How do I motivate my patients to quit smoking? Svein Høegh Henrichsen Anders Østrem Oslo, Norway

Transcription

1 How do I motivate my patients to quit smoking? Svein Høegh Henrichsen Anders Østrem Oslo, Norway IPCRG 2007

2 Conflicts of interest (last 3 years) Honoraria for lectures: BI, GSK, Pfizer, Roche Advisory board participation: Novartis, BI, Pfizer Page 2 - IPCRG 2012

3 Disclosures for NAME In compliance with COI policy, IPCRG 2014 requires the following disclosures to the session audience: Research Support/P.I. Employee Consultant Major Stockholder Speakers Bureau Honoraria Scientific Advisory Board No relevant conflicts of interest to declare No relevant conflicts of interest to declare No relevant conflicts of interest to declare No relevant conflicts of interest to declare No relevant conflicts of interest to declare No relevant conflicts of interest to declare No relevant conflicts of interest to declare Page 3 - IPCRG 2012 Presentation includes discussion of the following off-label use of a drug or medical device: <N/A>

4 The smoking epidemic 75% of smokers live in low or middle income countries Male smoking Page 4 - IPCRG 2012 World Health Organization. The Tobacco Atlas.

5 Prim Care Respir J Sep;17(3): IPCRG Consensus statement: tackling the smoking epidemic - practical guidance for primary care. van Schayck OC, Pinnock H, Ostrem A, et al. Page 5 - IPCRG 2012

6 Page 6 - IPCRG

7 IPCRG 2007

8 IPCRG 2007 First approach Interventions- Motivational Approach-Follow up

9 Should we do smoking cessation in primary care? Yes? o Why?? No? o Why? What are the barriers?? Page 9 - IPCRG 2012

10 Lack of time? Underestimation of the impact of our role; Not enough knowledge? Apprehension for not loosing the patient ; Reluctant to intervene in someone s private life; Page 10 - IPCRG 2012

11 The smoking epidemic 1 billion smokers 5 million people die every year This figure will have doubled by % of smokers want to quit <2% of smokers quit each year Primary care can help increase quit rate Page 11 - IPCRG 2012 World Health Organization. The Tobacco Atlas.

12 90 Cumulativ mortality (%) Quit Smoking Continued smoking 82 % % Years after AMI 13 Daly, BMJ, pas. Page 13 - IPCRG 2012

13 Minimal intervention Page 14 - IPCRG 2012

14 Page 15 - IPCRG 2012

15 Minimal intervention: Two questions to the patient: 1. Do you smoke? 2. Have you considered quitting? Page 17 - IPCRG 2012

16 Brief intervention in practice Cost effective : o Smoking cessation 400 to 1600/ life gained o 310 other interventions median !! We have the opportunity! o 80 % of smokers see the GP every year. Page 18 - IPCRG 2012

17 Brief intervention in practice Acceptable: o Patients see GPs as having a key and supportive role. Feasible: o Advice can take less than one minute o May use the time before consultation! Page 19 - IPCRG 2012

18 Brief intervention in practice It works! o Cochrane review ( Silagy 2003): Increase is cessation rate of about 2,5 % One quitter for every 20 patients ( NNT 40) o Combining brief advice with pharmacotherapy can considerably reduce numbers needed to treat (NNT). Page 20 - IPCRG 2012

19 Aim in Primary Care: Change how we work in Primary Care. o Identify all smokers (flag them) o Offer those motivated help to quit. How? Essential to offer brief advice to all when they contact primary care worker. Page 21 - IPCRG 2012

20 Results: Possibility of more advanced smoking intervention. Put smoking cessation on the agenda agree appointment for follow up. Aim is not to achieve cessation at once! Page 22 - IPCRG 2012

21 IPCRG 2007 Don`t just think about it - do it!!

22 IPCRG 2007 But what about motivation?

23 What do we tell those who are not motivated? The majority of smokers are more or less motivated to quit. 70 % want to give it up of these 40 % are willing to fix a quit date. Motivation can be influenced it is not static! Page 28 - IPCRG 2012

24 Motivational interviewing Key principles Regard the person s behaviour as their personal choice Let the patient decide how much of a problem they have Avoid argumentation and confrontation Encourage the patient to discuss the advantages and disadvantages of making a quit attempt Page 29 - IPCRG 2012 Fiore MC, et al. Treating tobacco use and dependence: US Department of Health and Human Services, 2000

25 Motivational tension Offering treatment can influence the choice Enjoyment of smoking Need for cigarette Fear of failure Concern about withdrawal Perceived benefits Worry about health Dislike of financial cost Guilt or shame Disgust with smoking Hope for success Page 30 - IPCRG 2012 Aveyard, P, et al. Managing smoking cessation. BMJ 2007;335:37-41

