review of current guidelines on smoking cessation · treatment to achieve smoking cessation,...

Postgraduate Course“Managing smoking cessation clinics”

Review of current guidelines on smoking cessation

Director , CNR Institute of Biomedicine and MolecularImmunology “Alberto Monroy”, Palermo, Italy

Head,Pulmonary Environmental Epidemiology Unit, CNR Institute of Clinical Physiology, Pisa, Italy

Professorof “Health Effects of Pollution”, School of Environmental Sciences, University of Pisa, Italy

2006-07 Past-President, European Respiratory Society (ERS)

Member of Planning Group, Global Alliance against chronicRespiratory Diseases (GARD)

DURATA: 25’

Giovanni Viegi, MD

Smoking cessation guidelines

• There is strong evidence that smoking cessation interventions

are highly cost-effective.

• English and US guidelines in place to offer recommendations on

smoking cessation

– West R, McNeill A and Raw M. Smoking cessation guidelines

for health professionals: an update. Thorax 2000; 55: 987-999

• thorax.bmj.com/content/55/12/987.full.pdf

– Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use

and Dependence. A Clinical Practice Guideline. Rockville, MD:

US Department of Health and Human Services, 2008.

• http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pd

f

Parrott S, et al. Thorax 1998; 53: S1-S38. Cromwell J, et al. JAMA 1997; 278: 1759-1766.

Smoking cessation guidelines -- UK

• 1998

– Raw M, McNeill A, West R. Smoking cessation guidelines for health

professionals. A guide to effective smoking cessation interventions for

the health care system. Health Education Authority. Thorax 1998;53

Suppl 5 Pt 1:S1-19.

• 2000

– West R, McNeill A, Raw M. Smoking cessation guidelines for health

professionals: an update. Health Education Authority. Thorax

2000;55(12):987-99.

Smoking cessation guidelines -- USA

• 1996

– Fiore M, Bailey W, Cohen S, et al. Smoking Cessation. Clinical Practice

Guideline No. 18. AHCPR publication No.: 96-0692. Rockville, MD, US

Department of Health and Human Services. Public Health Service,

Agency for Health Care Policy and Research, 1996

• 2000

– Fiore MC BW, Cohen SJ, et al. Treating Tobacco Use and Dependence.

A Clinical Practice Guideline Rockville, MD: US Department of Health

and Human Services. Public Health Service, 2000.

• 2008

– Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and

Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD:

U.S. Department of Health and Human Services. Public Health Service.

May 2008, 2008.

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Treating Tobacco Use and Dependence

A Clinical Practice Guideline

US Department of Health and Human Services

http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf

http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf

KEY POINTS OF THE

RECOMMENDATIONS

- 1 -

• Patients with respiratory disease have a greater and more

urgent need to stop smoking than the average smoker. They

should be encouraged to stop but many often find it more

difficult to do so (evidence level B).

ERS Task Force - Smoking cessation in patients with respiratory diseases: a high priority, integral component of therapy. Eur Respir J 2007;29(2): 390-417.

KEY POINTS OF THE

RECOMMENDATIONS- 2 -

• Respiratory physicians must take a proactive and continuing

role with each smoker in motivating him or her stop, provide

treatment to achieve smoking cessation, however long this

might take, and deal with relapses when these occur.

• Smoking cessation treatment must be considered integral to

the management of the patient’s respiratory condition.

• The role includes the following.

– (i) Regular assessment of smoking status using methods that can objectively

detect smoking (expired-air CO test) (evidence level C)

– (ii) Pharmacological treatment for nicotine dependence, […] (evidence level

B).

– (iii) Behavioural support, which should be intensive and multi-sessional, and

provided by someone who has been appropriately trained (evidence level B).


KEY POINTS OF THE

RECOMMENDATIONS

- 3 -

• Respiratory physicians must have adequate knowledge and

appropriate attitudes and skills;

• this requires training and continuing medical education,

which should be provided according to professional

standards and should be accredited (evidence level C).


KEY POINTS OF THE

RECOMMENDATIONS

- 4 -

• The cost of this strategy will partly be offset by a reduction

in attendance for exacerbations etc., but a budget must be

established to enable implementation of treatment

protocols and to provide medication and behavioural

support (evidence level A).


KEY POINTS OF THE

RECOMMENDATIONS

- 5 -

• It is important to check lung function regularly in order to

chart disease evolution, and to use this as a motivational

tool (evidence level C).


KEY POINTS OF THE

RECOMMENDATIONS

- 6 -

• Smokers not motivated to stop should be offered NRT to

reduce smoking and as a gateway to cessation (evidence

level B).


