LMCC/Smoking Cessation

Epidemiology

• single most preventable cause of illness and death
• 70% of smokers will see a physician every year
• of those aged 15 or older:
  • 22% are current smokers
  • average 16 cigarettes /day
  • highest prevalence between 20-24
  • higher in teen girls than teen boys
  • more individuals are quitting than in past

Management

General approach

• identify users, elicit their smoking habits and establish the results of prior quit attempts
• every smoker should be offered treatment
• Highest yield technique is to host >4 counselling session of > 10 minutes in length over a 12 month period
  • 14% will remain abstinent with counselling vs. 10%

Willing To Quit?

The 5 A's for patients willing to quit

Ask if patient smokes

Advise patient to quit

Assess willingness to quit

Assist in quit attempt

Arrange follow-up

Use a STAR to assist patients in developing a quit plan

Set quit date

Tell family and friends

Anticipate challenges

Remove tobacco products

• if a patient is pregnant advise them to quit without using pharmacotherapy

Nicotine Replacement Therapies (NRT)

• 20% abstinence @ 12 months
• Form of NRT is irrelevant to abstinence rates
• Contraindications: recent MI, serious or worsening angina, serious arrhythmia

Type	Dosage	Comment	Side Effects
Nicotine gum	2mg if < 25 cig/day 4mg if > 25 cig/day 1 piece q1-2h for 1-3 months, maximum 24 pieces/day	Chew until "peppery" taste, then place between gum and cheek to maximize absorption, continuing for 30 minutes	Usually transient: mouth soreness hiccups dyspepsia jaw ache
Nicotine Patch	Use for 8 weeks 21 mg/d x 4 weeks 14mg/d x 2 weeks 7mg /d x 2 weeks	Start with lower dose if <10cigs/day Change to patch q24h and rotate sides	skin irritation insomnia
Nicotine Inhaler	6-16 cartridges per day for 3 months with gradual tapering afterward		Cough irritation rhinitis
Nicotine Nasal Spray	1-2 sprays/hour Do not exceed 10 sprays per hour Do not exceed 80 sprays per day	Higher rate of dependence	irritation rhinitis

Buproprion (Zyban)

• 21% abstinence @ 12 months
• inhibits dopamine and norepinephrine reuptake
• patient is to smoke for first 2 weeks of treatment and then completely stop
• can be used with nicotine replacement therapy
• Contraindications: seizure disorder, eating disorder, MAOI use in past 15 days, use of Wellbutrin (an alternative labelling of buproprion marketed for depression)
• side effects: insomnia, dry mouth

Unwilling To Quit?

The 5 R's for patients unwilling to quit

Relevance to patient Risks of smoking Rewards of quitting Roadblocks to quitting Repetition of motivational intervention at each visit

Risks of smoking

Short term:

• shortness of breath
• asthma exacerbation
• impotence
• infertility
• pregnancy complications

Long term:

• increased risk of heart attack and stroke
• chronic obstructive pulmonary disease (COPD)
• lung cancer/other cancer

Environmental:

• higher cancer risks in spouse and children
• increase in sudden infant death syndrome
• asthma/respiratory infections in housemates

Benefits of smoking cessation

• improved health
• improved finances
• improved taste and smell
• sets a good example for children

Obstacles to smoking cessation

• fear of withdrawl
• weight gain
• fear of failure
• lack of support

Repetition

• reassure an unsuccessful patient that most people have multiple attempts before succeeding.

Recent quitter?

• the highest rate of relapse is within the first 3 months, therefore prevention at this time is imperative!
  • minimal practice: congratulate on success and encourage ongoing abstinence, reviewing the benefits of quitting and any unforeseen problems
  • prescriptive interventions can be used to address problems of weight gain, negative mood, withdrawal and lack of support.

References

Toronto Notes 2005