26 How can we understand our smokers? Research has identified stages the patient go through before they change behaviour. If we understand where they are we can offer help! Page 31 - IPCRG 2012

27 The cycle of change Relapse Maintenance Precontemplation Do you smoke? Have you considered quitting? Action Cycle of change Determination Contemplation Page 32 - IPCRG 2012 Adapted from Prochaska JO, DiClemente CC. J Consult Clin Psychol 1983; 51: 390-5

28 Pre-contemplation. Minimizing defiance o I do not smoke that much, I am sure it does not harm me Rationalisation o Grandma died at 93 and she smoked too Protest o no one is going to tell me. Helpless defeated o did try once but I could not do it too difficult for me Page 33 - IPCRG 2012

29 The doctors role Be an interested partner ask and explore. o Did you ever quit before? o What happened then? Be postitive o 2 weeks without smoking that was great! Ask permission to explain o Do you want me to tell you something about nicotine withdrawal? Offer help on their terms. Page 34 - IPCRG 2012

30 Maintenance Relapse Precontemplation Motivation Action Determination Contemplation Contemplation Want to and do not want to.. Quit? Or continue? Explore the ambivalence Page 35 - IPCRG 2012

31 Doctors role: Help to explore the ambivalence: What is the positive sides of smoking? What to you fear most when quitting? What are the negative? What do look forward to? Page 36 - IPCRG 2012

32 Relapse Maintenance Precontemplation From why to how: Motivation Action Contemplation Determination Determination Choose method Choose time Make a plan Offer help and consultation! Page 37 - IPCRG 2012

33 Doctors role: Make a plan together with your patient Offer a back-up a plan B Be interested and enthusiastic!! Page 38 - IPCRG 2012

34 Maintenance Relapse Precontemplation Action Motivation Contemplation Action = Smoking cessation! Determination Start Plan A o For example 5 consultations Important to have a Plan B o What to do if...? Page 39 - IPCRG 2012

35 Doctors role: Be available for the patient. Follow up with appointments. Ask, encourage and give positive feedback! Page 40 - IPCRG 2012

36 Maintenance Relapse Precontemplation Motivation Relapse. Action Contemplation Determination Relapse is not unusual! Important to gain experience and learn from the attempt. Soon as possible back to action Page 41 - IPCRG 2012

37 Doctors role: Encourage to new quit attempt. Point out what was achived. Offer more help. Page 42 - IPCRG 2012

38 Maintenance Relapse Action Motivation Precontemplation Contemplation Maintenance. Determination The smoker has become a non-smoker Shadows of the past is still there To be seen is still important. Page 43 - IPCRG 2012

39 Doctors role: Continue to see the patient. Give encouragement and credit Give positive feedback regarding health benefits. Page 44 - IPCRG 2012

40 Conclusion, motivation: To help a smoker to become a non-smoker is an exciting. GPs are in a unique situation where we can do a lot to help. Motivation is a dynamic process! Page 45 - IPCRG 2012

41 What to assess? Follow up Page 46 - IPCRG 2012

42 Obtain the patient s smoking history: Age commenced smoking. Number of cigarettes smoked daily. How soon after waking does the patient smoke. Previous attempts/success/aides used. Previous withdrawal symptoms experienced. Reasons for failure. Any smokers in the home. Motivation e.g. health, finance, family. Page 47 - IPCRG 2012

43 Prepare the patient to quit: Set a quit date and formulate coping strategies. Reward: for example a jar of money. Briefly discuss weight, diet and exercise. Ask the patient to identify a friend or family member who can be a steady source of support. Tell the patient to get rid of cigarettes, ash trays and lighters. Page 48 - IPCRG 2012

44 Assess: Fagerstrom Nicotine Dependence Questionnaire Questions Answer Score 1. How soon after you wake up do you smoke your first cigarette? 2. Do you find it difficult to refrain from smoking in public? Yes No Within 5 min 6 30 min min after 60 min 3. Which cigarette would you hate to give up most? The first one in the morning Any other 4. How many cigarettes a day do you smoke? 31 or more or less 5. Do you smoke more frequently during the first hours after waking than during the rest of the day? 6. Do you smoke if you are so ill that you are in bed most of the day? Yes No Yes No = high dependence; 5 7 moderate dependence; 1 4 = low dependence Page 49 - IPCRG 2012

45 CO CO measure is useful for reinforcing patient s motivation to quit Page 50 - IPCRG 2012

46 Smoking cessation programme Initial counselling session (45 minutes). Over 3 months - sessions x 4 (20 minutes each). Support literature. At one month, cessation validated by expired air CO measurement. Non-smokers asked to return at 6 months. Page 51 - IPCRG 2012

47 When do they start smoking again? 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 1 week 1 month 4 months Page 52 - IPCRG 2012

48 Inform about withdrawal syndrome Page 53 - IPCRG 2012

49 Nicotine withdrawal: Duration 2 days Lightheadedness 1 week Sleep disturbance 2 weeks Poor concentration Craving for nicotine D 10 weeks Increased appetite 4 weeks Irritability or aggression Depression Restlessness D Page 54 - IPCRG 2012 Action on Smoking and Health (ASH) Factsheet Number 11: Stopping Smoking.

