COPD Smoking Cessation

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Fifth Workshop Session

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Principles of Smoking Cessation :

Principles of Smoking Cessation Dr/Heba Gamal Lecturer of chest diseases

Learning objectives:

Learning objectives At the end of this presentation the participant will: Incorporate smoking cessation. Outline effective behavioral modification strategies for patients with nicotine dependence on smoking. 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.

ASK ABOUT USE AND EXPOSURE :

ASK ABOUT USE AND EXPOSURE   A full assessment includes the frequency of use, the products used, the degree of nicotine dependence, the history of previous quit attempts (including methods used and their effectiveness) The smokers' readiness to stop smoking at this time. A smoker's degree of nicotine dependence predicts the difficulty that he or she will have in quitting and the intensity of treatment likely to be required. Ask about intermittent smoking (nondaily smokers) 20%. Asses use of alternative tobacco products (eg, electronic cigarettes, cigars, bidis, snus, and pipes).

ADVISE SMOKING CESSATION :

ADVISE SMOKING CESSATION   Although not every patient counseled in smoking cessation will be prepared to consider quitting, there is clear evidence that brief physician advice interventions to quit (<5 minutes) at each encounter can increase smoking abstinence. The main therapeutic effect of physician advice is likely to promote motivation to quit. There was a small additional benefit of more intensive interventions compared with brief interventions(salivary nicotine metabolite levels, lung age). Complete smoking cessation is always preferable. Reducing the number of cigarettes smoked daily has been advocated as a possible alternative to complete cessation in patients who are unable to quit smoking.

ASSESS READINESS TO QUIT :

ASSESS READINESS TO QUIT   Smokers differ in their readiness to change their tobacco use. The clinician should assess the patients' willingness to make a quit attempt. . Five stages through which smokers are hypothesized to progress as they move from smoking to abstinence: precontemplation (not ready to quit), contemplation (considering a quit attempt), preparation (actively planning a quit attempt), action (actively involved in a quit attempt), and maintenance (achieved smoking cessation)

ASSIST SMOKERS READY TO QUIT :

ASSIST SMOKERS READY TO QUIT   Smokers should have access to appropriate resources to assist in smoking cessation. Assess the smoker's previous experiences with attempts to quit. Assessing the methods that have been tried and the smoker's degree of success with each is important in order to guide recommendations for the next attempt. Help the patient anticipate barriers to quitting and address barriers. Steps ?????

ASSIST SMOKERS READY TO QUIT :

ASSIST SMOKERS READY TO QUIT   The process of smoking cessation generally begins by setting a "quit day" within the next two to four weeks. Stop smoking completely on their quit day. Should be prepared to handle nicotine withdrawal symptoms and other barriers to quitting. Depending on the medication chosen, pharmacotherapy is started either before or on the quit date. There was no difference in abstinence rates between those who reduced smoking before the quit date and those who quit abruptly.

Addressing barriers to quit difficulty that smokers encounter when they try to quit. :

Addressing barriers to quit difficulty that smokers encounter when they try to quit. Nicotine withdrawal syndrome : Nicotine is a potent psychoactive drug that causes physical dependence. In the absence of nicotine, a smoker develops cravings for cigarettes and nicotine withdrawal symptoms. Symptoms peak in the first three days of smoking cessation and subside over the next 3 to 4 weeks. Symptoms include increased appetite and weight gain, dysphoria/depression, insomnia, irritability, anxiety, difficulty concentrating and restlessness. Failure to quit state: they have "tried everything" when in fact they may have not engaged in any formal smoking cessation counseling program and may have not used medications. Associate the pleasurable effects of tobacco use with environmental triggers such as their morning coffee, another drink, after meal.

Benefits of Quitting:

Benefits of Quitting Substantially reduces risk of all-cause mortality among patients with coronary heart disease 1 Significantly decreases mortality among those who have had a myocardial infarct 2 Substantially decreases cancer risk 3 Decreases risk of stroke 4 Improves airflow obstruction regardless of baseline lung function 5 Sources: 1 Critchley JA, Capewell S. JAMA. 2003;290:86-97; 2 Wilson K, et.al. Arch Intern Med. 2000;160:939-944; 3 U.S. Department of Health and Human Services. Health Benefits of Smoking Cessation. A Report of the US Surgeon General . Rockville, MD: U.S. Department of Health and Human Services; 1990; 4 Wannamethee SG, et.al. JAMA. 1995;274:155-160; 5 Scanlon PD, et al. Am J Resp Crit Care Med. 2000;161:381-390.

