Transcript Document

Preventing Strokes
One At a Time
Smoking Cessation
2009
Smoking Cessation
Learning Objectives
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.
Smoking Realities
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Tobacco kills 1 person every 6 seconds
WHO Report on the Global Tobacco Epidemic, 2008
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Smokers who smoke 20 cigarettes or more/day
increase their stroke risk 2-4 times
CMAJ 2008;179(12 Suppl):E1-E93
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There is no safe level of smoking.
OMA, 2008 Jan:75(1): 22-34
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Smokers have poorer functional outcomes after
stroke than non-smokers.
Cerebrovascular Disease, 2006:21 (4): 260-265
Smoking Prevalence in Canada
19%. Almost 5 Million Smokers (1995)
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BC 15%
Alberta 21%
Saskatchewan 22%
Manitoba 22%
Ontario 16%
Health Canada. Canadian Tobacco Use Monitoring Survey 2005,
Summary of Annual Results.
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Quebec 22%
New Brunswick 22%
Nova Scotia 21%
PEI 20%
Newfoundland 21%
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)
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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
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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
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Health care professionals have a golden
opportunity to initiate smoking cessation
programs
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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
behavior
use is also conditioned
The Cycle of Nicotine Addiction
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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?
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Butane (lighter fluid)
Cadmium (batteries)
Acetic Acid (vinegar)
Methane (Sewar gas)
Arsenic (poison)
Carbon monoxide
Hexamine (BBQ
lighter)
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Methanol (rocket fuel)
Paint
Ammonia (toilet cleaner)
Nicotine (insecticide)
Toluene (industrial
solvent)
Stearic Acid (candle wax)
Role of Environmental Stimuli in Nicotine Dependence
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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
Caggiula et al. Physiol Behav. 2002;77:683-687.
Smoking Cessation: A Comprehensive
Approach
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Two key components
 Pharmacological action of the nicotine
 Behavioural factors
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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):3B59B
An Approach to Smoking Cessation
“The Ottawa Model”
Identification
 Documentation
 Counseling
 Pharmacotherapy
 Long-term follow-up
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Reid RD, Pipe AL, Quinlan B. Can J Cardiol 2006;22:775-780
Smoking Cessation: Routine Clinical Practice
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“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
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ASK: Identify and document tobacco use
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ADVISE: In a clear, strong, personalized manner,
urge smoker to quit
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ASSESS: Is the smoker ready to make a quit
attempt?
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ASSIST: Use counselling and pharmacotherapy to
help him/her quit
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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
Assess…Readiness
How important is it for you to quit smoking?
1
2
3
4
5
How confident are you that you could succeed
in quitting for good?
1
2
3
4
5
Assess Readiness to Quit
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Ready to Quit within 30 days
-Develop a quit plan
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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
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Assist
Enhancing Motivation to Quit
Relevance
Risks
Rewards
Roadblocks
Repetition
Arrange
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Offer follow-up support
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Referral to local community resources
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Smoker’s Quit Lines
The “Ottawa Model” for smoking cessation
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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
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All smokers trying to quit should be offered
medication management
The following factors may influence selection of
medications
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insurance coverage
patient costs
likelihood of adherence
dentures
dermatitis
Contraindications
Pharmacotherapy for Tobacco
Dependence
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Nicotine Replacement Therapy (NRT)
 Long Acting
o
Patch
 Short Acting
o
o
o
Inhaler
Gum
Lozengers
Nicotine Replacement Therapy
Benefits
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NO Carbon monoxide ! NO oxidants !
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Helps to minimize withdrawal symptoms
and cravings
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4,999+ other chemicals, mutagens, etc are
not present!
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Almost doubles quit rates
Smoking Cessation “Station”
The following slides may be used in
smoking cessation station
Myths and Realities of Nicotine Replacement
Therapy
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Handout
 “Smoking Cessation and Nicotine Replacement
Therapy Myths and Realities”
Nicotine Replacement Guidelines
Weeks 1 to 6
Weeks 7 & 8
Weeks 9 & 10
20 or more
cigarettes/day
STEP 1 - 21mg
One patch daily
STEP 2 - 14mg
One patch daily
STEP 3 - 7mg
One patch daily
10-20
cigarettes/day
STEP 2 - 14mg
One patch daily
STEP 3 - 7 mg
One patch daily
< 10
cigarettes/day
STEP 3 - 7mg
One patch daily
If you smoke within
30 min of waking,
you may add another
form of NRT
Gum/Inhaler
/Lozenge
Gum/Inhaler
/Lozenge
(USED WITH PERMISSION from University of Ottawa Heart
Institute Smoking Cessation Program, The Ottawa Model)
Gum/Inhaler
/Lozenge
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.
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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 Therapy
INHALER
 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
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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
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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