Smoking Cessation 2009 Preventing Strokes One At a Time

Smoking Cessation

2009

Preventing StrokesOne At a Time

Smoking Cessation

At the end of this presentation the participant will

Commit to incorporating smoking cessation into practice as recommended in the Canadian Best Practice Recommendations for Stroke Care, 2008

Be competent in implementing the 5A’s into smoking cessation initiatives

Be able to counsel patients on using NRT Be aware of local resources for smoking

cessation.

Learning Objectives

Smoking Realities

Tobacco kills 1 person every 6 seconds WHO Report on the Global Tobacco Epidemic, 2008

Smokers who smoke 20 cigarettes or more/day increase their stroke risk 2-4 times CMAJ 2008;179(12 Suppl):E1-E93

There is no safe level of smoking. OMA, 2008 Jan:75(1): 22-34

Smokers have poorer functional outcomes after stroke than non-smokers.

Cerebrovascular Disease, 2006:21 (4): 260-265

Smoking Prevalence in Canada

BC 15% Alberta 21% Saskatchewan 22% Manitoba 22% Ontario 16%

Quebec 22% New Brunswick

22% Nova Scotia 21% PEI 20% Newfoundland 21%

Health Canada. Canadian Tobacco Use Monitoring Survey 2005, Summary of Annual Results.

19%. Almost 5 Million Smokers (1995)

Canadian Best Practice Recommendations for Stroke Care

2.1 Lifestyle & Risk Factor Management Persons at risk of stroke and patients who

have had a stroke should be assessed for vascular disease risk factors and lifestyle management issues (Diet, Sodium intake, Exercise, Weight, Smoking, and Alcohol intake)

They should receive information and counseling about possible strategies to modify their lifestyle and risk factors.

CMAJ 2008;179(12 Suppl):E1-E93 2.1

Canadian Best Practice Recommendations for Stroke Care, 2008 #2.1v

2.1.v. Smoking Smoking cessation and a smoke free

environment: nicotine replacement therapy and behavioural therapy.

For nicotine replacement therapy, nortriptyline therapy, nicotine receptor partial agonist therapy and/or behavioral therapy should be considered.

CMAJ 2008;179(12 Suppl):E1-E93 21v.

Smoking Cessation: Role of Healthcare

Health care professionals have a golden opportunity to initiate smoking cessation programs Credible Knowledgeable Supportive Resourceful Critical Incident

Smoking Cessation: Nicotine Addiction

A tenaciously addictive drug Nicotine withdrawal syndrome

irritability, anger, restlessness, impatience, difficulty concentrating,

depression, anxiety symptoms vary widely in intensity and duration

(may last several weeks or months)

Tobacco use is also conditioned behavior

The Cycle of Nicotine Addiction

Nicotine binding causes an increase in release of dopamine

Dopamine gives feelings of pleasure and calm The dopamine decrease between cigarettes leads to

withdrawal symptoms of irritability and stress The smoker craves nicotine to restore pleasure and

calmness Smokers generally titrate their smoking to achieve

maximal stimulation and avoid symptoms of withdrawal and craving

Jarvis. BMJ. 2004;328:277-279; Picciotto et al. Nicotine Tob Res. 1999;1:S121-S125.

What’s in a cigarette?

Butane (lighter fluid) Cadmium (batteries) Acetic Acid (vinegar) Methane (Sewar gas) Arsenic (poison) Carbon monoxide Hexamine (BBQ

lighter)

Methanol (rocket fuel) Paint Ammonia (toilet

cleaner) Nicotine (insecticide) Toluene (industrial

solvent) Stearic Acid (candle

wax)

Role of Environmental Stimuli in Nicotine Dependence

Play a role in reinforcing nicotine dependence Non-nicotine stimuli are important in both

motivating and maintaining smoking behavior Role of environmental vs pharmacologic stimuli in

nicotine dependence varies between men and women

Direct pharmacologic effects of nicotine are necessary but not sufficient to explain tobacco dependence; these effects must take into account the environmental/social context in which the behavior occurs

Direct pharmacologic effects of nicotine are necessary but not sufficient to explain tobacco dependence; these effects must take into account the environmental/social context in which the behavior occurs

Caggiula et al. Physiol Behav. 2002;77:683-687.

Smoking Cessation: A Comprehensive Approach

Two key components Pharmacological action of the nicotine Behavioural factors

Most effective methods of smoking cessation combine pharmacotherapy with advice and behavioural support

Jarvis MJ. BMJ 2004;328:277-279.Coleman T. BMJ 2004;328:397-399.Rigotti NA. N Engl J Med 2002;346:506-512.Hughes JR. CA Cancer J Clin 2000;50:143-151. O'Donnell DE et al. Can Respir J 2004;11(SupplB):3B-

59B

An Approach to Smoking Cessation

Identification Documentation Counseling Pharmacotherapy Long-term follow-up

“The Ottawa Model”

Reid RD, Pipe AL, Quinlan B. Can J CardiolCan J Cardiol 2006;22:775-780

Smoking Cessation: Routine Clinical Practice

“Initial, effective smoking cessation counseling can be delivered as part of routine clinical practice in as little as 2 minutes.”