50 Nicotine withdrawal: the 4 D s Drink water slowly Deep breathe. D Delay acting on the urge to smoke Do something else (eg exercise) D Page 55 - IPCRG 2012 Action on Smoking and Health (ASH) Factsheet Number 11: Stopping Smoking.

51 IPCRG 2007 Pharmacotherapy

52 Behandling 1. o Film Page 57 - IPCRG 2012

53 Pharmacotherapy Pharmacotherapy + behavioural counselling improves long-term quit rates Smokers of 10 or more cigarettes a day who are ready to stop should be encouraged to use pharmacologial support as a cessation aid Page 58 - IPCRG 2012 Aveyard P, West R. Managing smoking cessation. BMJ 2007;335;37-41

54 Medical therapy. Offer all who intend to quit. Increase chance of success. Groups: o NRT o Bupropion (Zyban) o Varenicline (Champix) o other Page 59 - IPCRG 2012

55 Plasma nicotine (ng/ml) Plasma nicotine levels contrast between cigarettes and NRT Cigarette 15 Spray 10 Gum/Inhaler/Tablet Time (minutes) Patch Adapted Page 61 from: - IPCRG Tobacco 2012 Advisory Group of the Royal College of Physicians 2000.

56 Odds ratio for abstinence after 12 months vs control NRT efficacy of different preparations after 12 months use NRT Gum Patch Spray Inhaler S/L tablet Silagy et al, The Cochrane Library Page 62 - IPCRG 2012

57 Nicotine Replacement Therapy NRT NRT different forms of administration: Nicotine patches: 16 or 24 hrs Nicotine gum: 2 or 4 mg Nicotine inhalator Nicotine nasal spray (+ sublingual-tablets) o combination may be best? Page 63 - IPCRG 2012

58 Page 65 - IPCRG 2012

59 Effects of NRT Prevent or reduce abstinence BUT: does not give the kick of a cigarette. Nose spray mimic best Only if full smoking cessation. Meta analysis: 71% better than placebo Page 66 - IPCRG 2012

60 Correct use of NRT: Should not be used for smoking reduction Fix a cessation date. Use high enough dose to avoid abstinece. Wait 6 weeks -2 months to taper off. Reduce the dose gradually to stop NRT after 4 weeks. Start 2 weeks before cessation date Page 67 - IPCRG 2012

61 Bupropion (Zyban) Noradrenalin- and dopamin system. Originally used as antidepressive Reduce craving for cigarettes More effective than NRT (?) Little side effects Bupropion vs. placebo o Odds ratio 2.73 ( ) Cochrane Library Page 68 - IPCRG 2012

62 Contraindications Bupropion: Known hypersensitivity for Bupropion Previous seizure Known CNS- tumour Bulimia / anorexia MAO- inhibitors (Aurorix) Bipolar depression Liver failure Uncontrolled hypertension Page 69 - IPCRG 2012

63 Side effects - Bupropion Usually mild and transient. Sleep disturbance/insomnia (up to 30%). Dry mouth (10-15%). Headache (10%). Nausea (10%), constipation (10%), and agitation (5-10%) Page 70 - IPCRG 2012

64 Bupropion / nicotine patch / combination. 40,00% 35,00% 30,00% 25,00% 20,00% 15,00% 10,00% 5,00% 0,00% 6 mndr. 12 mndr. Placebo Nik.plast. Buprop. Bu + nik Page 72 - IPCRG 2012

65 Bupropion: Recommended: o 1 depot tablet daily the first six days. o Then 1 depot tablet twice daily for 7-9 weeks (reduce in elderly, liver/renal disease). o It is recommended that the patient fix the quit date in week 2 when the dose is increased. Page 73 - IPCRG 2012

66 Varenicline Varenicline was developed for smoking cessation. Target is the nicotine receptor. Partial agonist; oagonist Stimulates the receptor to reduce craving abstinence. oantagonist Block the receptor so the effect of smoking is reduced. Acetylcholine receptor No clinically relevant interactions. Page 74 - IPCRG 2012 Varenicline

67 CA Responders (%) Cessation rates with Varenicline 50 Study Week Varenicline Bupropion Placebo 1. Data on file. Pfizer Inc. Page 75 - IPCRG 2012

68 Varenicline - Dosing Start one week before quit date. Take 0.5 mg tab x1for 3 days then 0.5 mg x2 for 4 days. After first 7 days, increase to 1 mg x 2 for 12 weeks! Take after eating, with a full glass of water Page 76 - IPCRG 2012 Cahill K, et al. Nicotine receptor partial agonists for smoking cessation. Cochrane Database Syst Rev 2007