Interventions:

Interventions Pharmacologic Behavioral Self-help materials Brief Advice Counseling Exercise Nicotine-replacement therapy Bupropion Varenicline

Pharmacotherapy:

Pharmacotherapy Patch (OTC) Gum (OTC) Lozenge (OTC) Inhaler (Prescription) Nasal Spray (Prescription) Bupropion Varenicline Nicotine-replacement Therapy (NRT) Prescription Medications

Nicotine-Replacement Therapy (NRT):

Nicotine-Replacement Therapy (NRT) Reduces nicotine withdrawal symptoms (e.g., anxiety, cravings, hunger) 1 All forms are effective 2 Effectiveness appears independent of intensity of additional support programs 2 Compatible with all other cessation interventions Limited evidence that combination NRT more effective than single formulations 2 BUT diffrence in bioavillabilaty explain. Sources: 1 Hughes JR, et.al. Arch Gen Psychiatry. 1991;48:52-59; 2 Silagy C, et.al. Cochrane Database Syst Rev. 2004;3:CD000146.

Practice:

Practice GUM: “CHEW AND PARK” COMBINATION GUM PLUS PATCH DOSE AND DURATION ACCORDING TO NUMBER OF Sig.

NRT:

NRT Headache GIT upset Insomnia Jaw Pain Site Irritation Recent MI Arrhythmias TMJ Possible Side Effects: Contraindications: MI; myocardial infarct; TMJ; temporomandibular joint disease.

Bupropion:

Bupropion Nor epinephrine and dopamine reuptake inhibitor Doubles odds of cessation relative to placebo 1 Efficacy undiminished by previous NRT use 2 Combining with NRT does not confer significant additive benefit 1 Sources: 1 Hughes JR, et.al. Cochrane Database Syst Rev. 2007(1):CD000031; 2 Durcan MJ, et al. Am J Health Behav. 2002;26:213-220.

Bupropion:

Bupropion Headache Dry mouth Tremor Rash Eating disorders Seizure disorders Bipolar disorder Recent MAOI use Possible Side Effects: Contraindications: MAOI; monoamine oxidase inhibitor.

Practice ZYPAN:

Practice ZYPAN

Varenicline:

Varenicline Nicotine partial receptor agonist that can ease craving and withdrawal symptoms Approved for smoking cessation in 2006 Increases smoking cessation ~3-fold compared to placebo 1 Source: 1 Cahill K, et.al. Cochrane Database Syst Rev. 2007;1:CD006103.

Varenicline:

Varenicline Nausea Headache Insomnia Severe renal impairment Possible Side Effects: Contraindications:

Practice titrated gradually :

Practice titrated gradually

Others 2nd line:

Others 2 nd line

Slide22:

Nortriptyline Cytisine Clonidine   SSRIs and anxiolytic A novel experimental approach : Nicotine vaccine 

The medication can put you on the 20 yard line, but the final 20 yards is the hardest. :

The medication can put you on the 20 yard line, but the final 20 yards is the hardest .

Behavioral Interventions:

Behavioral Interventions Self-help materials Brief Advice Counseling Exercise

Self-Help Materials:

Self-Help Materials Appear to increase long-term abstinence ~1.5-fold relative to no intervention 1 May be tailored to individual or type Should be available in office and provided to all smokers Source: 1 Lancaster T, Stead LF. Cochrane Database Syst Rev. 2005(3):CD001118.

Slide26:

to promote motivation to quit

The model of 5 Rs :

The model of 5 Rs   لسه فيه تاني Relevance   Risks Rewards Roadblocks   Repetition  

Change talk :

Change talk DAREN statment: D esire (I wish I could stop smoking). A bility (I could stop smoking). R easons (I want to quit because… ) N eed (I need to quit , must stop smoking) علشان كده خلى باللللللك هو بيتكلم بيقول ايه

Brief Advice (<3 Min):

Brief Advice (<3 Min) May be offered by clinician or nurse Should include firm quit recommendation and call attention to health outcomes and practical issues Increases odds of quitting ~1.7-fold compared to no advice 1 Absolute benefit appears greater for motivated patients Source: 1 Lancaster T, Stead LF. Cochrane Database Syst Rev. 2004(4):CD000165.

Individual Counseling:

Individual Counseling Improves quit rates for adults Recommended for adolescents May be more effective than team-based counseling especailly for adolescents When possible, should be >10 minutes, face-to-face, with trained specialist

Elements of a Counseling Intervention:

Elements of a Counseling Intervention Discuss previous quit experiences Anticipate challenges Assess patient’s household environment Provide patient with options for dealing with nicotine withdrawal Suggest abstaining from alcohol during quit attempt

Strategies to Cope with Nicotine Withdrawal:

Strategies to Cope with Nicotine Withdrawal Symptom Strategy Cravings/Urges Distract self Postpone cigarette Breathe deeply Call supportive person Irritability Engage in pleasurable activity Take hot bath Breathe deeply Hunger Select oral substitute Drink water or low-calorie drinks Source: Cofta-Woerpel L, et.al. Behav Med 2007;32:135-149.

Coping with Nicotine Withdrawal (cont) :

Coping with Nicotine Withdrawal (cont) Symptom Strategy Difficulty concentrating Take brisk walk Simplify schedule Take a break Depression Schedule pleasurable events Talk to supportive friend/family Get ample rest Reward self for working hard to quit Sleep disturbance Pace self Ask for help Source: Cofta-Woerpel L, et.al. Behav Med 2007;32:135-149.

