practical advice for managing smokers - cyberport
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Practical Advice For
Managing Smokers
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How can a Doctor Advice?
5 As (ask, assess, advise, assist, arrange)
European Society of Cardiology
Assess dependency
Personaling benefits of cessation Boosting Motivation
Recommending medication
Set Quit Date
Arrange follow-ups
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Determining smoking history, including:
Number and methods of previous quitattempts
Previous lengths of abstinence
achieved Whether smokers who quit recently are
calling themselves non-smokers
Usually patients visit for another health
problem So, a link might be made between
smoking and other health problems
But be careful not to accuse or
alienate
Outcomes of Asking About Smoking
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Assessing Dependency
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Assessing Dependency
There are smokers who will still smokeafter a serious illness
Use Fagerstroms test for Nicotine Dep
How many cigarettes do you smoke? How long after awakening do you
smoke your first cigarette?
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Advice To Stop Smoking:Common Elements
Systematically asking about smoking atevery visit
Strongly advising a smoker to quit
Offering treatment to aid the quitattempt
Providing or arranging for support
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Personally relevant to the patients
situation
Unambiguous
Non-judgmental Empathic
Advice to Quit Smoking Should Be:
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Give Strong Advice to Quit Smoking
Comparison
N
Trials
N
Participants
Pooled OR*
(95% CI)
Physician advice1
Minimal vs no advice (usual care)Intensive vs minimal advice
1715
13,7249775
1.66 (1.42-1.94)1.37 (1.20-1.56)
1. Lancaster T, Stead LF. Cochrane Database Syst Rev. 2004;(4):CD000165.
Abstinence rates in the table below are assessed at least 6 monthsfollowing intervention for quitting smoking
Minimal advice Single session lasting 1 follow up
Other materials besides a pamphlet
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Give a reason to quit
Acknowledge quitting can be difficult(may take many attempts)
Motivate the smoker by offeringassistance
Strong Advice to Stop Smoking:Examples of What You Can Say
Stopping smoking is the single best
thing that you can do to improve
your current and future health
Tobacco is very
addictive, so it can bevery difficult to give
up, and many peoplehave to try severaltimes before theysucceed
The important thing
is to keep trying
If you would like to
give up smoking, I canhelp you succeed with
support and proveneffective medication
If you are interested in
stopping smoking, thereare services and
medications which canhelp you in your quitattempt
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Benefits of Cessation
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Benefits of Cessation
We have to be direct and clear
As your doctor, I strongly advise you to
stop..
Show them models of heart disease Show them studies that smoking cessation
reduces heart disease
Smoking cessation can increase the HDL
Less LDL oxidation when stop smoking
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Motivational Support
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Motivational Support
Motivational Counseling
Empower the patient to make decision
We guide them to making the decision
It is the patient and NOT THE DOCTOR that isresponsible for the change in behavior
Help patient to explore and see ambivalence
Rate 1-10 why are you a 3 on the scale andnot 10?
Change is likely when patients are helped to makedecisions for themselves
If there is low scale use level of motivation todetermine the next step.
Once willing set Quit Date!
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Motivational Support
Express empathy and avoid arguments
Use I understand, I am sorry, OK ..
Ask also What you like/dislike aboutsmoking?
What are your concerns aboutsmoking?
Summarize
Where does that leave you now?
What will you do now? Raise Self EfficacyWill you quit now
rate 1-10?
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Motivational Support
Talk about roadblocks to stopping smoking Tie in potential advantages in quitting
Saving cost make them count how much theywill save
Example to children/grandchildren
Being in good health can exercise better
If they express poor desire to stop smoking donot stop giving support.
Continue to give support Tell them when theywant to stop to come and see you
Probably medication might help offer them Assure weight gain is better than smoking
It takes about 40kg excess to equal theharm of 10 cigarette per day
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Pharmacotherapy
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NRT and Non Nicotine Drugs
NRT make sure we know how to use it
Counsel and follow-up is important
Any one can do sometimes using 2 NRT will be
good. Guide patient on dose reduction
If not use properly restart and make sure it is doneproperly
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NRT and Non Nicotine Drugs
Non Nicotinic Drugs
Varenicline
Usual Course is 12 weeks
First determine QUIT DATE before startingVarenicline
Patient should be monitored for neuropsychiatriceffects ( depression, suicidal, behavior)
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Champix: Starter Pack (2 weeks)
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Behavioral Advice
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Smoking Cessation Behaviouralor Supportive Therapy1
Quitlines Group Counselling
Individual Counselling
Self-help
1. Fiore MC, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice
Guideline.US Department of Health and Human Services. Public Health Service; May2008. Available at: www.surgeongeneral.gov/tobacco/default.htm
Internet Resources
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Behavioral Advice
Combining Drugs and Counseling increases Quit rates
Make smokers think of high risk situation and think ofalternative coping strategies
Social events stay away or come prepare Announce Quit Date with at least 1 relative/friend
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Behavioral Advice
Quit Date
Should be within 4 weeks from a Doctors Visit
Date should be free of stress
If using with medication, make sure you plan the dateswell.
