Transcript Document

The Ottawa Model
for Smoking Cessation
for Smokers with
Cerebrovascular Disease
Robert D. Reid, Ph.D.
October 20, 2008
Disclosures
•
I have received research support in
the past 12 months from:
• PFIZER
• I have received consulting fees in
the past 12 months from:
• PFIZER, MINISTRY OF HEALTH
PROMOTION, HEALTH CANADA
Acknowledgements
Smoking and Stroke
 Smoking contributes to
12% to 14% of all stroke deaths
 Smoking may potentiate the effects
of other stroke risk factors
 Smoking increases stroke risk
– Acutely: effects on thrombus
formation
– Chronically: increased burden
of atherosclerotic disease
MRI of Brain
With an Acute Ischemic Stroke
Goldstein et al. Stroke. 2006;37:1583-1633; http://www.ucihs.uci.edu/stroke/whatisastroke.shtml.
Accessed October 19, 2007.
Smoking: Increased Progression of
Carotid Atherosclerosis
 Both active smoking and environmental tobacco smoke exposure are
Progression of Intima-Medial
Thickness, µm/3 y (95% CI)a
associated with increased progression of carotid atherosclerosis.
50
43.0
38.8
40
30
20
aAdjusted
31.6
32.8
Nonsmokers Nonsmokers
without
with
b
Exposure
Exposureb
Ex-smokers
without
Exposureb
25.9
Ex-smokers
with
Exposureb
Current
Smokers
for demographic characteristics, cardiovascular risk factors, and lifestyle variables (risk factor model
and Keys score, education, leisure activity, body mass index, and alcohol use). bTo environmental tobacco
smoke.
Howard et al. JAMA. 1998;279(2):119-124.
Smoking: Increased Risk of Fatal and
Nonfatal Stroke in Women
Relative Risk (95% CI)a
6
5
3.8
4
3
2.5
2.9
2
1.0
1
0
Nonsmokers
1-14
15-24
≥25
Cigarettes/Day
Current Smokers
aThe
probability of an event (developing a disease) occurring in exposed people compared with the probability of
the event in nonexposed people. Adjusted for age, follow-up period, history of diabetes, hypertension, high
cholesterol levels, and relative weight (in 5 categories).
Colditz et al. N Engl J Med. 1988;318(15):937-941.
Smoking: Increased Risk of Hemorrhagic
Stroke
Relative Risk (95% CI)a
12
<15 Cigarettes/day
(n=1914)
15 Cigarettes/day
(n=3265)
10
8
6
4
2.06
3.43
1.74
2.39
4.04
2.89
2
0
aThe
Nonsmokers
(n=20,339)
Total Hemorrhagic
Stroke
Intracerebral
Hemorrhage
Subarachnoid
Hemorrhage
probability of an event (developing a disease) occurring in exposed people compared with the probability
of the event in nonexposed people.
Adjusted for age, exercise, alcohol consumption, body mass index, history of hypertension, and history of
diabetes.
Kurth et al. Stroke. 2003;34:2792-2795.
Smoking: Increased Stroke Mortality
 Cigarette smoking increases the risk of mortality from stroke in men
60
50.6
Mortality Ratea
50
39.0
40
30.9
30
20
10
0
1-15
15-24
Cigarettes/Day
Current Smokers
aTwenty-year
age-adjusted mortality per 10,000 person-years for men. P<.014 for trend.
Hart et al. Stroke. 1999;30:1999-2007.
≥25
Summary: Smoking and Stroke
 Smoking contributes to 12% to 14% of all stroke deaths
 Increased risk of
–
–
–
–
–

Progression of carotid atherosclerosis
Stroke
Hemorrhagic stroke
Intracerebral hemorrhage
Subarachnoid hemorrhage
Increased stroke-related mortality
…an exquisitely crafted
drug delivery device
Nicotine Addiction
Nicotine rewards
smoking
Dopamine release
Signal to notice and
repeat
Nicotine alters
the brain
Psychological and
social forces are
at work
Acquired ‘drive’
(hunger)
Urge to smoke if
abstinent for a while
Reminders (cues)
increase urge
Pairing of stimuli
Beliefs about
stress control
Identity
Camaraderie
‘‘Why do people smoke . . . to relax; for the
taste; to fill the time; something to do with
my hands. . . . But, for the most part, people
continue to smoke because they find it too
uncomfortable to quit’’
Philip Morris, 1984
Philip Morris. Internal presentation. 1984, 20th March; Kenny et al. Pharmacol Biochem Behav. 2001;70:
531-549.