Other Counseling Options:

Other Counseling Options Group counseling Telephone counseling

Exercise:

Exercise Has acute effect on nicotine craving and withdrawal symptoms. 1 Weakly linked to improved quit rates when used alone or in addition to structured cessation program. 2 Confers numerous health benefits. Can reduce post-cessation weight gain. 3 Sources: 1 Taylor AH, et.al. Addiction. 2007;102:534-543; 2 Ussher M. Cochrane Database Syst Rev. 2005(1):CD002295; 3 Kawachi I, et.al. Am J Public Health. 1996;86:999-1004.

Alternative therapies :

Alternative therapies   Acupuncture : is included in some commercially available smoking cessation programs( was found to be less effective than nicotine replacement therapy). Hypnosis : The hypnotherapy for smoking cessation suggested some potential benefits. Financial incentives : Randomized trials have shown that financial rewards can increase smoking cessation rates compared with usual care.

ARRANGE FOLLOW UP :

ARRANGE FOLLOW UP   Follow-up should be scheduled within a week of the patient's quit date to provide reinforcement, monitor for adverse or side effects of pharmacotherapy, and monitor response to smoking cessation therapy. The patient can return for a follow-up appointment or be contacted by telephone, either from the clinician's office or by referring the smoker to a telephone quitline.

Slide38:

Proactive offer of treatment   An alternate approach to the 5A's, more in line with the concept of treating tobacco use as a chronic disease, is to proactively offer treatment, rather than assessing readiness to quit.

Slide39:

ISSUES IN SPECIFIC POPULATIONS

Smoking Cessation and Pregnancy:

Smoking Cessation and Pregnancy Active counseling interventions promote quitting in pregnant women 1 Interventions implemented during pregnancy reduce low birth-weight and incidence of pre-term birth Use of NRT controversial for pregnant and breast feeding women due to potential fetotoxicity and neuroteratogenicity 2,3 Sources: 1 Lumley J, Oliver SS, et.al. Cochrane Database Syst Rev. 2004(4):CD001055; 2 Ginzel KH, et al. J Health Psychol. 2007;12:215-224; 3 Ginzel KH. Ob Gyn News. 2007;42:8.

Pregnancy Categories for Pharmacotherapy:

Pregnancy Categories for Pharmacotherapy Agent FDA Pregnancy Category NRT Gum C NRT (All others) D Bupropion C Varenicline C

relapse&difficulty quitting  :

relapse&difficulty quitting     Relapse is common. Patients who relapse should be reminded that many patients require multiple attempts at smoking cessation before permanently quitting. Patients should be encouraged to again attempt smoking cessation. If a previous medication was helpful temporarily, we typically use the same therapy that worked for the patient previously but may recommend adding to it formal smoking cessation counseling program .

Psychiatric illness :

Psychiatric illness   Avoid using  varenicline  in patients with a current unstable psychiatric status or a history of suicidal ideation . Other clinicians take a more conservative approach and do not offer the drug to patients with depression . Bupropion  may be helpful for smoking cessation in patients with depression and schizophrenia, but can exacerbate illness in patients with bipolar disorder. Combination NRT is a good choice in individuals for whom the safety of varenicline or Bupropion is a concern. 

Cardiovascular disease :

Cardiovascular disease   In patients with stable cardiovascular disease (CVD), suggestions to use the same treatments as those in the general population. Both nicotine replacement therapy and  bupropion  are safe in this population. Concerns have been raised about  varenicline  in this population, but interpretation of the data is that varenicline is safe in patients with stable CVD.

Hospitalized smokers :

Hospitalized smokers   Because of smoke-free policies in many hospitals , hospitalization provides smokers with an opportunity to experience a period of nonsmoking in a setting that is free of the usual way to smoke. The illness precipitating the admission may also reinforce the smoker's perceived vulnerability to the harms of tobacco use. NRT IS OF CHOICE Motivated quit attempt

Preoperative smokers :

Preoperative smokers   In the preoperative setting, there is often a special motivation to stop smoking in order to reduce associated postoperative complications. Nicotine replacement therapy or varenicline (combined with behavioral interventions) are effective in these patients

Summary:

Summary Smoking cessation confers numerous well-established health benefits. Providers should initially assess a smoker’s degree of nicotine addiction. A proactive intervention strategy that includes counseling and/or pharmacotherapy should be tailored to the patient. Providers must individualize and personalize therapy. Relapse is common among smokers who try to quit so barriers should be assessed.

Something hopeful:

Something hopeful Patients who had previously failed tried again and succeeded. One said several did. لسه فيه أمل

SO be PATIENT to SUCCEED:

SO be PATIENT to SUCCEED الصبر...........

AS:

AS SMOKING CESSATION IS NOT A ONE SHOT DEAL.

THANK YOU:

THANK YOU