Disclaimers Smoking and Smoking Cessation Dr. Janneke Gradstein CCFP(EM) Yarmouth, NS Received CHA Funding 6 th Annual Ottawa Conference: State of the Art Clinical Approaches to smoking cessation. References Disease Interrupted: Tobacco Reduction and Cessation by Els et al http://www.cancercare.ns.ca/sitecc/media/cancercare/cost_of_tobacco_report.pdf The Ottawa Model for Smoking Cessation (workshop materials) The Tobacco Atlas 4 th edition by Eriksen et al Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment (CAN-ADAPTT) https://novascotia.ca/dhw/publications/moving-toward-tobacco- Free-NS-Strategy.pdf Objectives Where smoking has been and where it s going Money and profit in industry and government HOW TO HELP PEOPLE QUIT! Worldwide 1 billion male smokers 250 million female smokers Rates overall decreasing in richer nations Rates climbing rapidly in poorer nations Smoking Epidemic Develops over 100 years Staggered start times Wealthier nations got a head start Stages I - IV Statistics at Home Canada, 2012 Smokers over age 15: 16% Smoked in pregnancy ages 25-44: 4.8% Smoked in pregnancy ages 20-24: 22.8% In Nova Scotia, 2011 Smoked in pregnancy (all ages): 21.3% 1
Economic Analysis: USA 2000-2004 Value of cigarette sales: 71 billion$ per year Total cost of smoking: 193 billion$ per year Economic Analysis: Nova Scotia Government tobacco revenue (2011): $213.1 million / year Health Care costs: Direct: $170 million/ year Indirect: $760 million / year Total Government cost $950 million/year Source: https://novascotia.ca/dhw/publications/moving-toward-tobacco-free-ns-strategy.pdf Health Impact World Health Organization: Tobacco is the leading cause of preventable death and disease worldwide. Quitting Smoking and Life Expectancy Added life expectancy with smoking cessation: Age 35 8 years Age 65 2 years Health Canada: Tobacco smoking is the single most preventable cause of disease, disability and premature death in Canada. Am J Public Health. 2002;92:990 996 (Cancer Prevention Study II, American Census Data 1990) Smoking and Post-op Complications Post-op wound infection 12% in smokers 2% in never smokers (p<0.05) Ann Surg. Jul 2003; 238(1): 1 5 Smoking cessation pre-operatively lowers surgical complications by 41% Am J of Medicine 2011; 124(2): 144-154 Smoking and Post-op Complications Odds ratios for major surgical complications in smokers 30 Day Mortality: 1.3 (1.15 1.46) Myocardial infarction: 2.09 (1.80 2.43 Cardiac Arrest: 1.87 (1.58 2.21) Stroke: 1.53 (1.31 1.79) Pneumonia: 1.8 (1.11 2.92) Anesthesiology 2011;114(4):837-46 2
Addiction to Tobacco Addiction to Tobacco Addiction means continued smoking IN SPITE of knowing the harm! There are degrees of addiction AND dependence 50% of Canadian smokers tried to quit last year. 2/3 of those who tried to quit, tried more than once Addiction to Tobacco Approximately 60% of all Canadian smokers intend to quit in the NEXT 6 MONTHS. Addiction to Tobacco Approximately 25% of all Canadian smokers intend to quit THIS MONTH. What can you do? The single, most powerful, preventative intervention in clinical practice. Woolf SH. JAMA 1999; 282(24): 2358-65 What can you do? 1. Influence public policy 2. Counsel patients to quit Inpatients Clinic patients ER patients OB patients Surgical patients 3. Prescribe pharmacotherapy 3
Public policy and smoking cessation What constitutes counselling? LIMITING ADVERTISMENTS PRODUCT LABELLING BAN PRODUCT PLACEMENT SMOKE-FREE ZONES TAXATION PUBLIC EDUCATION MENTION the role of smoking in their health ASK I know it s so challenging, but if there s anything I can do to help OFFER pharmacotherapy INFORM people about programming: addictions services, pharmacies, smokershelpline, ONLINE, APPS! Explore quitting history and help make plans What constitutes counselling Don t forget maintenance counselling!! - follow up after quit - consider checking in (get staff to call?) - make a stressful event kit Quit rates - Impact of Counselling MOST people quit unassisted. BUT 6-12 month quit rates for physician advice <3 minutes: OR 1.3 (1.01 1.6) 3-10 minutes: OR 1.6 (1.2 