69 Schedule for smoking cessation week Prep. NRT Quit day zyban-champix Support Page 77 - IPCRG 2012

70 Vaccination against smoking Immune response to nicotine. o To elicit an immune response nicotine must bind to a larger particle. Antibodies will then circulate and bind to nicotine in the blood. o Will not cross blood brain barrier. o Reduction of free nicotine that can bind to receptor. NicVAX has done several clinical studies. o So far only safety, must also demonstrate clinical effect. Page 78 - IPCRG 2012

71 Genetics and smoking. Genes are associated with: o Reduced consumption of cigarettes (CYP2A6 mutations) o Increased spontaneous cessation. o Mutations in the gene for dopamine receptor increase the chase of cessation. Pharmacogenomics: Increased effect of NRT and Bupropion has been shown related to specific genes. Page 79 - IPCRG 2012

72 Other methods? Hypnosis: no documented effect. Acupuncture: no documented effect Buspiron + other SSRI: no effect Klonidin: some effect? Nortriptylin: some effect o Side effects limit their use. Page 80 - IPCRG 2012

73 Page 81 - IPCRG 2012

74 Thank you! Page 82 - IPCRG 2012

75 Prevent Relapse Most relapses within 3 first months Reinforce decision to quit Follow up Assist resolving residual problem Desire to quit smoking The 5 A s Yes No Patient examination Counselling No The 5 R s Low dependency Breastfeeding Pregnancy Adolescents High dependency Repeat counselling No co-morbidities Co-morbidities Discussing patient s preference Evaluate co-morbidities No severe co-morbidities Severe co-morbidities Counselling + Behavioural support Counselling + Behavioural support NRT Counselling + Behavioural support + Therapy (NRT or Buproprion or varenicicline) Refer to smoking cessation clinics

76 Smokers must want to stop smoking and must be willing to work hard to achieve the goal of smoking abstinence. Page 84 - IPCRG 2012 Brief Clinical Advice & Intensive Smoking cessation Programs

77 Page 85 - IPCRG 2012

78 Page 86 - IPCRG 2012 Case report I

79 Katie is 50 years old, recently widow, unemployed and mother of two children (they all live with her mother). She smokes 30 cigarettes/day. She visited her physician because of a respiratory infection. She has never tried to quit in the past. She has COPD and she takes LABA and theophyline. Her hypertension is uncontrolled. Page 87 - IPCRG 2012

80 A) Ask Complete Smoking history -age when started smoking -duration of smoking -cigarettes/24 h -nicotine of cigarettes -previous attempts to quit (which medicine) -other members in the family that smoke Page 88 - IPCRG 2012

81 B) Assess Do you ever think of trying to stop smoking? Readiness to change (open questions) What are the good things for you about smoking? -If you considered changing, what things might be difficult for you? -Do you see any advantages in changing? Nicotine dependence (Fagerstrom=9) Page 89 - IPCRG 2012

82 Cycle of change Based on Prochaska and DiClemente s model Page 90 - IPCRG 2012

83 Barriers-Motivation Barriers against smoking cessation: -Widow -Unemployment Facts favor smoking cessation (motivate): -Model for children -Children s health -Her own health -Make a new start -Less money spend Page 91 - IPCRG 2012

84 What medication should you give? -in what dosage? Page 92 - IPCRG 2012

85 Case 1: Maria Age 53 medical history (-),started to smoke 17, attempts to quit in the past none, pack years 80, 50 cigarettes/ day normal Fagerstrom 11 family history: son smokes Page 93 - IPCRG 2012

86 tbs varenicline 0,5-1 quit day: 14 or buproprion or buproprion plus nicorette patches Page 94 - IPCRG 2012

87 Case Amanda: 58 years old, diabetes melitus, sleep apnoea, hypetension, major depression, one suicide attempt 1 year before, epilepsia, started to smoke 20, attempts to quit never, 59 pack years 50/24 hrs normal. Fagerstrom 8, family history: none. Page 95 - IPCRG 2012

88 Refer or NRT Page 96 - IPCRG 2012

89 Case Jacobs: age 33, history of seizures. Age started to smoke 17, one attempt to quit for 20 days 6 years before, 16 pack years 28/24 hrs heavy. Fagerstrom 9, family history: all children smoke Page 97 - IPCRG 2012

90 varenicline 0,5-1 Page 98 - IPCRG 2012

91 Case Phyl 37 depression pregnant, started to smoke 14, never, 25 pack years 12/24 hrs heavy. Fagerstrom 4, family history: none Page 99 - IPCRG 2012

92 NRT Page IPCRG 2012

93 Thank you for your attention! Page IPCRG 2012