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October 20, 2008

The Ottawa Model for Smoking Cessation for Smokers with Cerebrovascular Disease Robert D. Reid, Ph.D. October 20, 2008. Disclosures. I have received research support in the past 12 months from: PFIZER I have received consulting fees in the past 12 months from:

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October 20, 2008

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  1. The Ottawa Model for Smoking Cessation for Smokers with Cerebrovascular DiseaseRobert D. Reid, Ph.D. October 20, 2008

  2. Disclosures • I have received research support in the past 12 months from: • PFIZER • I have received consulting fees in the past 12 months from: • PFIZER, MINISTRY OF HEALTH PROMOTION, HEALTH CANADA

  3. Acknowledgements

  4. Smoking contributes to 12% to 14% of all stroke deaths Smoking may potentiate the effects of other stroke risk factors Smoking increases stroke risk Acutely: effects on thrombus formation Chronically: increased burden of atherosclerotic disease Smoking and Stroke MRI of BrainWith an Acute Ischemic Stroke Goldstein et al. Stroke. 2006;37:1583-1633; http://www.ucihs.uci.edu/stroke/whatisastroke.shtml. Accessed October 19, 2007.

  5. Smoking: Increased Progression of Carotid Atherosclerosis • Both active smoking and environmental tobacco smoke exposure are associated with increased progression of carotid atherosclerosis. 43.0 38.8 31.6 Progression of Intima-Medial Thickness, µm/3 y (95% CI)a 32.8 25.9 NonsmokerswithoutExposureb NonsmokerswithExposureb Ex-smokers withoutExposureb Ex-smokers with Exposureb CurrentSmokers aAdjusted for demographic characteristics, cardiovascular risk factors, and lifestyle variables (risk factor model and Keys score, education, leisure activity, body mass index, and alcohol use). bTo environmental tobacco smoke.Howard et al. JAMA. 1998;279(2):119-124.

  6. Smoking: Increased Risk of Fatal and Nonfatal Stroke in Women Relative Risk (95% CI)a Nonsmokers 1-14 15-24 ≥25 Cigarettes/Day Current Smokers aThe probability of an event (developing a disease) occurring in exposed people compared with the probability of the event in nonexposed people. Adjusted for age, follow-up period, history of diabetes, hypertension, high cholesterol levels, and relative weight (in 5 categories).Colditz et al. N Engl J Med. 1988;318(15):937-941.

  7. Smoking: Increased Risk of Hemorrhagic Stroke Nonsmokers (n=20,339) <15 Cigarettes/day (n=1914) 15 Cigarettes/day (n=3265) Relative Risk (95% CI)a 2.06 4.04 1.74 3.43 2.39 2.89 Total Hemorrhagic Stroke Intracerebral Hemorrhage Subarachnoid Hemorrhage aThe probability of an event (developing a disease) occurring in exposed people compared with the probability of the event in nonexposed people.Adjusted for age, exercise, alcohol consumption, body mass index, history of hypertension, and history of diabetes. Kurth et al. Stroke. 2003;34:2792-2795.

  8. Smoking: Increased Stroke Mortality • Cigarette smoking increases the risk of mortality from stroke in men Mortality Ratea 1-15 15-24 ≥25 Cigarettes/Day Current Smokers aTwenty-year age-adjusted mortality per 10,000 person-years for men. P<.014 for trend. Hart et al. Stroke. 1999;30:1999-2007.

  9. Summary: Smoking and Stroke • Smoking contributes to 12% to 14% of all stroke deaths • Increased risk of • Progression of carotid atherosclerosis • Stroke • Hemorrhagic stroke • Intracerebral hemorrhage • Subarachnoid hemorrhage • Increased stroke-related mortality

  10. …an exquisitely crafted drug delivery device

  11. Nicotine Addiction Nicotine rewards smoking Nicotine alters the brain Psychological and social forces are at work Dopamine release Signal to notice and repeat Acquired ‘drive’ (hunger) Urge to smoke if abstinent for a while Reminders (cues) increase urge Pairing of stimuli Beliefs about stress control Identity Camaraderie

  12. ‘‘Why do people smoke . . . to relax; for the taste; to fill the time; something to do with my hands. . . . But, for the most part, people continue to smoke because they find it too uncomfortable to quit’’Philip Morris, 1984 Philip Morris. Internal presentation. 1984, 20th March; Kenny et al. Pharmacol Biochem Behav. 2001;70:531-549.

  13. Nicotine Withdrawal • Nicotine withdrawal syndrome consists of both somatic and affective symptomatology Withdrawal Syndrome Irritability, frustration, or anger Insomnia/sleep disturbance Anxiety (may increase or decrease with quitting) Increased appetite or weight gain Dysphoric or depressed mood Restlessness or impatience Difficulty concentrating American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision. Washington, DC: American Psychiatric Association; 2000.