2.0) >10 minutes: OR 2.3 (2.0 2.7) Fiore MC, Jaen CR, Baker TB, Bailey, WC, Benowitz, NL, Curry, SJ, et al. treating tobacco use and dependence: 2008 update. Clinical practice guideline. Rockville MD: U.S. Department of Health and Human Services. Quit Rates Impact of Pharmacotherapy Nicotine Replacement Therapy vs Placebo OR 1.6 Combined NRT vs Placebo OR 3.0 Cochrane Database Syst rev; 2008 Bupropion vs Placebo OR 2.0 7 RCTs of combined 8000 patients Varenicline vs Placebo OR 3.0 JAMA. 2006; 296(1): 47 63 Quit Rates: Readiness to Quit Helps but is NOT necessary for long-term success! Can change at a moment s notice For example: hospitalization doc: When did you quit smoking? patient: Today 4
Hospital Policy: The Ottawa Model Inpatient smoking cessation programs 6 month smoking abstinence Control group: 18.3% Intervention group: 29.4% OR 1.71 (1.11 2.64 P=0.02) Nicotine Tob Res. 2010 Jan; 12(1): 11-8 Hospital Policy: The Ottawa Model 1. Identification of smoking status 2. Bedside counselling (RT or RN) 3. Pharmacotherapy Nicotine withdrawal order set Smoking cessation order set 4. Automated Follow-up 5. Follow-up counselling Hospital Policy: The Ottawa Model Readmission (all cause): 30 days 13.3% 7.1% ARR 6.1% (CI 2.9% to 9.3% p<0.001) 2 years 45.2 33.6% ARR 11.6% (CI 6.5% to 16.8% p<0.001) Mortality (all cause): 2 years 15.1% 7.9% ARR 7.3% (CI 3.9% to 10.7% p<0.001) Mullen KA, Manuel DG, Hawken SJ, et al Effectiveness of a hospital-initiated smoking cessation programme: 2-year health and healthcare outcomes Tobacco Control 2017;26:293-299. Pharmacotherapy Nicotine patch Nicotine gum Nicotine lozenge Nicotine inhaler Nicotine mouth spray Bupropion (SR) (Zyban) Varenicline (Champix) Degree of Nicotine Dependence Influences likelihood of successful quit Informs intensity of intervention Changes type and amount of pharmacotherapy Can be measured with the Fagerström Test for Nicotine Dependence Fagerström Test for Nicotine Dependence 1. How many cigarettes per day do you usually smoke? 2. How soon after you wake do you smoke your first cigarette? <5 min 6-30 min >30 min 3. Do you find it difficult to stop smoking in non-smoking areas? 4. Which cigarette would you hate most to give up? The first 1 of the morning Other 5. Do you smoke more frequently in the first hours after waking up than during the rest of the day? 6. Does your smoking make you so ill that you are in bed most of the day? 5
Fagerström Test for Nicotine Dependence 1. How many cigarettes per day do you usually smoke? 2. How soon after you wake do you smoke your first cigarette? <5 min 6-30 min >30 min 3. Do you find it difficult to stop smoking in non-smoking areas? 4. Which cigarette would you hate most to give up? The first 1 of the morning Other 5. Do you smoker more frequently in the first hours after waking up than during the rest of the day? 6. Does your smoking make you so ill that you are in bed most of the day? Nicotine Replacement Therapy slower onset than cigarettes More stable plasma levels of nicotine 50% lower blood nicotine levels than smoking. Nicotine Replacement Therapy Concurrent smoking NOT contraindicated! Addiction potential is mild Much safer than smoking in cardiovascular diseases pulmonary diseases Pregnancy NOT a carcinogen Physiological effects on vital signs and perfusion significantly less than those of withdrawal Nicotine Patch 16 or 24 hour delivery formats Benefit of 16 hour format: less insomnia Benefit of 24 hour format: morning cravings Nicotine Patch Traditionally 1ppd: use 21mg patches for 6 weeks, 14mg patches for 2 weeks, 7mg patches for 2 weeks Reality do whatever works for you (multiple patches, longer courses) If relapse occurs, continue or resume the patch Nicotine Patch Onset slow, time to maximal effect 6 hours Dosing <10 cigarettes = 7mg 10 20 = 14mg >20 = 21mg >30 = 21mg + 7mg > 40 = 21mg + 21mg A pack of cigarettes is 20 or 25 cigarettes 6
