< LMCC
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
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