  14. Nicotine addiction is a chronic, relapsing condition1-3 Nicotine Addiction: A Chronic Relapsing Medical Condition • True drug addiction, similar to that of other drugs of abuse1,3 • Requires long-term, repeated clinical intervention4 • Nicotine addiction needs to be viewed as a chronic disease5 • Remission can be achieved with the proper interventions and treatments5 • Relapse is • Common2,4 • The nature of addiction, not the failure of the individual1 • Long-term smoking abstinence in those who try to quit unaided = 5%6 • Most relapse within the first 8 days4 • O'Donnell DE et al.Can Respir J 2004;11(SupplB):3B-59B. • Jarvis MJ. BMJ 2004;328:277-279. • Foulds J. Int J Clin Pract 2006;60:571-576. • Hughes JR. CA Cancer J Clin 2000;50:143-151. • Optimal Therapy Initiative (University of Toronto). Smoking cessation guidelines: How to treat your patient's tobacco addiction, 2000. • Fiore MC et al.JAMA 2002;288:1768-1771.

  15. A Comprehensive Approachto Smoking Cessation • Smoking addiction has two main components that need to be addressed: one related to the pharmacological action of inhaled nicotine and the other related to behavioural factors1-3 • Advice and behavioural support increase the chances of quitting successfully4,5 Most effective methods of smoking cessation combine pharmacotherapy with advice and behavioural support2,4 • 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.

  16. Identification of smokers Documentation Counseling Ready and not ready to quit, recently quit Pharmacotherapy Ready and not ready to quit Self-help materials Ready and not ready to quit Long-term follow up (IVR) Linked to nurse counsel +/or community resources The Ottawa Model for Smoking Cessation

  17. > 6500 admissions/yr > 1400 smokers/yr Assistance provided to 96% of smokers Ottawa Model at the University of Ottawa Heart Institute Long-term cessation rate pre-Ottawa Model:35% Long-term cessation rate with Ottawa Model:50%!

  18. Implementation of the Ottawa Model in Canadian Hospitals

  19. Ottawa Model effectiveness in 9 hospitals: 6-month continuous abstinence rate pre- vs. post-implementation Unadjusted OR = 1.9 (1.2 to 3.1) p=.008 Abstract submitted to SRNT 2009 (Dublin)

  20. Ottawa Model for Smoking Cessation - Outpatient

  21. Patient Waiting Room Survey • Tobacco use • Past 6 months • Past 7 days • Smoking history • Time to first cigarette • Importance and confidence • Concerns • Past use of medications

  22. Smoking Cessation Consult Form • Physician and nurse complete • Advise • Assess willingness to quit • Assist • Patient preferences • Contraindications • Select pharmacotherapy • Set quit date • Arrange follow-up

  23. Pharmacotherapy for Nicotine Dependence1-4 • Nicotine replacement therapy (NRT) • Long acting • Patch • Short acting • Gum • Inhaler • Bupropion SR • Varenicline • A new smoking cessation aid • O'Donnell DE et al.Can Respir J 2004;11(SupplB):3B-59B. • Foulds J. Int J Clin Pract 2006;60:571-576. • Challenge Quit to win. Pharmacological Aids. February 20, 2007. • CHAMPIX Product Monograph, Pfizer Canada Inc., January 2007.

  24. Effectiveness of various medications and combinations vs. placebo

  25. Quit Smoking Plan • Medications • Quit date • Quit smoking follow-up program • - 7, 5, 14, 30, 60, 90, 180 days around quit date • Preparing for your quit date

  26. TelASK IVR Call Patients Counselor Laptops Internet TelASK Servers Hospital Workstations

  27. IVR follow-up appears to be useful (2N=99) Reid et al, Pat Educ Counsel, 2007 Adjusted* OR = 2.27 (0.92-5.62; p=.07) *adjusted for age, LOS, quit attempts in past year, reason for hospitalization

  28. Social Norms and Tobacco …transform your clinical practice!

  29. Developing a Quit Plan • Set a quit date • Ideally within 2 weeks • Tell family, friends and coworkers • Request understanding and support • Anticipate challenges • First 2 weeks critical; nicotine withdrawal Sx • Remove tobacco products • Prior to quitting, avoid smoking in places where you spend a lot of time. Make home smoke-free

  30. Practical Counseling • Abstinence • Strive for total abstinence; not even a puff • Past Quit Experience • What helped and what hurt before. Build on success • Anticipate Triggers and Challenging Situations • Overcome through delay, avoidance and substitution • Alcohol • Common trigger for relapse • Other Smokers • Quit together or at least avoid smoking in their presence • Provide supplementary material including information on quitlines

  31. Enhancing motivation to quit • Relevance • Encourage patient to indicate why quitting is personally relevant • Risks • Ask the patient to identify potentially negative consequence of continued smoking • Rewards • Ask the patient to identify potential benefits of quitting • Roadblocks • Ask the patient to identify barriers to quitting and providing treatment • Repetition • Repeat the intervention during each visit

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