Transcript Document 706280

Tobacco Cessation
Interventions
Lunch and Learn Seminar Series
for Physicians, Family Health
Teams, and other Health/Allied
Health Practitioners
Session 1:
Nicotine Replacement
Therapy
Faculty: Dr. Peter Selby, MBBS, CCFP, MHSc FASAM
Housekeeping
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Please sign-in
Please ensure you have completed Learning Assessment 1
http://www.surveymonkey.com/s/fhtapril2011la1
A link to Learning Assessment 2 will be sent by e-mail
Both Learning Assessments are required for the Letter of
Completion
If you haven’t already, please dial-in via audioconference
Conference #: 1-800-669-6180
Participant Code: 925619
The Adobe Connect webinar will remain ON until 1:00 pm
Announcement by Minister Best of funding for Family Health Teams to
provide free NRT to patients, January 19, 2011
(L-R) Dr. Catherine Zahn, President and CEO of CAMH, Dr. Anne DuVall, President of the
Ontario College of Family Physicians; The Honourable Margarett Best, Minister of Health
Promotion and Sport; and, Dr. Peter Selby, Clinical Director, Addictions Program and Head of
the CAMH Nicotine Dependence Clinic.
Dr. Peter Selby, MBBS, CCFP, MHSc FASAM
[email protected]
(416) 535-8501 ext. 6859
Dr. Peter Selby is the Clinical Director of Addictions Programs and Head
of the Nicotine Dependence Clinic at the Centre for Addiction and Mental
Health as well as Associate Professor in the Departments of Family and
Community Medicine- Dalla Lana School of Public Health-and Psychiatry
at the University of Toronto. He is a Principal Investigator at the Ontario
Tobacco Research Unit. Some of his areas of research include smoking
cessation especially in smokers with co-morbid conditions, and webbased interventions. Dr. Selby is also Principal Investigator of the STOP
study, which is investigating the effectiveness of NRT in different types of
intervention settings. He is involved in the development of knowledge
translation programs in smoking cessation especially in pregnancy and
those with concurrent addiction and mental health problems. Dr. Selby is
the Executive Director of the TEACH project - a continuing education
certificate program in smoking cessation counselling.
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Disclosures
Dr. Peter Selby
Dr. Rita Selby
Spousal: Sanofi-Aventis, Boehringer Ingelheim, Bayer
(Speaker's honorarium, Advisory board)
Schering Canada (Buprenorphine training 2000)
Johnson & Johnson Consumer Health Care Canada
Pfizer Inc. Canada, Pfizer Global
Sanofi-Synthelabo Canada
GSK Canada
Genpharm and Prempharm Canada
NABI Pharmaceuticals
(Paid consultant and advisory board member)
V-CC Systems Inc. and eHealth Behaviour Change
Software Co. (Paid consultant)
Grants: Health Canada, Smoke Free Ontario, MHP, CTCRI, CIHR
Alberta Health Services (formerly Alberta Cancer Board),
Vancouver Coastal Authority
(Research Funding: Principal & Co-Investigators)
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The recipient of the funding is in
compliance with the CMA and the
CPA guidelines / recommendations
for interaction with the
pharmaceutical industry.
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Disclaimer
These materials (and any other materials provided in
connection with this presentation) as well as the
verbal presentation and any discussions, set
out only general principles and approaches to
assessment and treatment pertaining to tobacco
cessation interventions, but do not constitute
clinical or other advice as to any particular
situations and do not replace the need for
individualized clinical assessment and treatment
plans by health care professionals with knowledge
of the specific circumstances.
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Disclaimer: TEACH Curriculum Development
The TEACH Curriculum and slides were developed and compiled with funding
from the Government of Ontario, Ministry of Health Promotion. Content of
slides are primarily based on evidence based guidelines including:
US Guidelines Treating Tobacco Use and Dependence: clinical Practice
Guideline 2008 Update. US Department of Health and Human Services,
Public Health Service
Rethinking Stop-Smoking Medications: Treatment Myths and Medical
Realities OMA Position Paper, January 2008.
