1. BY: SHAWNA HARPER JUNE 16 TH, 2015 SMOKING CESSATION

2. OBJECTIVES Epidemiology of Smoking and Smoking Cessation 5 As of Smoking Cessation – Ask, Advise, Assess Assist, Arrange. Non-pharmacological and Pharmacological management. Smoking Cessation in Special Populations

3. EPIDEMIOLOGY 16% of adults are current smokers in Canada (2012 Health Canada stats) More than 70% want to quit, 44% try to quit each year Most smokers who attempt to quit do not use cessation aids and are usually unsuccessful; two- thirds relapse within 48 hours. Only 4-7% annually will be successful 2/3 of patients that relapse want to attempt to quit again within 30 days

4. EPIDEMIOLOGY

5. 5 A’S OF SMOKING CESSATION ASK ADVISE ASSESS ASSIST ARRANGE

6. ASK Ask if Patient Smokes Ask “have you used tobacco in the last 6 months?” Ask ALL patients – especially adolescents and pregnant women Ask ALL patients – recognize that people may stop or start at any time.

7. ADVISE Advise Patient to Quit “As your clinician, I need you to know that quitting smoking is the most important step you can take to protect your health now and in the future.” Discuss the risks of smoking and benefits of smoking cessation Be Clear, Strong and Individualize the Discussion

8. RISKS OF SMOKING Cancer Can cause cancer almost anywhere in your body If nobody smoked, 1 of every 3 cancer deaths in the US would not happen Increases risk of lung cancer by 25 times. Cardiovascular Disease Increased risk of coronary artery disease by 2-4 times Increased risk of stroke by 2-4 times Respiratory Disease COPD, which includes emphysema and chronic bronchitis Others Infertility Pregnancy risks: IUGR, preterm delivery, SIDS, behavioral disorders. Lower bone density Don’t forget about the risks of second and third hand smoke***

9. ASSESS Assess stage of change Pre-contemplation, Contemplation, Preparation, Action, Maintenance, Relapse Assess Readiness Given everything going on in your life, on a scale of 1 to 10, how important is it for you to quit smoking? Given everything going on in your life, on a scale of 1 to 10, how confident do you feel you will be able to quit smoking? Assess Roadblocks Triggers – social situations, EtOH use, stress at work. Other smokers in household Fears about quitting – i.e. weight gain, increased stress.

10. ASSIST Behavioural treatment Pharmacotherapy

11. BEHAVIOURAL TREATMENT There is dose response relationship between counselling and quit success. Smokers who are attempting to quit should have counseling at least once prior to their quit date, the week following their quit date and weekly thereafter. Formats shown to be effective include face-to-face contact (group or individual) counselling as well as contact by telephone, mobile text messaging and internet sites.

12. BEHAVIOURAL TREATMENT S – Set a quit date within 2-4 weeks T – Tell family, friends, coworkers and request their support A – Anticipate challenges – plan for options to deal with cravings and avoidance of triggers. R – Remove tobacco products from home, car, work environments.

13. PHARMACOTHERAPY First Line Nicotine Replacement Therapy (NRT) Zyban (Bupropion SR) Champix (Varenicline) Second line Nortriptyline Clonidine Other Hypnosis Laser Acupuncture

14. PHARMACOTHERAPY There is insufficient high-quality evidence to recommend one first-line medication over another in a stepped care pathway. However, due to safety concerns, Health Canada modified the product monograph for both Zyban and Champix to advise prescribers to consider the use of NRT prior to these medications. However, Zyban and Champix are not considered second-line medications.

15. NICOTINE REPLACEMENT THERAPY Quit Rate is Double Placebo Available forms = Patch, Gum, Lozenge, Inhaler, Mouth Spray Quit Date = Start date of NRT Combining the Nicotine Patch with “as needed” gum, inhaler, lozenges or spray can be more effective than the individual products because it provides a steady baseline level of nicotine with “boluses for flexibility and treatment of cravings. Caution in patients with arrhythmia, angina, Post MI.

