KICK BUTT

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KICK BUTT

• A review of evidence based approaches to smoking
  cessation
• Based on The Cochrane Collaboration Library of
  medical evidence

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Kevin Saunders M.D.

• Family physician with River Grove Medical Clinic
• Practice in the north end since 1985
• Spent 10 years as the Medical Advisor at the
  Wellness Institute _at_ Seven Oaks General Hospital
• Developed and delivered a smoking cessation
  program there
• Special interests in medical research and medical
  education

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Disclosure

• I have done Phase III pharmacologic research with
  all the major pharma companies
• I did sit on an ad board for Pfizer relating to
  Champix
• I have no financial interest in any of the
  products mentioned

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Smoking Cessation
The single most powerful preventive intervention
in clinical practice
Rivara FP et al. Am J Prev Med 2004
27(2)118-25.
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Smoking Prevalence in Canada 19Almost 5
Million Smokers
Newfoundland Labrador 21
Alberta 21
B.C. 15
Manitoba 22
PEI 20
Québec 22
Saskatchewan 22
Ontario 16
Nova Scotia 21
New Brunswick 22
Health Canada. Canadian Tobacco Use Monitoring
Survey 2005, Summary of Annual Results.
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Tobacco Dependence Is a Medical Condition, Not a
Lifestyle Choice
What are the effects of nicotine?
Why do people continue to smoke?
Drop in nicotine levels leads to craving and
withdrawal symptoms
PHYSICAL DEPENDANCE
Heishman SJ. Nicotine Tob Res 1999 1(Suppl
2)S143-7.
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Quitting Smoking Unaided Pooled data
3-5

• Long-term smoking abstinence in those who try to
  quit unaided 35
• Most relapse within the first 8 days

Hughes JR et al. Addiction. 2004992938.
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A Comprehensive Approachto 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 chances
  of quitting successfully4,5

Most effective methods of smoking cessation
combine pharmacotherapy with advice and
behavioural support2,4

• Jarvis MJ. BMJ 2004328277-279.
• Coleman T. BMJ 2004328397-399.
• Rigotti NA. N Engl J Med 2002346506-512.
• Hughes JR. CA Cancer J Clin 200050143-151.
• O'Donnell DE et al. Can Respir J
  200411(SupplB)3B-59B.

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The Three Strategies Proven to Help Smokers Quit

• Brief advice support from themselves, their
  family and their physician, as well as groups,
  helplines and web-based resources
• Behavioural therapies quitting skills, such as
  avoiding people, places and situations that
  trigger their urge to smoke
• Medication

Hughes JR. CA Cancer J Clin 2000 50(3)143-51.
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Effect of Physician Advice on Likelihood of
Quitting
Consistent physician advice doubles the
spontaneous rate of quitting.
Law M, Tang JL. Arch Intern Med 1995
155(18)1933-41.
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Behavioral Therapy

• Behavior modification simply means having a plan
  to change your routine as it relates to daily
  cigarette usage
• Avoiding the riskiest situations what to do when
  one would be smoking favorite cigarettes of the
  day substituting activities at these times
  distractions for the brain
• No evidence as to whether intensive counselling
  is more effective or not in outcomes

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Overview of various therapies
Combining medication with brief advice or
behavioural therapy increases CA up to six times.
Adapted from Hughes JR. CA Cancer J Clin. 2000
50(3)143-51.
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Comparing Medications
Represents results from Weeks nine through 24
follow-up
OR odds ratio CI confidence interval
Hughes JR et al. Cochrane Database Syst Rev 2004
4CD000031 Jorenby DE et al. JAMA 2006
296(1)56-63 Silagy C et al. Cochrane Database
Syst Rev 2004 3CD000146.
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What About Hypnotherapy and Accupuncture

• not enough evidence to show whether or not
  hypnotherapy can help people trying to quit
  smoking.
• no consistant evidence that active accupuncture
  or related techniques increased the number of
  people who successfully quit smoking. However
  accupuncture could be better than doing nothing,
  at least in the short term, and not enough
  evidence to dismiss the possibility that it may
  have an effect

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Relapse Prevention

• Nicotine addiction is a chronic, relapsing
  condition
• Previous quit attempts are a good predictor of
  eventual success
• Relapses should be viewed as learning
  experiences
• Patients should not be made to feel guilty
• Try to understand the situation and find a way to
  deal with it (problem solving !)
• Repeating courses of medication often necessary

Fiore MC et al. Clinical practice guideline
treating tobacco use and dependence. US
Department of Health and Human Services. Public
Health Service 2000. Available at
www.surgeongeneral.gov/tobacco/default.htm
Hellman R et al. Health Educ Res 1991
6(1)77-86.
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