The development or delivery of the TEACH curriculum was not influenced or
funded in any part by tobacco industry. TEACH has not received funding
from the tobacco industry. The development of the TEACH curriculum has
not been influenced by pharmaceutical industry. TEACH project did receive a
$10 000 unrestricted grant from Pfizer, to develop video vignettes that are
used in our training. Information presented on pharmacotherapy refers to
generic products only, and recommendations are based on existing
research, including the US guidelines. An algorithm is provided to help
practitioners determine if and which pharmacotherapy is appropriate for a
smoker.
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Session 1: Learning Objectives
1.
2.
3.
4.
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Describe the types of nicotine replacement
options
Apply evidence-based guidelines in
prescribing/recommending nicotine
replacement medications
Introduce “reduce to quit” as an option for
patients who are ambivalent about quitting
Apply new knowledge and skills to your
practice with your patients
# 1 Chronic Disease?
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Percentage of
Relapsed
at
Abstinent
Still
Percentage
6 Months Still Abstinent
Quitting Smoking Unaided:
Analysis of 4 Studies
100
80
60
40
3 - 5%
20
0
0
50
100
150
200
Days Since Quit Date
Long-term smoking abstinence in those who try to
quit unaided = 3%–5%
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Hughes JR et al. (2004)
Immediate Withdrawal Symptoms
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Cravings to smoke
Frustration
Anger
Anxiety
Difficulty concentrating
Restlessness
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Not accounted for by other
mental health or physical
conditions.
Can occur within a few
hours of abstinence from
nicotine
Peak in 1- 4 days
Can last up to six months
or longer
Late-Onset Withdrawal Symptoms
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Nausea
Diarrhea/constipation
Shakiness
Dizzy (typically more mild)
Appetite change
Fatigue (can also last up to six months or longer)
Sleep disturbances
Headaches
Clumsiness
Medications for Quitting Smoking
Medication
Nicotine
gum
Nicotine
lozenge
Nicotine
patch
Nicotine
inhaler
Bupropion
Varenicline
Treatment
length
1-3 months
12 weeks
8-12 weeks
12-24 weeks
7-12 weeks
12 -24weeks
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Main side
effects
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Upset
stomach
Hiccups
Mouth
irritation
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Irregular
heartbeat
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Nausea
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Heartburn
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Hiccups
Disturbed
sleep
(insomnia,
abnormal/vivi
d dreams)
Headache
Site rash
(pruritis
erythema,
burning)
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Dosage
2 mg, 4 mg
2 mg, 4 mg
5 mg,
10 mg,
15 mg
Effectiveness
at six months
or longer†
(OR [CI])
1.66
(1.52-1.81)
3.69 *
(2.74-4.96)
1.81
(1.63-2.02)
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Adapted from Le Foll & George
(2007),
Shiffman et al (2002)
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Irritation
of throat
and nasal
passages
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Sneezing
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Coughing
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insomnia
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Nausea
Dry
mouth
Nausea
Sleep
disturbances
Constipation
Flatulence
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 Dyspepsia
6-12
cartridges
per day
150-300
mg/day
0.5 mg qd to 1
mg bid
2.14
(1.44-3.18)
2.06
(1.77-2.40)
2.83*
(1.91-4.19)
* 4mg, effectiveness
at 6-weeks
Nicotine Replacement Therapy (NRT)
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Provides the body with nicotine to help
minimize withdrawal symptoms and
cravings
Eliminates toxic substances one gets
from cigarettes
Shown to almost double quit rates
Most effective when combined with
counselling
Can be used to help “reduce” smoking
– Can start before quit date
Who should use NRT?
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Not everyone needs NRT
Not everyone can afford NRT
A behavioural intervention may be more
effective for those that smoke 10 cigarettes
or less or are non-daily smokers
Need to assess case by case
– Discuss with client
– Use tools to assess dependence
Ask about tobacco use: How much do you smoke? 0 - ___ cigarettes per day (cpd)?
(one large pack = 25 cpd, one small pack = 20 cpd)
Yes
Algorithm for Tailoring Pharmacotherapy for Smoking Cessation1,2
Advise: As your physician, I am concerned about your tobacco use,
and advise you to quit. Would you like my help?
