Intervention strategies

Smoking Cessation
A team work
Isabella Sudano2 and Brigitt Kubli1
1Division
of Internal Medicine,2University Heart Center, Dept. of Cardiology, all in University Hospital Zurich, Zurich Switzerland
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Jha P et al., NEJM
2013
Is it worth to quit smoking!
Within a few hours, the level of carbon monoxide in the blood begins to
decline.
Within a few weeks, heart rate and blood pressure return to normal, sense of
smell and taste improved. Moreover, people who quit smoking have improved
circulation, produce less phlegm, and don’t cough or wheeze as often.
Within several months of quitting, people can expect substantial improvements
in lung function
Quitting smoking progressively reduces the risk of developing and dying from
cancer, cardiovascular disease and chronic lung diseases
In your outpatient clinic…
A
Ask about smoking Status
B
Brief advice to stop for all people who smoke
Ask
Advice
Assess
Assist
Refer
Arange
(independent of motivation to quit)
C
Provide evidence-based Cessation support to those who
express will to quit
Cornuz J. Schweiz Med Forum 2011;11(9):156-159
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McRobbie H. NZ Med JDokumentenname
2008;12:57-70
BRIEF ADVISE: Advise to stop smoking
 «Stop smoking is the best you can do for your health»
 «As a physician, I have to recommend that you stop
smoking»
 Important: factual, neutral, technical information without
undertone / threat, not preachy
 Explain how Symptoms / Risk of diseases / existing
diseases are related to smoking
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Lancaster Cochrane Library 2004; Cohen Ann Intern Med 1989; Robinson
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Provide Cessation support /
ASSESS: Evaluation of motivation
 «How big is your desire to quit smoking?»
- I‘m highly motivated (I wish to quit within one month)
- I do not know, sometimes I‘ll quit, uncertain
(I wish to quit within the next 6 months)
- I‘m not interested in quitting, I like smoking
Lancaster Cochrane Library 2004; Cohen Ann Intern Med 1989;
Robinson J Datum
Fam Pract
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Intervention strategies:
for smokers not willing to quit
• Minimal Intervention: ~ 3 minutes
•Aim of the consultation: Sensitizing, „keep door open“
•How to do it: talk about barriers
«What needs to happen so that you would consider a smoking
cessation?»
«What would be a reason to quit?»
• Follow-up: talk again about smoking and smoking cessation
•=> Increase abstinence rate of about 1-3% to 5-6% (after 1 year)
Lancaster, Cochrane Database 2004; Cornuz et al. (2004);
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USDHHS Guideline 2000; West Thorax
2000 Datum Seite 6
Intervention strategies:
smokers who are uncertain
• Short Intervention: ~ 5 Minutes
• Aim of the consultation: verify uncertainess, recognize the
discrepancy between current and desired behavior
• How to do it:
weight up advantages and disadvantages? Recognize and discuss
obstacles (weight gain, stress, living with other smokers, withdrawal
symptoms, relapse, depression)
USDHHSDokumentenname
Guideline 2000
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Advantages
of smoking
Disadvantages
of stop smoking
Disavantages
of smoking
Advantages
of stop smoking
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Technique to „prove uncertainess“
•
•
•
•
Ask questions that trigger self-reflection
Active Listening
Summarize
Compare
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Intervention strategies:
sor smokers willing to quit I
Medium (10-15 min) or more intensive intervention (~ 30 min
Aim: support behavior change, prevent relapse
 Support decision to quit
 Evaluate smoke history, assess nicotine dependence, ask about previous
abstinence phases
 Bring health complaints and physical symptoms in association with
tobacco consumption, possibly COHb measurement
 Analyse personal motives for quitting and the personal win
 Explain as nicotine is responsible for addiction and withdrawal
development, prescribe medication if needed
 Defining goal: choose a date for the smoking cessation, prepare for it
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Intervention strategies:
for smokers willing to quit II
 Awareness of personally important situations those are related to smoke
 Develop coping strategies
 Elaborate behavioral strategies for risk situations: anticipate, avoid
distractions, resist, escape
 Talk about weight increase
 Relapse prevention ("not a single one any more»)
 Other strategies (sports, relaxation, think about today)
 If needed provides brochures and recommend specialists
 Follow-up: 1 + 2 + 4 + 8 weeks & according to the smoker‘s wish
 In case of relapses: no self-accusation, continue smoking cessation, identify
relapse situation and plan prevention strategy
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Smoking counseling: Obstacles I
 Withdrawal symptoms:
 Explain addiction and withdrawal process
 Provide nicotine replacement therapy
 Relapse/Relapses and failure:
 As a mean a smokers need 5 time to try before I‘ll be a non-smoker
 Smoking cessation is a learning process, every trying will increase your
experience
 Stress:
 Select the right moment (no crisis, but also not postpone!)
 To cope with stress: relaxation, physical exercise
 Smoking in the environment:
 Use Non smoking areas; learn to refuse the proposed cigarette
 Stop with someone else, inform environment, talk with smoking partners
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USDHHS
Guideline
2000
Smoking counseling: Obstacles II
 Weight increase:
 Big obstacle, not only in women
 Weight increase after smoking cessation: around 80%
 As Average 4-5 kg increase after 12 months
 argest weight gain within the first 3 months
 16% loose weight, 13% gain more than 10kg
 It is a consequence of withdrawal and compensation by food
 Benefits of quitting >> Risk weight gain
 Advice on nutrition and physical activity
 Nicotine Replacement and/or Bupropion: weight increase avoided or
delayed
 Tackle a problem after another
Aubin et al. BMJ, 2012
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(Weight gain in smokers after quittingDokumentenname
cigarettes:Datum
meta-analysis)
Which drugs shall we use?
