contemporary issues & contemporary practice · nicotine addiction and to ... the authors...
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Clinical Smoking Cessation in 2015
Contemporary Issues & Contemporary Practice
Andrew Pipe, CM, MD Robert Reid, PhD
Division of Prevention & Rehabilitation
Transforming …
Professional Behaviours
Institutional Practices
Patient Care
Little Bobby Reid
Declaration
In the past I have received research and educational support from, and/or served as a consultant to:
PFIZER
GSK JOHNSON & JOHNSON
AMGEN
5,000,000 daily smokers Annual quit rate of 1.3% > 80% say they want to quit 42% made a quit attempt this year 41% have history of mental illness Cessation services reach < 5%
Source: OTRU 2012
Motives for Smoking
• Affiliative attachment
• Automaticity • Cognitive
enhancement • Craving • Cue exposure • Loss of control
• Negative reinforcement
• Positive reinforcement
• Social/environmental goads
• Taste/sensation • Weight control
Adapted from McEwen et al, Manual of Smoking Cessation 2006
Nicotine Addiction
Nicotine rewards smoking
Nicotine alters the brain
Psychological and social forces are
at work
Dopamine release Signal to notice and
repeat
Acquired ‘drive’ (hunger)
Urge to smoke if abstinent for a while Reminders (cues)
increase urge Pairing of stimuli
Beliefs about stress control
Identity Camaraderie
N Engl J Med 2014;371:2353-2362
Cytisine is a plant-based alkaloid which, like varenicline, is a partial agonist of
nicotinic acetylcholine receptors.
N Engl J Med 2014;371:2353-2362
Kaplan–Meier Curve for Time to First Relapse
N Engl J Med 2014;371:2353-2362
When combined with brief behavioural
support, cytisine was superior to NRT in
helping smokers quit, but was associated with more adverse
events.
Smoking Cessation “The Most Important
Preventive Intervention!”
Gaemperli O, et al Curr Pharm Des 2010;16:2586-2597
Adoption
Fidelity
Cost to Implement
Penetration
Sustainability
IMPLEMENTATION OUTCOMES
Structural
Organization
Smoker
Intervention
Smoker Provider
CAUSAL FACTORS
The Ottawa Model results in significant reductions in 2-year healthcare utilization
and risk of death
All-cause readmissions
(p<.0001)
NNT: 7
21% 21%
Smoking-related readmissions
(p<.0001)
NNT: 10
ER visits (p=.04)
NNT: 25
9% 40%
Death (p=.0002)
NNT: 14
MyQuit Partners
N Engl J Med 2014;370:2219-2227
Adverse Effects of Long-Term or Heavy Use of Marijuana
N Engl J Med 2014;370:2219-2227
Level of Confidence in the Evidence for Adverse Effects of Marijuana on Health and Well-Being
What to do about e-cigarettes
Harm reduction potential – Vapour vs. Smoke Cessation of smoking? Dual-Use? Tobacco industry – Perpetuation of smoking? Initiation of smoking? – Adolescents?
The E-cigarette.
Nicotine & Tobacco Research 2014;doi:10.1093/ntr/ntu213
Almost a third of e-cigarette users are
nonsmokers, suggesting that e-cigarettes
contribute to primary nicotine addiction and to
re-normalization of tobacco use.
Nicotine & Tobacco Research 2014;doi:10.1093/ntr/ntu234
Seven percent of Ontario high school students who have
never smoked a tobacco cigarette in
their life report using an e-cigarette
“This letter reports a chemical analysis of vapor from electronic cigarettes that shows high levels of formaldehyde, a known carcinogen. The authors project that the associated incremental lifetime risk of cancer could be higher than that of long-term smoking.”
Jensen R P et al N Engl J Med 2015;372:392-394
Making Healthier Choices Act, 2014:
Ban the sale of e-cigarettes to anyone under the age of 19.
Prohibit the use of e-cigarettes where the smoking of tobacco is prohibited.
Ban the sale of e-cigarettes where the sale of tobacco is prohibited.
Prohibit the display and promotion of e-cigarettes in places where e-cigarettes or tobacco products are sold.
Ban the sale of flavoured tobacco products, with a delayed implementation date for menthol-flavoured tobacco products.
Increase maximum fines for those who sell tobacco to youth, making Ontario's maximum fines the highest in Canada.
Strengthen enforcement to allow for testing of substances used in waterpipes (e.g. hookahs, shisha) in indoor public places.
Andrew Pipe Starter Kit
Bob Reid
Images intended for health warnings in Africa, showing (clockwise from top left) birth defects, rotting teeth, gangrene, impotence, throat cancer and blindness
Two of the American warning images ruled to have violated the right of free speech
The four text warnings that have been present on US packets of cigarettes since 1984
Top L-R: Taiwan, India, Belgium, Thailand, Ireland, USA. Bottom: UK, China, Uruguay, Australia, Mexico
A side-opening pack of cigarettes
A "book pack" without warnings on the inside
