SMOKING CESSATION PANBC Conferenc e Nov 5, 2016 —————————— Steve Petrar Anesthesiologist St. Paul’s Hospital
OBJECTIVES Epidemiology, current smoking trends, & tobacco addiction Smoking cessation counseling, quit aids, & resources Benefits of smoking cessation in surgical patients E fficacy of interventions by perioperative providers anesthesiologists, nurses, RTs, & surgeons
EPIDEMIOLOGY & TOBACCO ADDICTION Global epidemiology Canadian patterns Attributable harms Mechanisms of addiction
GLOBAL EPIDEMIOLOGY Age-standardized smoking prevalence among men, 2012 Age-standardized smoking prevalence among women, 2012 JAMA 2014
GLOBAL EPIDEMIOLOGY Leading cause of preventable death Global prevalence declining: 20% of deaths in men >30 Men : 41% ➙ 31% (1980 - 2012) 5% of deaths in women >30 Women : 11% ➙ 6% (1980 - 2012) Up to 1/2 of current users will die of tobacco related disease One billion smokers worldwide 6 million deaths annually attributed to tobacco worldwide ~60% prevalence in Russian/ Chinese men ~600K from second-hand smoke WHO 2013, The Tobacco Atlas 2012
CANADIAN TRENDS Following widespread recognition of the harms of smoking & public health efforts to combat tobacco use, smoking rates have steadily declined Tobacco Use in Canada: Patters and Trends 2013
WHY IS TOBACCO ADDICTIVE? Nicotine binds nicotinic AcH receptors in the CNS Primarily in the ventral trigeminal area (VTA) Resultant dopamine release in the nucleus accumbens is linked to reward
COUNSELING, QUIT AIDS, & RESOURCES Approach to cessation counseling Assessment of nicotine dependance Pharmacologic quit aids
OVERVIEW OF CESSATION COUNSELING A. Pharmacotherapy + psychosocial treatment offered to every smoking interested in quitting B. Provision of pharmacotherapy standard practice C. Psychosocial interventions : Support every quit attempt Dose-response effect between session duration and success (but short sessions are still useful) A variety of formats are effective (self-help, individual, group, help-line, web-based, etc) Advise on how to avoid high-risk situations for relapse Canadian Smoking Cessation Clinical Practice Guidelines 2011, US PHS Guideline for Treating Tobacco Use & Dependance 2008
THE 5 A’S
TRANSTHEORETICAL MODEL (STAGES OF CHANGE)
FAGERSTROM TEST FOR NICOTINE DEPENDANCE & HSI
PHARMACOTHERAPY Nicotine Replacement Therapy MUST be dosed based on 0.5mg daily x 3d (NRT) estimates of nicotine 150mg daily x 3d 0.5mg BID x 4d dependance and daily 150mg BID x 7-12wks 0.5-1mg BID x 12wks initiate quit after 1st week nicotine requirements Initiate quit after 1 week (coming up in 2 slides!) Antidepressant Nicotine Acetylcholine Receptor Buproprion partial agonist - Varenicline (Zyban) (Champix)
NICOTINE REPLACEMENT THERAPY (NRT) Reduces physiologic withdrawal symptoms Avoids carcinogens, mutagens, chemicals, and toxins present in tobacco smoke Requires TITRATION to effect
NRT AND CARDIOVASCULAR EVENTS Isn’t NRT unsafe in patients with CVS disease? Doesn’t it increase cardiac events? Very high doses (higher than available NRT) may adversely affect microvascular anastomoses of free flaps Now, widely accepted that NRT does not increase risk of perioperative complications - ACS/MI, stroke, mortality Former conclusions that NRT increases CVS events were driven by increase in tachycardia and palpitations (largely benign) Mayo Clin Rev 2015
BUPROPION SR (ZYBAN) 150mg daily x 3 days, then 150mg BID x 7-12 weeks Initiate quit attempt after 1 week of Rx Side effects: Dry mouth, dizziness, insomnia, restlessness Lowers seizure threshold Contraindicated in seizure d/o, eating d/o, intracranial abnormality quitnow.ca, Cochrane 2014
VARENICLINE (CHAMPIX) Partial ⍺ 4 β 2 nicotinic ACh receptor 0.5mg daily x 3d, then 0.5mg BID x 4d, then 0.5-1mg BID x 12wks Initiate quit attempt after 1 week of Rx Side effects: Nausea (30%), insomnia, vivid dreams, CVS risk?, neuropsych? Contraindicated in CVS disease? Psychiatric disease?