16. LOZENGES (NICORETTE, THRIVE)

17. LOZENGES Initial strength: Thrive: 1mg if or equal to 20 cigs per day Nicorette: 2mg if first cigarette is >30min after waking, 4mg if <30mins Max: Thrive: 25 per day for 1mg strength, 15 per day for 2mg strength. Nicorette: 15 per day Use beyond 6 months is not recommended. Side Effects: Hiccups, GI disturbances, Jaw pain Interaction: Avoid use of acidic beverages and foods (coffee, fruit juices, soft drinks, alcohol) while chewing and 15 minutes before or after – decreases absorption. Directions: Lozenges should be allowed to slowly dissolve and moved from one side of the mouth to the other periodically. Can take 15-30 minutes to start working.

18. GUM (NICORETTE, THRIVE, GENERICS)

19. GUM Initial strength: 2mg for light smokers 4mg for heavy smokers Maximum: 20 pieces per day, for up to 6 months Side Effects: Hiccups, GI disturbances, Jaw pain. Interaction: Avoid use of acidic beverages and foods (coffee, fruit juices, soft drinks, alcohol) while chewing and 15 minutes before or after – decreases absorption. Directions: Instruct patient to bit down once or twice then park gum between teeth and gums for about 1 min, bite the gum a few more times then park the gum again. Repeat bite and park process x 30 mins. Can take 15-30 mins to start working.

20. INHALER (NICORETTE)

21. INHALER Dose: 1 cartridge as needed for first 6-12 weeks (usually 6 cartridges per day initially) gradual reduction in use over next 6-12 weeks, stop when reduced to 1-2 cartridges per day Max: 12 cartridges per day Side effects: Mild local irritation (cough, throat irritation, stomatitis, rhinitis) that may decline with continued use, headaches, nausea, dyspepsia. Interaction: Avoid use of acidic beverages and foods (coffee, fruit juices, soft drinks, alcohol) while chewing and 15 minutes before or after – decreases absorption Directions: Each cartridge lasts for about 20 minutes of puffing and delivers 4mg of nicotine (2mg absorbed). Take short, shallow inhalations. Store at room temperature. Protect from heat, cold and light. Hand-mouth activity of using inhaler is preferred by some smokers while others find it a trigger.

22. MOUTH SPRAY (NICORETTE QUICKMIST)

23. MOUTH SPRAY Dose: Use 1-2 sprays every 30-60mins. Maximum: Sprays per episode, 4 sprays per hour, 64 sprays per day. Side Effects: Altered sense of taste, headaches, hiccups, nausea/vomiting, dyspepsia, oral soft tissue pain, stomatitis, dry mouth, burning lips. Interaction: Avoid use of acidic beverages and foods (coffee, fruit juices, soft drinks, alcohol) while chewing and 15 minutes before or after – decreases absorption. Directions: Each spray delivers 1mg of nicotine. Spray must be primed with first use or after 2 days if not using. Spray into mouth avoiding the lips. Do not swallow for a few seconds after spraying. Do not inhale while spraying.

24. PATCHES (NICODERM, HABITROL, GENERICS)

25. PATCHES Dose – see box labels or algorithm on next slide Adverse effects Skin sensitivity and irritation (most common) Abnormal dreams, insomnia, nausea, dyspepsia Interactions No significant drug interactions Directions Advise to not smoke while using the patch Apply to non-hairy area for 16-24 hours

27. ZYBAN (BUPROPION) Dose: 150mg SR daily x 3 days then BID 7-12 weeks Quit Date: 7-14 days after starting Side effects Dry mouth, constipation, agitation, insomnia, headache, tremor Contraindicated: Seizure conditions Eating disorders – anorexia/bulimia (recent or remote) Liver failure MAOI use Advantages Minimal weight gain, helps depression, can use with NRT, quit rate double placebo.

28. CHAMPIX (VARENICLINE)

29. Dose: 0.5mg daily po x 3 days then 0.5mg bid x 4 days then 0.5mg-1.0mg BID for 12-24 weeks. Quit Date: 7-14 days after starting Side effects: Nausea, bad dreams, insomnia Caution: Neuropsychiatric side effects such as suicidal/homicidal ideation has been reported. Monitor closely for mood changes. Should not be combined with NRT Reduce dose if renally impaired. Advantages: No drug interactions (except NRT), quit rate is triple placebo.

30. ARRANGE Follow-up within one week of quitting, then weekly thereafter as necessary to optimize therapy and to identify and manage early relapse (if not in person then at least my phone) During follow-up Identify challenges, and anticipate new ones Encourage continued smoking cessation If relapse – review and encourage recommitment to quitting.

