The Last Kiss

An Internist’s Look at Smoking Cessation

AIMGP 2007Ken Locke MD, FRCPC

Learning Objectives

• Understand the burden of tobacco addiction and associated harms

• Appreciate smokers’ perspectives on smoking and smoking cessation

• Understand the stages of self-change model

• Understand the role of pharmacologic support

• Understand how to help patients access support resources in Toronto

Tobacco as an addiction

• Describe the level of tobacco dependence of the following smokers:– A 25 year old woman who has 2-3 cigarettes when

out on weekends with friends– A 40 year old executive who has 2-3 cigarettes per

day (after meals), more during times of stress at work; occasional days without

– A 57 year old man who smokes 25 cigarettes per day, generally 15-30 minutes apart

• What else do you need to know about them?

How tobacco dependence works

• Cigarettes deliver nicotine to brain in 10-16 seconds… faster than IV injection

• Levels fall rapidly, prompting the need for further exposure

• Nicotine’s “reward” is a simultaneous feeling of stimulation and relaxation

• Within a few cigarettes, smokers experience withdrawal and the need for more nicotine

Other aspects of tobacco dependence

• Strong secondary cues to smoke are reinforced by nicotine’s rewards

• Common features: finishing a meal, driving, stress, seeing cigarette packages, being around other smokers

• Smokers typically regulate their nicotine intake between narrow limits – avoiding both withdrawal and adverse effects

80% of smokers want to quit by age 20; symptoms of withdrawal such as those above are a powerful disincentive

Some epidemiology

• Currently, 19% of Canadians over 15 smoke at least occasionally (3/4 daily)

• Currently fewer new smokers among young men than young women (15-19)

• 50% of smokers will die prematurely, on average 8 years of life lost per smoker

• Greatest benefit to smoking cessation occurs before age 35 but longevity improves at ALL ages and states of health

How do smokers feel about smoking?

• The majority (over 2/3) would like to quit• At least 1/3 will make multiple quit

attempts• 10-15% have no interest in quitting and

will never attempt it• Smoking and associated quit attempts are

associated with low self-esteem and feelings of failure/inadequacy – leading to more urges to smoke

Ask your patients…

• “I’m a smart woman doing a very stupid thing. I just can’t seem to stop.”

• “Quitting smoking is like having to kiss someone you love for the very last time.”

• “Since I quit, I feel like I’ve lost a friend. I don’t regret it, but it is a real loss that a non-smoker will NEVER understand.”

• “I beat myself up every time I have a cigarette. But it’s the only thing I get to do in life that’s ‘just for me.’ I know I can’t do it forever, but now’s not the time to stop.”

• Quotes from patients seen at MSH and UHN in 2006

Promoting Smoking Cessation

• Unassisted quit attempts have a 3-5% long-term success rate

• With assistance, long-term success can be as high as 40% (in RCTs)

• 2 major components:– Behavioural/psychosocial support– Pharmacologic support

Behavioural Support

• Fundamental ingredient is readiness for change – an ingredient that only the patient can supply

• Patients typically evolve through 5 stages of change as they ready themselves:– Precontemplation – generally not receptive– Contemplation – beginning to explore ways/means– Preparation – active planning, eg. Date setting– Action – moving forward– Maintenance – consolidating the “new habit” –

successful if maintained for > 6 months

Behavioural Support

• Physicians’ role:– Precontemplative: Be “available” if/when patients

show signs of moving ahead– Contemplative: Educate on options, help set

reasonable expectations re withdrawal and relapse– Preparation: Prescribe therapy, provide access to

resources, encourage a support network– Action: Reinforce measures to combat withdrawal– Maintenance: Reward success (eg. note when health

improves); encourage patients who relapse to try again when they are ready

Relapses

• The minority of smokers will succeed on their first quit attempt (more likely in men than women)

• More relapses = greater chance of success on the NEXT quit attempt

• Encourage patients to learn from how the relapse occurred

• Remain supportive and positive throughout• Understand that “backtracking” is common when

relapse occurs – may need to regroup

Pharmacologic Support

• In general, behavioural support alone achieves long-term abstinence rates of 10% or less

• Pharmacologic support in addition to behavioural support at least doubles this

• 2 forms:– Nicotine replacement– Non-nicotine based therapies

Nicotine Replacement

• Principle: Nicotine has few risks but is the addictive component of tobacco; remainder of tobacco has all of the risks but no addictive potential

• Therefore – give the nicotine without the tobacco

• NRT is associated with doubling of quit rates

How to use NRT

• Long acting (eg. Patch): – Best for regular smokers (>10 cigarettes/day)– Dose according to time of earliest cigarette in

day– Remember for patients in hospital!

• Short acting (eg. Gum, inhaler)– Best for situational smoking, light smokers– Teach patients to take it in anticipation of urge

How to use NRT

• Side effects: nausea, headache, hiccups (pruritus and erythema for patch)

• Generally well tolerated – adjust dose if symptoms severe

• Continue for at least 6 months then taper gradually

• Watch for withdrawal

• Patients who relapse must stop NRT

Non-nicotine based therapy

• Bupropion– Atypical antidepressant; complex actions– Similar efficacy to NRT; best results when

both used together– Must be started 1 week prior to quit date– Dose doubled after quit; total of 8 weeks’

treatment– Adverse effects: insomnia, dry mouth,

pruritus (common); seizures (rare)

Non-nicotine based therapy

• Varenicline– Newest agent to be approved in Canada– Nicotine receptor partial agonist– Meta-analysis in Cochrane suggests it is

slightly more effective than bupropion– Details on use/combination therapy not yet

available

Upcoming Therapy

• Nicotine Vaccine:– Currently in the Phase II trial stage– Dose-finding studies in precontemplative

smokers have found unintended quit rates of up to 30%

– Adverse effects minimal (no serum sickness)– Applicability to general smoking population

not clear

Patient Self Help

• Patient-oriented materials available on Internet– www.quitnet.org (peer support – US based)– www.hc-sc.gc.ca (Health Canada Website)– www.stupid.ca (aimed at <25 year old group)

• Toronto Public Health has an excellent phone based support program

Summary

• Keys to assisting smokers in quitting:

– An understanding/empathic approach– Awareness of their readiness to change– Behavioural support is essential– Pharmacologic support increases the chances– Promoting mastery of the problem will assist

patients in avoiding long term consequences of smoking