VARENICLINE (CHAMPIX) 2012 Cochrane meta-analysis of 14 trials, 6166 patients Abstinence at ≧ 6mo was “2 to 3 fold greater” with varenicline RR 2.27 (CI 2.02 - 2.55) Subsequent 2013 Cochrane review added 1 more (positive) trial RR 2.88 (CI 2.40 - 3.47) Cochrane 2012
VARENICLINE AND CVS EVENTS 2012 meta-analysis of 22 trials No significant increase is CVS events related to varenicline Risk difference 0.27% (CI -0.1% - 0.63%) “Not clinically or statistically significant” BMJ 2012
VARENICLINE AND NEUROPSYCHIATRIC EVENTS There WAS a Meta-analysis of 39 trials, ~11,000 patients significant No significant increase in: increase in insomnia, Suicide / attempted suicide / suicidal ideation abnormal Depression / irritability / aggression dreams, and fatigue! Death BMJ 2015
E-CIGS? We get it, you vape…
E-CIGS Evidence to date graded as “low” or “very low” quality Nicotine E-cig may be as effective as NRT for achieving 6mo abstinence (poorly verified - “very low quality”) No significant “harms” captured in review Concerns: Lack of standardization / quality control Smokers who would have quit continue to “smoke” Re-normalization of smoking behavior & targets youth Cochrane 2014
BENEFITS IN SURGICAL & PERIOPERATIVE PATIENTS Mechanism of harm Plastic surgery Major surgery Cardiac surgery Cancer surgery
MORE COMPLICATIONS!!!! thromboxane A2 increased blood viscosity impaired immune response tissue hypoxia vasoconstriction carcinogenesis catecholamine release impaired ciliary function thrombogenesis increased platelet activation polycythemia increased oxygen free-radicals CO toxicity impaired gas exchange endothelial dysfunction systemic inflammation accelerated atherosclerosis J Am Coll Surg 2012
HOLD ON A MINUTE…… “the fact that anesthesiologists rarely see their patients 4 weeks or more before surgery presents a dilemma: if one is unable to advise the patient to stop smoking 8 weeks or more before surgery, is it preferable for the patient to continue smoking?” Miller, 7th ed. 2010 Doesn’t quitting immediately before surgery increase complications?? NO! This is out-dated and false. Patients should ALWAYS be advised to quit
STILL NOT CONVINCED? Arch Int Med 2011, Can J Anes 2012, Anes Analg 2011
PLASTIC SURGERY necrosis of the wound OR 3.61 (CI 2.78-4.68) wound dehiscence OR 2.86 (CI 2.78-4.68) surgical site infection OR 2.12 (CI 1.56-2.88) Ann Plastic Surg 2013
MAJOR SURGERY NSQIP data corresponding to ~142K patients who underwent one of 16 “major” surgeries Primary outcome was occurrence of a predefined adverse post- operative outcome or “complication” Am J Surg 2015
CARDIAC SURGERY 2,587 consecutive CABGs, 18% current smokers (n=475) Retrospective cohort study Increased pulmonary complications in smokers ( OR:1.59 , 1.21-2.10) Ann Thor Surg 2008
CANCER SURGERY Current smokers had significantly more surgical site infections , Current smokers had significantly compared to non smokers more pulmonary complications , compared to Current smokers had significantly OR 1.20 (CI 1.05 - 1.38) non smokers higher mortality , compared to VASQIP database study including 20,413 patients non smokers OR 1.96 (CI 1.68 - 2.29) Gastrointestinal, lung/thoracic, and Urologic cancer surgeries OR 1.41 (CI 1.08 - 1.42) Divided into current, prior, or never smokers Ann Surg Onc 2014
EFFICACY OF INTERVENTIONS IN PERIOPERATIVE PATIENTS Counseling + NRT Verenicline Bupropion
COUNSELING + NRT patients randomized to counseling & free supply of NRT vs brief / no specific smoking intervention Anaesthesia 2009, Anes Analg 2013
COUNSELING + NRT Fast forward one year… 7-days pre-op abstinence sig. higher for intervention group RR 4.0 CI 1.2-13.7 / NNT 9.3 30-day abstinence sig. higher for intervention group RR 2.6 CI 1.2-5.5 No significant difference in perioperative outcomes complications / morbidity / mortality / LOS / etc. Anes Analg 2013, Anes Analg 2015
COUNSELING + NRT 3 week pre-op & 4 week post-op abstinence sig. higher for intervention group 20/55 (36%) vs 1 / 62 (2%) (p<0.001) 1 year abstinence sig. higher for intervention group 18/55 (33%) vs. 9/62 (15%) (p=0.03) Anaes 2009
SPH - NRT We have PPO’s for NRT for inpatients!
VARENICLINE 12mo. abstinence rate of 36.4% vs 25.2% in the 286 patients booked for elective surgery enrolled in PAC treatment group vs placebo randomized to varenicline or placebo RR 1.45 (CI 1.01 - 2.07) initiated Rx one week pre-op; quit date 24 hrs pre-op all received standardized counseling (15min session x 2) Primary outcome = abstinence at 12 months Anesthesiology 2012
COCHRANE 13 trials, 2010 patients enrolled Behavioral therapy (counseling) Scheduled quit date NRT Varenicline Cochrane 2014
COCHRANE Authors conclude: Behavioral support + NRT increases abstinence Behavioral support + NRT may reduced complications Varenicline increases long-term quitting Varenicline does not increase periop abstinence or reduce complications Intensive counseling + NRT appears to have the greatest periop effect Cochrane 2014
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