Nicotine Withdrawal
 Nicotine withdrawal syndrome consists of both somatic and affective
symptomatology
Withdrawal Syndrome
Irritability,
frustration,
or anger
Anxiety
(may increase
or decrease
with quitting)
Insomnia/sleep
disturbance
Increased appetite
or weight gain
Restlessness
or impatience
Dysphoric or
depressed mood
Difficulty concentrating
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text
Revision. Washington, DC: American Psychiatric Association; 2000.
Nicotine Addiction: A Chronic
Relapsing Medical Condition
 True drug addiction, similar to that of other drugs of abuse1,3
 Requires long-term, repeated clinical intervention4
– Nicotine addiction needs to be viewed as a chronic disease5
– Remission can be achieved with the proper
interventions and treatments5
Nicotine
addiction
is a chronic,
relapsing
condition1-3
 Relapse is
– Common2,4
– The nature of addiction, not the failure of the individual1
 Long-term smoking abstinence in those who try to quit unaided = 5%6
 Most relapse within the first 8 days4
1.
2.
3.
4.
5.
6.
O'Donnell DE et al. Can Respir J 2004;11(SupplB):3B-59B.
Jarvis MJ. BMJ 2004;328:277-279.
Foulds J. Int J Clin Pract 2006;60:571-576.
Hughes JR. CA Cancer J Clin 2000;50:143-151.
Optimal Therapy Initiative (University of Toronto). Smoking cessation guidelines: How to treat your patient's tobacco addiction, 2000.
Fiore MC et al. JAMA 2002;288:1768-1771.
A Comprehensive Approach
to Smoking Cessation
 Smoking addiction has two main components
that need to be addressed: one related to the
pharmacological action of inhaled nicotine and
the other related to behavioural factors1-3
 Advice and behavioural support increase the
chances of quitting successfully4,5
1.
2.
3.
4.
5.
Jarvis MJ. BMJ 2004;328:277-279.
Coleman T. BMJ 2004;328:397-399.
Rigotti NA. N Engl J Med 2002;346:506-512.
Hughes JR. CA Cancer J Clin 2000;50:143-151.
O'Donnell DE et al. Can Respir J 2004;11(SupplB):3B-59B.
Most effective methods of
smoking cessation combine
pharmacotherapy with
advice and behavioural
support2,4
The Ottawa Model for Smoking
Cessation
1. Identification of smokers
2. Documentation
3. Counseling
– Ready and not ready to quit,
recently quit
4. Pharmacotherapy
– Ready and not ready to quit
5. Self-help materials
– Ready and not ready to quit
6. Long-term follow up (IVR)
7. Linked to nurse counsel +/or
community resources
Ottawa Model at the University
of Ottawa Heart Institute
• > 6500 admissions/yr
• > 1400 smokers/yr
• Assistance provided to
96% of smokers
Long-term cessation rate pre-Ottawa Model: 35%
Long-term cessation rate with Ottawa Model: 50%!