KEY POINTS OF THE

RECOMMENDATIONS

- 7 -

• Smokers who are not interested in stopping or reducing

should be advised that the physician will return to the

question at a later visit (evidence level C).


ASSESSMENTS

• Smoking status

• Motivation to give up

• Dependence

• Earlier smoking cessation experience

• Carbon monoxide

• Spirometry and smoking cessation

• Comorbidity


Smoking status

• Usually a direct question is enough

• CO in exhaled air, cotinine from saliva, urine or blood and

inspecting the patient’s fingers and breath can yield valuable

information

• Smoking status should be noted prominently in the patient’s

record, including the type of tobacco use (cigarettes,

cheroots, cigars or pipe) and quantity-inclusive pack-yrs*

*Pack-years = no. cig. smoked per day x no. years of smoking / 20


Motivation to give up

• A willingness or strong motivation to quit seems to be crucial for

successful smoking cessation

• An approach where smoking can be discussed in an unthreatening,

respectful and emphatic way is required

• There is no good, validated measure for assessing degree of motivation

• Ask the patient to rate, on a 10-point scale

– “How important is it for you to give up smoking?”

(10 “extremely important”; 0 “no importance”)

– “If you were to decide to stop smoking, how confident are you that

you would succeed?”

(10 “entirely certain that I would succeed”; 0 “entirely certain I would

fail”)


Assessing readiness to quit smoking

Motivation Self-efficacy Outcome

high score high score good readiness to give up,

a quit date can be set

immediately

high score low score treatment and support are

critical for success

low score high score effective health education

is critical

low score low score motivation and self-

efficacy need to be built up

Dependence

• Number of cigarettes smoked daily alone is not an optimal measure of

nicotine dependence

• Biochemical measures from blood plasma, saliva and urine:

– Nicotine

• short half-life of about 2 h

• nicotine concentrations are dependent on time of day and when

the last cigarette was smoked

– Cotinine (recommended)

• half-life of 15–20 h

• nonsmoking level < 15 ng·mL-1

• nonsmokers not exposed to second-hand smoke, up to 10 ng·mL-1

• smoker’s average level, around 200 ng·mL-1

• Nocturnal smoking (infrequent)

ERS Task Force - Smoking cessation in patients with respiratory diseases: a high priority, integr ng·mL-1 apy. Eur Respir J 2007;29(2): 390-417.

ERS Task Force - Smoking cessation in patients with respiratory diseases: a high priority, integr ng·mL-1 apy. Eur Respir J 2007;29(2): 390-417.

• The higher the score, the stronger is the dependence and the more

difficult it is to give up.

• The FTND score also predicts severity of withdrawal and need for

pharmacological treatment

Earlier smoking cessation experience

• Ask about experiences from earlier quit attempts:

– longest period without smoking

– difficulties and withdrawal symptoms

– any methods used that helped

– what trigged relapse

– whether anything positive was experienced during

abstinence


Carbon monoxide (1)

• The assessment of CO can be seen as an indicator of total smoke intake

• The CO concentration can be obtained easily by asking the smoker to

exhale into a CO analyser

• Interpreting results:

– under normal environmental conditions, a nonsmoker’s CO value

should not exceed 4 ppm

– current smokers > 10 ppm

– half-life of CO is about 4 h, but this is somewhat exercise dependent

– readings in the morning are lower than in the afternoon

– within 1–2 days after the last cigarette, the CO level will be normal

– in smoking reduction, often the smoker compensates for the potential

reduction in nicotine intake by inhaling more effectively from each of

the remaining cigarettes


Carbon monoxide (2)

• Motivational “CO effect”, recommended procedure:

– the therapist first exhales into the device, showing the normal CO

concentration of 1–3 ppm

– then the smoker blows into the machine where she/he immediately

and invariably sees much higher readings of about 10–20 ppm

• Rapid normalisation after smoking cessation is very rewarding for the

subject to see.

• After normalisation of the CO level, assessment can be used to monitor

progress during follow-up

• An abnormal CO value can be used to inform the smoker of the

mechanisms by which smoking, and particularly CO, contributes to

cardiovascular disease


Spirometry and smoking cessation

• to detect lung diseases in susceptible smokers

• to increase smoking cessation rates, as a consequence of a

reinforced motivation to quit caused by the objective

demonstration of lung function impairment

• offer health professionals a tool to show objectively the

effects of smoking, tailored to the individual patient


CHARACTERISTICS OF RESPIRATORY

PATIENTS WHO SMOKE

• Why respiratory patients are a difficult target

• Self-medication for comorbidity

• Dependence

• Smoke inhalation pattern

• Weight control


“Tolerance” to the quit advise &

hypothesis on selection of “Recalcitrant

Smokers”

Repeated advice to quit smoking | Same treatments suggested repeatedly

Years of smoking

Respiratory symptoms Worsening of respiratory symptoms

Quit fails

• Smoking is believed as cause of respiratory symptoms

fails fails

• Self-medication for depressed mood and anxiety

• Higher level of nicotine dependence

Based on: Tonnesen et al. Smoking cessation in patients with respiratory diseases: a high priority, integral component of therapy. Eur Respir J 2007; 29(2): 390-417.