Andrew Pipe, MD, CM Chief, Division of Prevention and Rehabilitation, University of Ottawa Heart Institute

Brief Intervention Using the 5A’s

ASK: Identify and document tobacco use

ADVISE: In a clear, strong, personalized manner, urge smoker to quit

ASSESS: Is the smoker ready to make a quit attempt?

ASSIST: Use counselling and pharmacotherapy to help him/her quit

ARRANGE: Schedule follow-up contact Preferably within 1 week after the quit date

Fiore MC et al. JAMA 2002;288:1768-1771

Documenting

Copied with permission, Ottawa Heart Institute, The Ottawa Model

Ask…

Have you used any form of tobacco in the last 6 months?

Copied with permission, Ottawa Heart Institute, The Ottawa Model

Advise…

“I know quitting smoking can be difficult. We’re here to help.”

“The most important thing we can do for your health is to help you quit smoking.”

Be Clear, Strong, Personalized

Copied with permission, Ottawa Heart Institute, The Ottawa Model

Assess

Copied with permission, Ottawa Heart Institute, The Ottawa Model

How important is it for you to quit smoking?

How confident are you that you could succeed in quitting for good?

1 2 3 4 5

Assess…Readiness

1 2 3 4 5

Assess Readiness to Quit

Ready to Quit within 30 days-Develop a quit plan

Not Ready to Quit-Provide self help and follow-up

Assist

Assist in setting a quit date Pharmacotherapy as appropriate Provide educational material based

on readiness to quit Provide information on community

quit smoking programs

Assist

Enhancing Motivation to QuitRelevanceRisksRewardsRoadblocksRepetition

Arrange

Offer follow-up support

Referral to local community resources

Smoker’s Quit Lines

The “Ottawa Model” for smoking cessation

Includes an automated telephone call Asking readiness:

o Ready to Quit/ Not Ready to Quit/ Recently Quit

2-3 minutes each call Providing access to a smoking cessation

counselor

Choosing Pharmacotherapy

All smokers trying to quit should be offered medication management

The following factors may influence selection of medications insurance coverage patient costs likelihood of adherence dentures dermatitis

Contraindications

Pharmacotherapy for Tobacco Dependence

Nicotine Replacement Therapy (NRT) Long Acting

o Patch

Short Actingo Inhaler o Gumo Lozengers

Nicotine Replacement Therapy

Benefits

• NO Carbon monoxide ! NO oxidants !

Helps to minimize withdrawal symptoms and cravings

4,999+ other chemicals, mutagens, etc are not present!

Almost doubles quit rates

Smoking Cessation “Station”

The following slides may be used in smoking cessation station

Myths and Realities of Nicotine Replacement Therapy

Handout “Smoking Cessation and Nicotine

Replacement Therapy Myths and Realities”

Nicotine Replacement GuidelinesWeeks 1 to 6 Weeks 7 & 8 Weeks 9 &

10

20 or more cigarettes/day

STEP 1 - 21mgOne patch daily

STEP 2 - 14mg One patch daily

STEP 3 - 7mgOne patch daily

10-20 cigarettes/day

STEP 2 - 14mgOne patch daily

STEP 3 - 7 mgOne patch daily

< 10 cigarettes/day

STEP 3 - 7mgOne patch daily

If you smoke within 30 min of waking, you may add another form of NRT

Gum/Inhaler /Lozenge

Gum/Inhaler/Lozenge

Gum/Inhaler/Lozenge

(USED WITH PERMISSION from University of Ottawa Heart Institute Smoking Cessation Program, The Ottawa Model)

A Sample of a Titration Protocol for Nicotine Replacement Therapy

An example: If after initial application of Nicotine patch,

withdrawal or cravings persist, consider adding short acting form of Nicotine Replacement Therapy, such as inhaler, gum or lozenge.

If after 24 hours, cravings continue to persist, consider adding a 7mg Nicotine patch. (increase by 7mg increments at a time only).(USED WITH PERMISSION from University of Ottawa Heart

Institute Smoking Cessation Program)

Nicotine Replacement TherapyINHALER 10 mg nicotine per

cartridge Nicotine delivered to

oral cavity, throat & upper respiratory tract (a small fraction reaches the lungs)

Puff as needed to manage cravings

Avoid eating or drinking 15 minutes before/during use

Cost: $40/week

PATCH Apply to a clean,

dry, non hairy area on upper part of body (arms, chest, back)

Replace patch every 24 hours

Remove at bedtime if difficulty sleeping at night

Cost: $25-30/week

(USED WITH PERMISSION from University of Ottawa Heart Institute Smoking Cessation Program)

Nicotine Replacement Therapy

GUM/LOZENGE: Often used in break through cravings Teach patient proper technique Gum: “bite and park” technique, chew

for 30 minutes Lozenge: allow to dissolve slowly

Smoking Cessation

Buprion

Rationale: smoking and depression Relieves psychological cravings and

physiological withdrawals

Varenicline Provides relief from craving & withdrawal--

Agonist effect Blocks satisfaction and rewarding effects of

nicotine--Antagonist effect

USED WITH PERMISSION from University of Ottawa Heart Institute Smoking Cessation Program

Canadian Best Practice Recommendations for Stroke Care, updated 2008

www.canadianstrokestrategy.ca