Motivational
Interviewing
Assess the 5 R’s:
Relevance
Rewards
Risk
Roadblocks
Repetition
No
Cold
Turkey
No response
Has bupropion/NRT failed? N
Is weight gain a concern? N
Want to quit within 7 days? Y
= NRT
(Gum, Patch, Lozenge or Inhaler)
No
Yes
Low importance or confidence (≤ 5)
High importance or confidence (>5)
Assist in Quit Attempt: Would you like to quit abruptly?
Have you tried quitting cold turkey?
Yes
No
Yes: Pharmacotherapy
options
Has NRT failed?
Y/N
Is weight gain a concern? Y
…History of seizures? N
...History of mental illness? N
…Eating disorder?
N
...Allergic to bupropion?
N
...Previous non-responder? N
Want to quit within 7 days? N
= Bupropion SR
Has bupropion/NRT failed? Y
Is weight gain a concern? N
...History of seizures?
N
…History of mental illness?
N
…Eating disorder?
N
...Allergic to varenicline? N
...Previous non-responder? N
Want to quit within 7 days? N
= Varenicline
Choose the following combinations:
1. Two or more forms of NRT
a. patch (15mg) + gum (2mg)
b. patch + inhaler
c. patch + lozenge
2. Bupropion + form of NRT
a. Bupropion + patch
b. Bupropion + gum
No Varenicline with NRT
Arrange Follow Up
1. Monitor carefully
2. Consider contraindications
3. Consider comorbidities and specific
pharmacotherapy
4. Consider dual purpose medications
5. If after 4 weeks no response,
consider alternative 1st line
medications.*
@ 4 weeks
Partial response
Consider combination
pharmacotherapy, based on:
1. failed attempt with
monotherapy
2. breakthrough cravings
3. level of dependence
4. multiple failed attempts
5.experiencing nicotine withdrawal
Assess Readiness: Given everything going on in your life, on
a scale of 0-10, where 0 is lowest…
How important is it for you to quit smoking?
How confident are you that you can quit smoking?
Developed by Peter Selby, MBBS, CCFP. This algorithm is based on: Bader, McDonald, Selby, Tobacco Control, 2009: 18: 34-42. Fiore MC et al., Clinical Practice Guideline:
Treating Tobacco Use and Dependence, May 2008. Gray, Therapeutic Choices: 5th Ed., 2007, Chapter 10: 147-157.
Reduce to Quit (RTQ)
Step 1: (0-6 weeks)
- Smoker sets a target for no. of cigarettes per day to cut down
and a date to achieve it by (at least 50% recommended)
- Smoker uses gum to manage cravings
Step 2: (6 weeks up to 6 months)
- Smoker continues to cut down cigarettes using gum
- Goal should be complete stop by 6 months
- Smoker should seek advice from HCP if smoking has not
stopped within 9 months
Step 3: (within 9 months)
- Smoker stops all cigarettes and continues to use gum to relieve
cravings
Step 4: (within 12 months)
- Smoker cuts down the amount of gum used, then stops gum use
completely (within 3 months of stopping smoking)
*N.B. for 2nd line medications (clonidine and nortriptyline), see
guidelines.
