Smoking Cessation. Disclosures. Thank You. None

Transcription

1 Smoking Cessation Dr. Jamie Kellar; BSc, BScPhm, PharmD Clinician Educator Centre for Addiction and Mental Health Assistant Professor Leslie Dan Faculty of Pharmacy Disclosures None Thank You Several slides have been shared by Dr. Tony George and Clinicians who work with the TEACH project at CAMH. 1

2 Learning Objectives At the end of this presentation you will be able to: Describe why pharmacists should implement smoking cessation interventions. Discuss the role of behavioural support in smoking cessation protocols Implement a structured pharmacotherapy plan for patients wanting to quit smoking Assist patients from special populations with smoking cessation List pharmacotherapy products that are in development for smoking cessation Smoking Fact or Fiction Tobacco use is the leading preventable cause of death worldwide? 50% of quit attempts fail in the first week 2/3 of smokers who try to quit use behavioural or pharmacological assistance? Smokers double odds of quitting if pharmacotherapy is used? Outcomes of cessation interventions are comparable with other chronic disease management (hypertension, asthma, diabetes) Tobacco Use in Canada Tobacco kills 1 in 5 Canadians, or 45,000 people every year (more than deaths due to traffic accidents, suicides, homicides, drug abuse and HIV-AIDS combined) (Physicians for a Smoke-Free Canada, 2003) Economic impact of smoking estimated at $17 billion every year (Rehm et al., 2006) 90% of people who smoke became addicted before age 18 (Fiore et al., 2008) Tobacco-related disease accounts for at least 500,000 hospital days each year in Ontario alone (MHP, 2009) Rates of smoking are much higher among subpopulations: e.g.,90% - people with schizophrenia, 90% - people with opioid dependence (Kalman, Morisette and George, 2005; NIDA, 2008) 2

3 Smoking Environment in Canada 17-19% of Canadians 15 and older are current smokers (CUTMS 2008) 27% are former smokers 56% never smoked 55% of daily smokers have 1 st cigarette within 30 min of waking up and 75% within the first hour Newfoundland & Labrador 21% B.C. 15% Alberta 21% Saskatchewan 22% Manitoba 22% Health Canada. Canadian Tobacco Use Monitoring Survey 2005, Ontario 16% Québec 22% New Brunswick 22% PEI 20% Nova Scotia 21% Summary of Annual Results. Why Should Pharmacists Get Involved? Accessible, trusted health care professionals Therapeutic alliance with patients 70% of smokers want to quit Only 3-5% of unassisted quit attempts are successful vs. 20% success for those receiving cessation counseling and/or medication 3

4 Tobacco Dependence Is a Disease Assessing Tobacco Dependence 3 or more of the following required for a diagnosis of Nicotine Dependence: Tolerance Withdrawal The substance is used in larger amounts or over a longer period than was initially intended. Unsuccessful efforts to cut down, regulate or discontinue use 4

5 A great deal of time spend obtaining the substance or recovering from its effects Important social, occupational, or recreational activities may be given up or reduced because of substance use Substance use continues despite the individuals realization that the substance is contributing to a psychological or physical problem Neurocircuits Involved In Drug Dependence! VTA 5

6 Fagerstrom Test for Nicotine Dependence (FTND) 1) How soon after you wake up do you smoke your first cigarette? 3 = Within 5 minutes. 2 = 6 to 30 minutes. 1 = 31 to 60 minutes. 0 = After 60 minutes. 2) Do you find it difficult to refrain from smoking in places where it is forbidden? 0 = No 1 = Yes 3) Which cigarette would you hate most to give up? 1 = The first one in the morning. 0 = All others. 4) How many cigarettes per day so you smoke? 3 = 31 or more. 2 = 21 to 30 1 = 11 to 20 0 = 10 or fewer. 5) Do you smoke more frequently during the first hours after waking than during the rest of the day? 0 = No 1 = Yes 6) Do you smoke if you are so ill that you are in bed most of the day? 0 = No 1 = Yes A score of 5 or higher is consistent with a moderate level of nicotine dependence Calculate Pack History # cigarettes/day x # years smoked 20 = pack years Cessation Interventions 6

