# LMCC/Smoking Cessation
## Epidemiology

* single most preventable cause of illness and death
* 70% of smokers will see a physician every year
* of those aged 15 or older:
** 22% are current smokers
** average 16 cigarettes /day
** highest prevalence between 20-24
** higher in teen girls than teen boys
** more individuals are quitting than in past

## Management
### General approach

* identify users, elicit their smoking habits and establish the results of prior quit attempts
* every smoker should be offered treatment
* Highest yield technique is to host >4 counselling session of > 10 minutes in length over a 12 month period
** 14% will remain abstinent with counselling vs. 10%

### Willing To Quit?
#### The 5 A's for patients willing to quit

Ask if patient smokes
Advise patient to quit
Assess willingness to quit
Assist in quit attempt
Arrange follow-up

#### Use a STAR to assist patients in developing a quit plan

Set quit date
Tell family and friends
Anticipate challenges
Remove tobacco products
* if a patient is pregnant advise them to quit without using pharmacotherapy

#### Nicotine Replacement Therapies (NRT)

* 20% abstinence @ 12 months
* Form of NRT is irrelevant to abstinence rates
* Contraindications: recent MI, serious or worsening angina, serious arrhythmia
| Type | Dosage | Comment | Side Effects |
| Nicotine gum | 2mg if < 25 cig/day 4mg if > 25 cig/day 1 piece q1-2h for 1-3 months, maximum 24 pieces/day | Chew until "peppery" taste, then place between gum and cheek to maximize absorption, continuing for 30 minutes | Usually transient: mouth soreness hiccups dyspepsia jaw ache |
| Nicotine Patch | Use for 8 weeks 21 mg/d x 4 weeks 14mg/d x 2 weeks 7mg /d x 2 weeks | Start with lower dose if <10cigs/day Change to patch q24h and rotate sides | skin irritation insomnia |
| Nicotine Inhaler | 6-16 cartridges per day for 3 months with gradual tapering afterward | | Cough irritation rhinitis |
| Nicotine Nasal Spray | 1-2 sprays/hour Do not exceed 10 sprays per hour Do not exceed 80 sprays per day | Higher rate of dependence | irritation rhinitis |

#### Buproprion (Zyban)

* 21% abstinence @ 12 months
* inhibits dopamine and norepinephrine reuptake
* patient is to smoke for first 2 weeks of treatment and then completely stop
* can be used with nicotine replacement therapy
* Contraindications: seizure disorder, eating disorder, MAOI use in past 15 days, use of Wellbutrin (an alternative labelling of buproprion marketed for depression)
* side effects: insomnia, dry mouth

### Unwilling To Quit?
#### The 5 R's for patients unwilling to quit

Relevance to patient Risks of smoking Rewards of quitting Roadblocks to quitting Repetition of motivational intervention at each visit

#### Risks of smoking

Short term:
* shortness of breath
* asthma exacerbation
* impotence
* infertility
* pregnancy complications
Long term:
* increased risk of heart attack and stroke
* chronic obstructive pulmonary disease (COPD)
* lung cancer/other cancer
Environmental:
* higher cancer risks in spouse and children
* increase in sudden infant death syndrome
* asthma/respiratory infections in housemates

#### Benefits of smoking cessation

* improved health
* improved finances
* improved taste and smell
* sets a good example for children

#### Obstacles to smoking cessation

* fear of withdrawl
* weight gain
* fear of failure
* lack of support

#### Repetition

* reassure an unsuccessful patient that most people have multiple attempts before succeeding.

### Recent quitter?

* the highest rate of relapse is within the first 3 months, therefore prevention at this time is imperative!
** minimal practice: congratulate on success and encourage ongoing abstinence, reviewing the benefits of quitting and any unforeseen problems
** prescriptive interventions can be used to address problems of weight gain, negative mood, withdrawal and lack of support.