Nicotine Patch
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24 hour continuous dose of nicotine
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16 hour continuous dose of nicotine
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21, 14 and 7mg patches (applied every 24h)
15, 10, and 5 mg (applied every 16h)
Off-label use – higher than 21mg dose for highly
dependent smokers
Potential side effects
– May cause sleep disturbance or nightmares
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Remove before bed
Skin irritation
Clear patch
How to Use the Patch
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Apply to clean dry area above the waist, rotating
site daily
Remove old patch before applying new one
Do not use lotion, moisturizing soap
Touch only small corner of adhesive
Ensure complete adherence of patch
Wash hands in water after application
Discard old patch out of reach of children, animals
– can be harmful
Nicotine Gum
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Provides body with nicotine for 20-30 minutes
2 & 4 mg doses
Responds to the immediate urge to smoke
Oral gratification
Must be able to chew gum (i.e. no dentures, TMJ)
Potential side effects
– Upset stomach, hiccups
Chewing too fast: review
 proper use of gum
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How to Use Nicotine Gum
2 mg
Use in combination with
patch as a breakthrough
medication; typically if smoke
<pack/day
4 mg
Use in combination with
patch or alone; typically if
smoke > pack/day
 Chew one piece at a time, no more
than 1 per hour
 Use every hour – if not in
combination with patch
 Up to 20 pieces per day as needed
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How to Use Gum (2)
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Chew and park in between teeth and cheeks
Absorbed via buccal mucosa
Repeat chew every minute or so
Each piece lasts approximately 30 minutes
Do not chew within 30 minutes of
caffeine/acidic products
Nicotine Inhaler
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Small, cigarette-shaped vaporizer
Satisfies sensory and ritualistic aspect of smoking
One cartridge contains 10mg of nicotine and 1mg
menthol
Absorbed in oral cavity, throat and upper respiratory
tract by “puffing”
Potential side effects
– throat & mouth irritation, headache, nausea,
indigestion(<20%)
How to use the Nicotine Inhaler
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Single cartridge equivalent to 4-5 cigarettes
- or 20 minutes of continuous use
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Puff like cigar, not deeply into the lungs
May notice a burning, warm or cool sensation when
inhaling – OK unless it becomes bothersome
Clean inhaler on a regular basis with soap and water
Can use up to 6 cartridges/day – use as needed
Nicotine Lozenge
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1 mg and 2 mg dosages
Max of 15 mg / day should be used
Slowly suck until strong taste is noticed
Rest lozenge between cheek and gum
Wait 1 minute or until taste fades
Repeat sucking
Each lozenge takes about 30 minutes to consume
Use only 1 at a time
Reduce to Quit (RTQ)
Using NRT Gum
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WHO
Smokers not ready or unable to quit abruptly
GOAL
50% reduction in daily cigarette consumption
between 6 weeks and 4 months of treatment
HOW
Self-titrate to the level of nicotine to reduce
withdrawal symptoms. A reduction of
cigarette consumption should be continued
until complete cessation can be attempted
WHEN
Craving to smoke in order to prolong smokefree intervals for as long as possible
Shiffman, Ferguson, & Strahs, 2009
RTQ
Using NRT Gum
HOW
LONG
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HOW
MUCH
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If such a reduction has not been achieved by 4
months, the patient should be further counselled
and/or re-evaluated.
A quit attempt should be made as soon as the
patient feels ready – but not later than 6 months
after the start of treatment.
Regular use of the gum beyond 12 months in the
Quitting Gradually program is generally not
recommended.
Maximum of 20 pieces gum / day
Shiffman, Ferguson, & Strahs, 2009
Quitting “Gradually” Comparable to
Abrupt Cessation
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Recent meta-analysis of 3,670 participants and
10 RCT’s indicates similar cessation rates
Clients can be given the choice
Gradual cessation can be supplemented with
behavioural and self-help interventions
Linden, Aveyard, & Hughes, 2010
Dependence Potential of
Nicotine Delivery Devices
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Dependence potential tends to correlate with
time to peak concentration
Because the nicotine is delivered differently,
more slowly and at lower doses in NRT, it is
significantly less addictive then smoking
Le Houezec, 2003
Dependence Potential of
Nicotine Delivery Devices
Reaches brain within 15-20 secs for
non-daily and less dependent and 30
secs for daily, dependent smokers
0
1 hr
Gum, lozenge,
inhaler peaks in 20
– 30 minutes
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Rose et al., 2010
2 hrs
Patch peaks
in 2 – 6 hrs
Questions?
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Case Example: Jeanne (1)
Jeanne is a 54 year old, divorced female who reports
smoking 30-35 cigarettes per day. She began smoking at
the age of 14 with her parents in the family home. She
was referred to the clinic by her respirologist as she was
diagnosed with chronic obstructive pulmonary disease
(COPD) 3 months prior.
Jeanne lives alone but she smokes in her apartment and
in her car. Her friends and family who smoke are allowed
to smoke in her home and car. She also smokes at work
in a courtyard with her co-workers.