7 To Quit Smoking To successfully quit smoking patients have to: Overcome pharmacologic nicotine dependence Cope with nicotine withdrawal Extinguish strong behavioural associations with smoking Tobacco Treatment Methods Large evidence base to support effective methods for treating tobacco dependence. Two modalities have strong evidence of efficacy: Behavioural Support Pharmacotherapy Each modality effective on its own, however combination has superior efficacy to either on own. 7

8 Role of Behavioural Support and Pharmacotherapy Behavioural Support Enhances motivation Teaches quitting skills Pharmacotherapy Ease physical comfort of nicotine withdrawal Quell urges to smoke Change is not something you do to people, but with people Behavioral Treatments for Tobacco Dependence Brief advice from pharmacist or other health care professional Motivational Interviewing (MI) Coping Skills Relapse-Prevention Community Support Groups (HSFO, CCS) Hypnosis Acupuncture Rapid Smoking (Aversive Therapy) 8

9 Brief Tobacco Interventions CDC recommends brief interventions to assist patients with smoking cessation Dose-Response relationship between session length and abstinence rates Dose-Response relationship between number of sessions and treatment effectiveness. USPHS, 2008 Pharmacotherapy 9

10 Oropharyngeal irritation Varenicline Nicotine Replacement Therapy Delivers nicotine in non-combustible form to alleviate withdrawal symptoms None of products available are absorbed through lungs hence cannot reproduce cigarettes rapid delivery to nicotine to arterial circulation. 2 distinct patterns of delivery (transdermal/oral) 10

11 NRT Fact or Fiction Smoking while on the patch increases risk of heart attack? 21 mg is the highest patch strength that should be administered to patients? NRT is addictive NRT can used as long as needed, even if this means using it for years? Smokers who are pregnant cannot use NRT? 11

12 Effectiveness and Safety of NRT Recent study of 2767 predominantly middleaged smokers not ready to quit: half were given NRT (gum, inhaler or choice of therapy) and half were given placebo for up to 18 months Primary Outcome was six months of sustained abstinence from smoking Results overwhelmingly positive NRT was well tolerated Those using the NRT achieved six months of sustained abstinence & most lasted beyond months 12

13 Cardiac Disease and NRT NRT is safer than smoking Cigarette smoke causes Increase in heart rate Blood pressure Increased clotting time Polycythemia NRT has not been associated with any increase in cardiac events (heart attack, stroke) NRT Tips Combine long acting patch with short acting product Extend Treatment beyond 8-12 weeks Start NRT about 2 weeks prior to quit date Packaging labels still include outdated restrictions, hence educating patients is essential. Assess readiness to discontinue NRT Bupropion SR (Zyban ) 13

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15 Special Populations Pregnancy and Lactation Patients with Mental Health and Addiction (MHA) Disorders Is it Safe to Get MHA Patients to Quit Smoking? Short Answer: Yes In schizophrenia, smoking cessation does not exacerbate psychotic or depressive symptoms (e.g. George et al., 2000; Evins et al., 2001; George et al., 2002; Evins et al., 2005). In major depression, some longitudinal studies by the Columbia group (Glassman et al., 1988; 1990) do suggest some increased risk of depression with smoking cessation, but several other studies have not supported this conclusion (Niaura et al., 2001; Thorsteinsson et al., 2001). In anxiety disorders, little evidence that cessation can exacerbate PTSD or GAD, and in fact severity and frequency of panic attacks in Panic Disorder may be higher in smokers versus non-smokers (Breslau and Klein, 1999). In alcoholics, there is evidence that quitting smoking and drinking concurrently may increase risk of alcohol relapse by 30% (Joseph et al., 2004) 15

16 Cigarette Smoking, Cytochrome P450 and Psychotropic Drug Plasma Levels DeLeon, J. (2004). Psychiatric Serv. 55: Novel Smoking Cessation Drugs - The Perils of Drug Development Useful Resources Telephone Smokers Helpline Canadian Cancer Society National Cancer Institute, Tobacco Control Research Branch American Lung Association

17 Questions? 17