to follow-up. None of the trials was adequately powered to detect individual differences in CV events. Although the included trials were double blinded, differences in ascertainment mediated by the cardiac symptoms of nicotine withdrawal is possible. In the absence of source data, we could not assess for potential blinding failure, blinding biases or differences in ascertainment, or determine whether the events were immediate or delayed. The cardiovascular events were not pre-specified. Thus, we could not determine whether diagnoses were clinical diagnoses or confirmed by established diagnostic criteria. Finally, the applicability of our findings to smokers with unstable cardiovascular disease remains uncertain because these people were excluded from the trials,

63 63 For Internal Use Only Commentary by Hays, T. CMAJ, Sept 6, % increased risk of serious cardiovascular adverse events, must be tempered by the rarity of these events among participants in both treatment groups (1.06% among patients given varenicline and 0.82% among patients given placebo) The rate of participants lost to follow-up was greater in the placebo arm [ ] that favours fewer events counted among participants given a placebo. The best outcome from this analysis would be more rigorous and adequately powered studies The worst outcome would be for health care providers to abandon the use of varenicline Is varenicline a safe drug? Multiple randomized clinical trials and metaanalyses indicate that it is. Is varenicline risk free? Clearly it is not, as the metaanalysis presented by Singh and colleagues shows. However, the risk for serious cardiovascular adverse events is low and is greatly outweighed by the benefits of diminishing the truly heartbreaking effects of smoking.

64 64 For Internal Use Only Limitations of the Meta-Analysis as Identified by authors: Our estimates are imprecise owing to the low event rates. The trials enrolled different populations, evaluated different doses of varenicline and had different lengths of follow-up and proportions lost to follow-up. None of the trials was adequately powered to detect individual differences in CV events. Although the included trials were double blinded, differences in ascertainment mediated by the cardiac symptoms of nicotine withdrawal is possible. In the absence of source data, we could not assess for potential blinding failure, blinding biases or differences in ascertainment, or determine whether the events were immediate or delayed. The cardiovascular events were not pre-specified. Thus, we could not determine whether diagnoses were clinical diagnoses or confirmed by established diagnostic criteria. Finally, the applicability of our findings to smokers with unstable cardiovascular disease remains uncertain because these people were excluded from the trials,

65 For Internal Use Only

66 Difference in risk of treatment emergent, cardiovascular serious adverse events associated with varenicline use in 22 double blinded, placebo controlled, randomised trials BMJ 2012;344:e2856

67 Meta-analysis of all published, randomised controlled trials found no significant increase in cardiovascular serious adverse events associated with varenicline use. BMJ 2012;344:e2856

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69 The consequence of inflated risk estimates can be unnecessary public alarm & real harm, since patients may discontinue drug treatment & clinicians may recommend treatments of reduced efficacy. BMJ 2012;344:e2856

70 Smoking and Professional Practice There is a need to ensure that cessation efforts are coordinated, systematized, and integrated into all professional practice settings.

71 Canadian Journal of Cardiology 2011;27:

72 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:

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

74 Assistance with smoking cessation can be provided in every health-care setting.

75 Transforming Institutional Practices Professional Behaviours Patient Care

76 Breaking Free from Tobacco

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78 Remember A link to the Online Course Evaluation will be sent by e- mail. A link to Learning Assessment 2 will also be sent by e- mail. This must be completed by April 3, 2013 in order to receive your Letter of Completion Next session: April 24 th, 2013: Pharmacotherapy: Advancements in Cessation Medications **Application period will be open on Tuesday April 2, 2013** Lunch & Learn Seminar Series 2012/13 78

79 Thank You! Lunch & Learn Seminar Series 2012/13 79