31. ELECTRONIC DELIVERY SYSTEMS (EDS) Electronic Delivery Systems (EDS) EDS contain a battery-powered mechanism to heat and vapourize a liquid chemical mixture composed of varying amounts of nicotine, propylene glycol and other chemicals and/or impurities. Health Canada does not recommend using EDS due to lack of safety information regarding exposure to vapourized propylene glycol (among other chemicals used in the products). EDS are not regulated and the efficacy of EDS for smoking cessation is unproven. The first RCT to examine the efficacy of nicotine-containing EDS showed similar abstinence rates between EDS and nicotine patches. The debate continues since their potential benefits may or may not outweigh their potential risks.

32. ALTERNATIVE TREATMENTS Low-level Laser Therapy Hypnosis Acupuncture Magnet Therapy

33. CASE 1 Mrs. P is a 55 year old female with a 25 year smoking history. She spends $70 a week on cigarettes. She has been trying to quit smoking “cold turkey” on and off for the past 10 years. She states that she needs help with quitting but feels she can’t afford any of the medications. What can you do to help this patient?

34. CASE 1 FHTs Quit Smoking Program– some offer smoking cessation counselling and free NRT Heart Institute Quit Smoking Program Fee: $10, treatment and support provided by nurse specialist. MyQuit.ca 2 hour Quit Smoking work-shops, 5 weeks free NRT patches 4 week Quit Smoking Groups, Free NRT available See Ottawa Public Health website for Resources

35. CASE 2 25 year old female with a 10 year smoking history. She is healthy except for a history of anxiety/depression, for which she is receiving counseling. She has been trying the NRT products but has been unsuccessful in quitting. She really wants to quit smoking but is terrified about gaining weight. What is the best treatment option?

36. POST-SMOKING CESSATION WEIGHT GAIN Risks from continuing to smoke outweigh the risk of weight gain Quitting smoking with or without pharmacotherapy is associated with changes in body weight. Pharmacotherapy use is associated with less weight gain than quitting with behavioural methods alone. Zyban is associated with the least weight gain due to its anorexiant properties. Most changes occur in the first 3 months of quitting with an average increase of 4-5kg at 12 months. 16% of quitters lose weight

37. CASE 3 31 year old female who has smoked for the past 10 years (~15 cigarettes per day). She presents to the clinic today because she had a positive pregnancy test yesterday and believes she is 6 weeks pregnant. She is concerned about her smoking and its affect on the baby. She is requesting help with smoking cessation as she doesn’t think she can quit alone. What are her treatment options?

38. CASE 3 Management options in Pregnancy: Behavioural treatment/Counselling*** FIRST LINE Pharmacotherapy – There is limited evidence on the efficacy and safety of pharmacotherapy in pregnancy. They are all class C or D medications. Therefore avoid all pharmacotherapy unless the woman is unable to quit using behavioural measures alone. If unable to quit, offer lowest-effective dose of short-acting nicotine (gum) after 2 nd trimester, no agreement to the maximum number of pieces per day. Reserve patches for heavily dependent smokers and those who do not respond to the gum and recommend removal after 16 hours (i.e. at bedtime) to reduce fetal exposure.

39. CASE 3 Resources Ottawa Public Health Helping You Quit – in Pregnant and Breastfeeding Women, provides free counseling and free NRT Pregnets.ca Information for moms and moms-to-be Online support forum

40. CASE 4 Bobby, a 15 year old male, comes to your office for his periodic health exam. You go through your HEADSS assessment and find that he has been smoking for the past 2 years and is currently smoking 5-10 cigarettes per day. You have a long discussion with him about the risks of smoking and convince him to try quitting!!!! What management options are available?

41. CASE 4 Community based (i.e. non-clinical) tobacco control programs for your may be an important resource. Ottawa Public Health – School Health Team – offers quit smoking support for students in high school through work-shops, one-on- one counselling and nicotine patches. Dr. Lena’s Clinic for Adolescents Free counselling is available with referral (Age 12-19) To date there is limited evidence that either NRT or Zyban are effective in young smokers. However, they have been shown to be safe.

42. REFERENCES Therapeutic Choices: 7 th Edition Canadian Family Physician Centre for Addiction and Mental Health (CAMH) Ottawa Public Health Family Medicine Notes

43. THANK YOU !