Smoking Cessation

1. Preventing Strokes One At a Time Smoking Cessation 2009

2. 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.

3. 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 timesCMAJ 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

4. BC 15% Alberta 21% Saskatchewan 22% Manitoba 22% Ontario 16% Quebec 22% New Brunswick 22% Nova Scotia 21% PEI 20% Newfoundland 21% Smoking Prevalence in Canada 19%. Almost 5 Million Smokers (1995) Health Canada. Canadian Tobacco Use Monitoring Survey 2005, Summary of Annual Results.

5. 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, andAlcohol 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

6. 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.

7. Smoking Cessation: Role of Healthcare • Health care professionals have a golden opportunity to initiate smoking cessation programs • Credible • Knowledgeable • Supportive • Resourceful • Critical Incident

8. 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

9. 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.

10. 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) What’s in a cigarette?

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

12. 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

13. An Approach to Smoking Cessation Identification Documentation Counseling Pharmacotherapy Long-term follow-up “The Ottawa Model” Reid RD, Pipe AL, Quinlan B. Can J Cardiol 2006;22:775-780

14. 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

15. 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

16. Documenting Copied with permission, Ottawa Heart Institute, The Ottawa Model

17. Ask… Have you used any form of tobacco in the last 6 months? Copied with permission, Ottawa Heart Institute, The Ottawa Model

18. 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

19. Assess Copied with permission, Ottawa Heart Institute, The Ottawa Model

20. How important is it for you to quit smoking? How confident are you that you could succeed in quitting for good? Assess…Readiness 1 2 3 4 5 1 2 3 4 5

21. Assess Readiness to Quit Ready to Quit within 30 days -Develop a quit plan Not Ready to Quit -Provide self help and follow-up

22. 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

23. Assist Enhancing Motivation to Quit Relevance Risks Rewards Roadblocks Repetition

24. Arrange • Offer follow-up support • Referral to local community resources • Smoker’s Quit Lines

25. The “Ottawa Model” for smoking cessation • Includes an automated telephone call • Asking readiness: • Ready to Quit/ Not Ready to Quit/ Recently Quit • 2-3 minutes each call • Providing access to a smoking cessation counselor

26. 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

27. Pharmacotherapy for Tobacco Dependence • Nicotine Replacement Therapy (NRT) • Long Acting • Patch • Short Acting • Inhaler • Gum • Lozengers

28. 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

29. Smoking Cessation “Station” The following slides may be used in smoking cessation station

30. Myths and Realities of Nicotine Replacement Therapy • Handout • “Smoking Cessation and Nicotine Replacement Therapy Myths and Realities”

31. Nicotine Replacement Guidelines (USED WITH PERMISSION from University of Ottawa Heart Institute Smoking Cessation Program, The Ottawa Model)

32. 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)

33. 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 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 Nicotine Replacement Therapy (USED WITH PERMISSION from University of Ottawa Heart Institute Smoking Cessation Program)

34. 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 Nicotine Replacement Therapy

35. 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

36. Canadian Best Practice Recommendations for Stroke Care, updated 2008 www.canadianstrokestrategy.ca