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Case Example: Jeanne (2)
Jeanne has tried to quit 3 times in her lifetime. She has
tried acupuncture, going "cold turkey" and using the
nicotine patch. She reports that none of these strategies
really worked for her. Her longest quit attempt was for 7
days, because she was hospitalized. She relapsed within
a day of her discharge from the hospital and resumed
smoking between 30-35 cigarettes per day immediately.
When she doesn't smoke she gets strong cravings,
“obsessed with thoughts of smoking,” extremely irritable,
anxious and unable to concentrate.
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Case Example: Jeanne (3)
Jeanne reports drinking alcohol socially about once per
week, approximately 2-3 glasses of wine per occasion.
She reports a history of depression although she is not
currently taking any medication or receiving any type of
support for this issue. She reports that medication in the
past has not made much of a difference.
Jeanne has been to hospital emergency rooms twice in the
past month because of extreme difficulty breathing. She
reports feeling enormous pressure to quit smoking
because of her diagnosis of COPD and she reports that
she feels ashamed to discuss her smoking with her
respirologist.
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Case Example: Jeanne (4)
Jeanne would like to completely quit smoking
but she has no set date in mind and she has no
idea how to achieve this, because everything
she has tried in the past has failed. Ideally, she
hopes to have quit completely within 6 months.
She rates the importance of quitting smoking at
a 10/10 and her confidence level as a 4/10.
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Discussion Questions
Jeanne states that she has tried the patch in the past and
that it did not work for her.
1. Why might this be the case?
2. Does her past experience with the patch rule out NRT
as a first option?
3. Given Jeanne’s tobacco use history and level of
dependence, what dosage of NRT would you start
with?
4. How will you determine optimal dosage and
effectiveness of this strategy?
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For reflection/discussion…
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What will you take a away from this session?
How will your learning impact your clinical
practice?
What is one thing you will commit to trying with
patients in the coming week?
Resources
Nicotine Does Not Promote Lung Cancer Growth in Mouse Models
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American Association for Cancer Research
CAMH Knowledge Exchange
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Available at http://knowledgex.camh.net/
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A website developed for professionals
working in primary care and in the
mental health and addictions field,
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Provides easy-to-access, practical online
information and tools
Provides primary care providers with the
CAMH–St. Joseph’s Health Centre
‘Addictions Toolkit’ which includes links to
resources for patients
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Primary Care ADDICTION TOOLKIT
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CAN-ADAPTT
The Canadian Action Network for the Advancement, Dissemination and
Adoption of Practice-informed Tobacco Treatment (CAN-ADAPTT) is a
Practice-Based Research Network (PBRN) committed to facilitating research
and knowledge exchange among those who are in positions to help smokers
make changes to their behaviour (e.g., practitioners, healthcare/service
providers) and researchers in the area of smoking cessation.
Members will receive:
 Updates on CAN-ADAPTT’s research and funding opportunities
 Access to CAN-ADAPTT’s Tobacco Control Guidelines
 Access to CAN-ADAPTT’s discussion board
 Notices of General Meetings
And may also benefit by:
 Networking/collaborating with other health care/service providers
 Exchanging knowledge and expertise of better smoking cessation practices
To become a member, simply visit www.can-adaptt.net
and click "register" to fill out the short registration form found on the home
page.
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Other Resources
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www.smokershelpline.ca
www.dart.on.ca
http://Knowledgex.camh.net
http://www.samhsa.gov
http://www.niaaa.nih.gov
Lung Association Reference: 1888 344 LUNG
http://www.tobaccocontrol.bmj.com
Remember …
Online Course Evaluation:
http://www.surveymonkey.com/s/fhtapril2011eval
 Learning Assessment 2:
http://www.surveymonkey.com/s/fhtapril2011la2
 This must be completed by April 27th in order to receive your
Letter of Completion
 STOP Study Data Survey:
http://www.surveymonkey.com/s/fhtstopdata2
 These links will also be sent out by email!!
 Next session: May 25th, 2011:
Brief Tobacco Screening and Assessment
**Application period will be open April 21st**

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Thank
you!
Copyright
Copying or distribution of these materials is
permitted providing the following is noted on
all electronic or print versions:
© CAMH/TEACH
No modification of these materials can be
made without prior written permission of
CAMH/TEACH.
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