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Follow Up
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Follow-Up
The most important part in Smoking Cessation
Offer as much as possible and try to make sure thatphysician do not put barriers to follow-up
Any kind of follow-up is possible
Any Health Care personnel can do it.
A health care personnel associated with the doctor ora stop smoking clinic is more effective.
Health Care needs to be trained for smokingcessation clinic.
Make it a regular schedule
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Developing a System:Long-term Follow Up
Who carries out long-term follow up andwhat form should this take?
How do you optimize the system to help arelapsed patient who is still willing to quit?
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Relapse Patient
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Keep the patient motivated
Schedule follow up (even minimalcontact)
Praise periods of abstinence Explain to patients that a lapse is not a
failure (continue the quit attempt)
Offer the patient other support (eg,
quitlines, group therapy)
Office- or hospital-based systems can helpthe healthcare provider improve support
Providing or Arranging Support
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Relapse Patient
Keep data of all smokers who haveenrolled in your stop smoking clinic
Contact them once a year WNTD
Tell them you are still there for them.
Encourage them to quit smoking again.
Learn from the relapse to cope better
Better to use medication and closer follow-
ups
Developing a ystem:
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Developing a ystem:Identification and Documentationof Smokers
30% of smokers say they are not askedabout smoking status at a clinic visit1
How do you proactively identify anddocument patients in your practice who
should quit smoking?
How could a system improve thisidentification and documentation?
1.
Reid RD et al (2009) Patient Educ Couns76:99-105
Example of a Successful Tobacco
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Example of a Successful TobaccoDependence Treatment System:The Ottawa Model
Reid RD, Pipe AL, Quinlan B. Can J Cardiol2006;22:775780
http://www.ottawamodel.ca
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The Systematic Approach of theOttawa Model
Patient Registration/Assessment
Physician AdmittingOrders
Nursing History
Patient Care Maps Critical Pathways Kardex
Ottawa Model SmokingCessation Consult Form
Standard Orders forPharmacotherapy
Self-help Material
IVR* System and NurseCounselling for 6 Months
Community Cessation
Identification &Documentation
Counselling &Pharmacotherapy
Follow Up
and/or and/or
and/or and/or
*IVR = Interactive Voice Response Follow-up System and Databasehttp://www.ottawamodel.ca/en_about.php#1
Quit Lines Programmes
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Roadblocks to Treating TobaccoDependence
In spite of practical, effective therapies,why isnt smoking cessation more common in clinical
practice?Physician-perceived barriers1
Lack of patients interest
Lack of reimbursement
Lack of time Lack of access to other support
resources
Lack of training
Treat other diseases beforesmoking
Believes cessation heightensother symptoms
Not their job to treat smoking
Patient-perceived barriers
Enjoyment of smoking
Craving
Stress relief
Withdrawal symptoms
Weight gain
Fear of failure
Costs
Discouragement
Timing of classes
Disrupt social relations
1. American Legacy Foundation. Physician Behavior and Practice Patterns Related toSmoking.AAMC; 2007. Available at: http://www.aamc.org/workforce/smoking-
cessation-full.pdf2. UW-CTRI. Barriers to Quitting Smoking. 2005. Available at:http://www.ctri.wisc.edu/Publications/publications/BarrierstoQuitting.2.28.pdf
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How Would You Manage aSmoker
1. Making a first quit attempt?
2. Who has repeatedly failed to quit?
3. With past history of depression?
4. With a physical comorbidity (eg, COPD)?
5. Who claims that medications are not working?6. Who considers successful reduction in daily
smoking as a success, but who has not quit?
7. Who is teenager?
8. Who is concerned about drug interactions with an
existing medication for another disorder?
9. Who has never been willing to quit?
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Thank you.