• Nicotine replacement therapy
• Bupropion
• Varenicline
Nicotine replacement therapy
How it works: All nicotine replacement products deliver only nicotine
(no other toxical substances.)
The delivered Nicotine acts on Nicot. Ach receptors
Nicotine acts as a substitute against the withdrawal symptoms
How nicotine will be absorbed:
Patches: Transdermal / skin
Chewing gum, lozenges, Microtabs: oral mucosa
Inhaler and mouth-spray: oropharyngeal mucosa
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Guideline 2000
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Nicotine replacement therapy
Patches: ca 6 CHF/Stk
Candies 1 mg 36 Stk ca 20 CHF, 96 Stk ca 45 CHF
Candies 2 mg 36 Stk ca 25 CHF, 96 Stk ca 55 CHF
Chewingum 2 mg:
Nicotinell 24 Stk ca 12 CHF, 96 Stk ca 45 CHF
Nicorette 30 Stk ca 15 CHF, 105 Stk ca 65.90 CHF
Chewingum 4 mg:
Nicotinell 24 Stk ca 16 CHF, 96 Stk ca 55 CHF
Nicorette 30 Stk ca 20 CHF, 105 Stk ca 65.90 CHF
Inhaler 10 mg:
42 Patronen ca 55.90 CHF
Microtabs 2 mg:
30 Stk. Ca 19.90 CHF, 100 Stk ca 58.50 CHF
Mundspray (150 Dosen) 59.00 CHF
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Bupropion (Zyban®)
- Antidepressiv: inhibitor of Dopamine and Nor-Adrenaline reuptake
- Reduces Craving and inhibits weight gain
- It can be used as an alternative as well as together with nicotine
replacement therapy
How to start: one week before smoking cessation: Zyban 1-0-0
starting on day 8: Zyban 1-1-0
How long should I use it: if possible up to 8 weeks
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Bupropion (Zyban®)
- How much it costs 40 Tbl. 130.10 CHF, 100 Tbl. Ca 330 CHF
- Side effects: sleeping disordes, dry mouth
- Contraindications: Epilepsy, anorexia, MAO inhibitors, alcohol
abuse, pregnancy, adolescents (age <18)
- Cave: concomitant use of other antidepressants, antipsychotics, it
may influence your ability to drive and to operate machinery
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Varenicline (Champix®)
Highly selective binding to α4β2 Nicot. Ach receptor
Acts as a partial agonist
Agonistic: reduces Craving and withdrawal symptoms - no weight effect
Antagonistic: reduces the effect of nicotine (reward)
It can be used as an alternative as well as together with nicotine replacement
therapy
- How to use it: Day 1-3
Champix 0.5 mg 1-0-0
Day 4-7
Champix 0.5 mg 1-0-1
from day 8 on
Champix 1.0 mg 1-0-1
- How long should I take it: if possible up to 12 Weeks
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Varenicline (Champix®)
- How much it costs initial pack 4W 121 CHF, 112 Tab ca. 180
CHF
- Side effects: Nausea (30%), Sleep disorders (13%),
Abnormal dreams, dizziness (6%), increase in appetite
- Contraindications:, pregnancy, adolescents (age <18)
- Cave: it may influence your ability to drive and to operate
machinery
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How many are smokefree after 1 year
Abstinence rates
Nikotine replecement
10-15%
Bupropion
15-20%
Varenicline
20-25%
Self-quitters
1-5%
Cochrane Syst Rev 2008;16;(3):CD00610
Jorenby D. JAMA 2006;296:56-63
Hughes J. Addiction
2004;99;29-38
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Electronic cigarette
Developed in China in 2004, sold in Brazil, Canada, Finland, Israel, Lebanon, the
Netherlands, Sweden, Turkey and the United Kingdom.
Varenicline (Champix®)
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E-cigarette: WHO Position
• "The electronic cigarette is not a proven nicotine
replacement therapy“
• “But WHO knows of no evidentiary basis for the
marketers' claim that the electronic cigarette helps
people quit smoking. Indeed, as far as WHO is
aware, no rigorous, peer-reviewed studies have
been conducted showing that the electronic
cigarette is a safe and effective nicotine
replacement therapy.”
• "If the marketers of the electronic cigarette want to
help smokers quit, then they need to conduct
clinical studies and toxicity analyses and operate
within the proper regulatory framework“
WHO: Geneva, 19Dokumentenname
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E-cigarette SGP/SGPP Position
The SGP / SGPP recommend to keep the current ban on the sale of nicotine-containing ecigarettes in Switzerland until benefits and risks will be clarified. Current data are regarding
this topic insufficient.
The federal government should treat e-cigarettes with or without nicotine as tobacco
products.
The e-cigarettes should be sold to persons under the age of 18.
E-cigarettes and liquid containing nicotine should be taxed at the same level as traditional
cigarettes and other tobacco products (tobacco tax).
The public use of e-cigarettes should be subject to the same limitations as it applies to
combustible tobacco products
E-cigarettes manufacturers should report data health benefit and safety of their products.
E-cigarettes should be subject to the same standard evidence of proof, which currently apply
to similar products.
The content of e-cigarettes cartridges must be disclosed, regulated and controlled
Schweizerische Gesellschaft für Pneumologie (SGP);
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Schweizerische Gesellschaft für Pädiatrische
Pneumologie (SGPP) 2014
Nationale
Rauchstopplinie:
0848 000 181
Bestellen: www.at-schweiz.ch / www.stop-tabac.ch/de
Rauchentwöhnungs-Programme im Internet:
www.zielnichtrauchen.ch
www.feelok.ch
www.stop-tabac.ch/de
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Vielen Dank für Ihre Aufmerksamkeit!
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