Nicotine Patch Nicotine Patch Dose titration If usually smokes <30 min from waking, add 7mg If cravings are still high Add a short acting NRT Increase patch by 7mg increments Side effects: itching, burning, insomnia, chest pain and arrhythmias, dyspepsia Cost: approximately 25$ for 7 patches, any strength (ie $100 a month) Nicotine Gum Dosing 2 and 4mg strengths available Use 4mg if smoke <30min after waking 10-20 pieces/day After 6 weeks taper (or not) Onset of action: 30 minutes Nicotine Gum Technique matters! Chew 1-2x then park 1 minute 1 piece lasts 30 minutes Chew every 1-2 hours NOT EFFECTIVE IN ACIDIC ENVIRONOMENT No food or drink 30 minutes before Won t work if swallowed Nicotine Gum Side effects: light-headedness, nausea, chest pain, arrhythmias Caution: Dentures and fillings, TMJ dysfunction Cost: approximately 40$ for 105 (120$ a month for 10 a day) Nicotine lozenge/pastilles Side effects: light-headedness, nausea, chest pain, arrhythmias OK for dentures or TMJ dysfunction Technique: Allow to dissolve slowly and switch sides NOT EFFECTIVE IN ACIDIC ENVIRONOMENT No food or drink 30 minutes before Won t work if swallowed 7
Nicotine lozenge/pastilles Dosing 1,2 and 4mg lozenges Use 1-2 lozenges 8-15 times per day use for 6 months then taper (or not) Onset 30 minutes Cost: 40$ for 88 (136$ per month for 10 a day) Nicotine Inhaler Does NOT work below 10 degrees celcius absorbed through the oral mucosa Onset 30 minutes 6-12 cartridges a day (4mg/cartridge) Nicotine Inhaler Side Effects: headache, nausea, burning, tingling of mouth, chest pain, arrhythmias, salivation, dyspepsia Technique works better if rinse mouth first Place mouthpiece in mouth and inhale deeply Inhale multiple times over 5-20 minutes Nicotine Inhaler Dosing 20 inhalations = 1mg nicotine = 1 cigarette Usually 6-12 cartridges are used per day for 3 months, then reduced gradually (or not) Cost 11$ for 6 cartridges (330$ a month for 6/day) Nicotine Mouth Spray Absorbed via oral mucosa Onset 10 minutes (or sooner) Dose: 1 spray = 1mg nicotine = 1 cigarette (good for impatient people) Cost: 42$ per bottle (150 sprays) Nicotine Mouth Spray Technique Spray into mouth Avoid inhaling Avoid swallowing for a few seconds after spray Technique works better if rinse mouth first Place mouthpiece in mouth and inhale deeply Inhale multiple times over 5-20 minutes 8
Nicotine Inhaler and Mouth Spray hand-mouth habit? Bupropion SR Synthesized in 1968 oldest smoking cessation drug we have. Mechanism of action Unknown Low abuse potential? Bupropion SR Positive side effects: less weight gain, less depression Negative side effects: insomnia,headache, dry mouth, nausea, anxiety, rash risk of seizures 1:1000 Contraindicated if risk factors for seizure! Bupropion SR Interactions Inhibits CYP 450 (2B6) Check CNS and cardiac drugs Metabolism potentiated by anticonvulsants Metabolism slowed by antiretrovirals Bupropion SR Varenicline Dosing: Bupropion SR 150mg OD x3d then BID x 12 weeks Consider extending up to 12 months Quit 8 days later Coverage: may be covered as Bupropion SR Cost: $28/month as Buproprion Entered human clinical trials in 1999 partial agonist of the α 4 β 2 nicotinic acetylcholine receptor mesolimbic system Agonist effect in brain BUT blocks the effects of nicotine in the brain Does NOT block the effects of nicotine on the rest of the body 9
Varenicline Minimal drug interactions Side effects Nausea Insomnia Abnormal dreams Neuropsychiatric events - no Cardiovascular events no Needs to be taken with food Dosing: Varenicline Usual 0.5mg OD x 3 days, then 0.5mg BID x 4 days, then 1.0mg BID x 12+ weeks Start 8 35 days before quit date Titrate! Varenicline Cost 1 month supply $131.09 Half strength $65.54 12 week supply $360 A word about caffeine Smoking potentiates caffeine metabolism After cessation caffeine levels may double or triple! Caffeine toxicity mimics and worsens cravings NRT does not prevent this! A word about e-cigarettes Not regulated Produced by the tobacco industry Proceed with caution Population health impact Gateway to smoking Teen smoking initiation RE-Normalization of smoking after HUGE antismoking public health efforts Surgical patients Cardiac patients Obstetrical patients Psychiatric patients Special populations 10
Thank you! 11