Self-medication for comorbidity

• High prevalence of depression or low mood in respiratory patients who

smoke

– Depression is independently associated with smoking and failure to give up

– Depressed mood is also one of very few withdrawal symptoms that predicts

relapse to smoking

• Anxiety level, which is often a part of depression, is higher among COPD

smokers

• Relapsing after a quit attempt may be a way to escape from depressive

mood and anxiety


Prevalence of psychological distress and depressed mood is higher in COPD/asthmatic patients who smoke than in COPD/asthmatic patients who do not smoke

Wagena EJ,et al. Psychological distress and depressed mood in employees with asthma, chronic bronchitis or emphysema: a population-based observational study on prevalence and the relationship with smoking cigarettes. Eur J Epidemiol 2004; 19(2): 147-53.

Patients with chronic bronchitis (with respect to asthmatic and healthy individuals) show a higher prevalence of depression and anxiety, regardless of smoking habit.

In patients with chronic bronchitis, the probability of having anxiety and depression significantly increases in ex- and current smokers

Wagena EJ, et al. Risk of depression and anxiety in employees with chronic bronchitis: the modifying effect of cigarette smoking. Psychosom Med 2004; 66(5): 729-34.

Dependence &

Smoke inhalation pattern• Respiratory smoking patients, and particularly COPD patients, have higher

dependence on tobacco

• Whereas smokers in general tend to inhale smoke in two steps, firstly

taking the smoke into the mouth and upper airways and then inhaling it

into the lungs, smokers with COPD seem to inhale the smoke more

directly into the lungs


With respect to smokers without COPD, smokers with COPD show higher cigarettes consumption, higher nicotine dependence, higher levels of expired CO and inhale smoking more frequently

Jimenez-Ruiz CA, et al. Smoking Characteristics : Differences in Attitudes and Dependence Between Healthy Smokers and Smokers With COPD. Chest 2001; 119(5): 1365-1370.

Weight control

• Weight gain of 4–5 kg typically observed during the first year after quitting

smoking might be an advantage for many end-stage COPD patients, where

low BMI is associated with a poorer prognosis

• Theoretically weight gain might also be beneficial in lung cancer patients

with decreased appetite


SMOKING REDUCTION

Definition

• A decrease in the number of cigarettes (or amount of

tobacco) smoked daily

• A 50% reduction or more in daily cigarettes has been chosen

arbitrarily in most studies, confirmed by any decrease in

exhaled CO levels

• Smoking reduction makes it possible to recruit smokers who

are not interested in abrupt cessation

• The reduction process should be viewed as a gateway to

complete cessation


SMOKING REDUCTION

Implementation

• Patients with respiratory disorders who smoke and who are

not motivated to quit

• Prescribe NRT for 3 months and recommend to reduce

number of cigarettes per day by ≥ 50% during the first 1– 2

weeks and then to try to reduce further

– If the smoker has not reduced by 50% after 3 months, NRT should be

stopped as the chance of subsequent quitting is low

– In smokers who have reduced by 50% at 3 months, NRT should be

continued for up to 1 yr, but after 6 months the patient should be

recommended to try to stop smoking completely


ORGANISATIONAL ANCHORAGE AND

EDUCATION

• Smoking cessation services should be an integral part of a

chest unit, in the same way as lung function testing and

bronchoscopy

– offering advice and help to all smokers with respiratory diseases

independently of the smoker’s motivation

– focusing primarily on those who want to try to quit

– supporting smoking reduction in smokers who are unable to quit

• As a minimum, chest departments should offer

– smoking cessation support

– NRT and/or bupropion SR

– at least four follow-up visits to all smokers


Equipment and staffing

• To assess CO level, nicotine dependence and motivation to

quit

• One or two staff members should be responsible for the

smoking cessation programme, staff training, and

management of the practical aspects

• If the clinic cannot offer smoking cessation services, there

should be written flowcharts stating where to refer the

patients

• To engage GPs in smoking cessation, as many patients consult

their GP frequently


review of current guidelines on smoking cessation · treatment to achieve smoking cessation,...

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