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

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%

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

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

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.