Implementation of the Ottawa
Model in Canadian Hospitals
38
Number of hospitals
40
35
30
27
25
18
20
15
8
10
5
1
0
2004
2005
2006
Year
2007
2008
Ottawa Model effectiveness in 9 hospitals: 6-month
continuous abstinence rate pre- vs. post-implementation
Percentage of patients smoke-free at 6-months
40.0%
Unadjusted OR = 1.9 (1.2 to 3.1) p=.008
35.0%
30.0%
25.1%
25.0%
20.0%
14.9%
15.0%
10.0%
5.0%
0.0%
Pre-Ottawa Model
Implementation
Post-Ottawa Model
Implementation
Abstract submitted to SRNT 2009
(Dublin)
Ottawa Model for Smoking
Cessation - Outpatient
Patient Waiting Room Survey
• Tobacco use
– Past 6 months
– Past 7 days
•
•
•
•
•
Smoking history
Time to first cigarette
Importance and confidence
Concerns
Past use of medications
Smoking Cessation Consult
Form
•
•
•
•
Physician and nurse complete
Advise
Assess willingness to quit
Assist
–
–
–
–
Patient preferences
Contraindications
Select pharmacotherapy
Set quit date
• Arrange follow-up
Pharmacotherapy
for Nicotine Dependence1-4
 Nicotine replacement therapy (NRT)
– Long acting
 Patch
– Short acting
 Gum
 Inhaler
 Bupropion SR
 Varenicline
– A new smoking cessation aid
1.
2.
3.
4.
O'Donnell DE et al. Can Respir J 2004;11(SupplB):3B-59B.
Foulds J. Int J Clin Pract 2006;60:571-576.
Challenge Quit to win. Pharmacological Aids. February 20, 2007.
CHAMPIX Product Monograph, Pfizer Canada Inc., January 2007.
Effectiveness of various medications
and combinations vs. placebo
Medication
Number of arms
Estimated odds
ratio
Estimated
abstinence rate
Placebo
80
1.0
13.8
Varenicline (2 mg/d)
5
3.1 (2.5-3.8)
33.2 (28.9-37.8)
Nicotine patch
32
1.9 (1.7-2.3)
23.4 (21.3-25.8)
Nicotine gum
15
1.5 (1.2-1.7)
19.0 (16.5-21.9)
Bupropion SR
26
2.0 (1.8-2.2)
24.2 (22.2-26.4)
Patch + Gum (ad lib)
3
3.6 (2.5-5.2)
36.5 (28.6-45.3)
Patch +
Bupropion
3
2.5 (1.9-3.4)
28.9 (23.5-35.1)
Quit Smoking Plan
• Medications
• Quit date
• Quit smoking follow-up program
– - 7, 5, 14, 30, 60, 90, 180 days around quit
date
• Preparing for your quit date
TelASK IVR Call
Counselor
Laptops
Patients
Internet
TelASK Servers
Hospital
Workstations
% Abstinent
IVR follow-up appears to be useful
50
45
40
35
30
25
20
15
10
5
0
46
42
37
(2N=99)
35
Usual Care
Group
IVR Group
Reid et al, Pat Educ
Counsel, 2007
12 weeks
52 weeks
Adjusted* OR = 2.27 (0.92-5.62; p=.07)
*adjusted for age, LOS, quit attempts in past year, reason for
hospitalization
Social Norms
and
Tobacco
…transform your
clinical practice!
Developing a Quit Plan
• Set a quit date
– Ideally within 2 weeks
• Tell family, friends and coworkers
– Request understanding and support
• Anticipate challenges
– First 2 weeks critical; nicotine withdrawal Sx
• Remove tobacco products
– Prior to quitting, avoid smoking in places where you
spend a lot of time. Make home smoke-free
Practical Counseling
• Abstinence
– Strive for total abstinence; not even a puff
• Past Quit Experience
– What helped and what hurt before. Build on success
• Anticipate Triggers and Challenging Situations
– Overcome through delay, avoidance and substitution
• Alcohol
– Common trigger for relapse
• Other Smokers
– Quit together or at least avoid smoking in their presence
• Provide supplementary material including information
on quitlines
Enhancing motivation to quit
• Relevance
– Encourage patient to indicate why quitting is personally
relevant
• Risks
– Ask the patient to identify potentially negative consequence
of continued smoking
• Rewards
– Ask the patient to identify potential benefits of quitting
• Roadblocks
– Ask the patient to identify barriers to quitting and providing
treatment
• Repetition
– Repeat the intervention during each visit