A Clinical Flow-Chart for the “Treatment-Resistant Smoker”

Renee Bittoun

Background

• Most smokers want to quit (Fong, 2004)

• Very few do not (about 6% in Australia)

• Many/most fail at quit attempts with or without pharmacotherapies (Cohrane Reviews)

WHO: International Framework Convention on Tobacco Control,

2005The Framework Convention on Tobacco

Control (FCTC): Article 1. Section D.

harm reduction strategies

to improve the health of a population by eliminating or reducing their consumption

of tobacco products

Background to harm-reduction

• Using pharmacotherapies while smoking inhaled toxicants (Fagerstrom,2002)

• Potential gateway to quitting (Fagerstrom, 2005; Hughes, 2005)

• Harm-reduction agenda a softer,

not the “stop smoking or you’ll die” dogma of abrupt quitting (Warner, 2005)

Benefits of using NRT for Harm-reduction and Temporary Abstinence

• Relief of craving and other withdrawal symptoms

• Reduced cigarette consumption and prevention of compensatory smoking

• Smokers may learn that they can manage without tobacco for several hours

motivation to quit

Back ground to combination therapies

• Combination therapies show good outcomes in “hard-to-treat” smokers (Bittoun, 2005)

• A flow chart has been developed for clinicians that directs management of the difficult smoking patient: from the disinterested to the poor responders

• The flow-chart shows increasing therapies as required, using clinical signs and symptoms (withdrawal) to guide treatment choices

Application

• Apply strategies, both NRT and smoking---to mental health/intellectually disabled smokers

• 90% comorbid COPD patients using combination/harm reduction

Some Results

• 16% no pharmacotherapies• 16% oral NRT (gum,lozenge)• 16% on 2 X 21mg patch• 21% on 2 X 21mg patch plus oral NRT• 5% on 3 X 21mg patch• 5% on Bupropion• 1% on Bupropion plus 21mg patch• 20% lost to follow-up

Reconciliation

• Many do not have the “wherewithal” to quit as:- too hard (overwhelming withdrawals) pharmacotherapies too expensive limited understanding of withdrawals• Akrasia (lack of will-power, inability to reconcile

your want/need with your action, loss of control=addictive behaviour) (Aristotle, 4BCE; Heather, 1998; Ainslie, 2001)

• Harm-reduction may be a softer option

CONCLUSION• Don’t abandon the “hard-to-treat” “can’t quit”

smoker

• Develop a hierarchy of strategies for smokers that begins with permanent cessation using increasing combinations as required but----

• Consider harm-reduction for resistant smokers• ?? Unethical to exclude recommending harm

reduction behaviours to resistant smokers as an alternative to the “Quit or You’ll Die” Dogma.