04 - steve's presentation -smoking cessation nov 5 2016 panbc · 1/4/2016 · smoking...
TRANSCRIPT
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SMOKING CESSATIONPANBC
Conference
Nov 5, 2016——————————
Steve Petrar
AnesthesiologistSt. Paul’s Hospital
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OBJECTIVES
Epidemiology, current smoking trends, & tobacco addiction
Smoking cessation counseling, quit aids, & resources
Benefits of smoking cessation in surgical patients
Efficacy of interventions by perioperative providers
anesthesiologists, nurses, RTs, & surgeons
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EPIDEMIOLOGY & TOBACCO ADDICTION
Global epidemiology
Canadian patterns
Attributable harms
Mechanisms of addiction
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Age-standardized smoking prevalence among men, 2012
GLOBAL EPIDEMIOLOGY
Age-standardized smoking prevalence among women, 2012
JAMA 2014
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GLOBAL EPIDEMIOLOGY
Global prevalence declining:
Men: 41% ➙ 31% (1980 - 2012)
Women: 11% ➙ 6% (1980 - 2012)
One billion smokers worldwide
~60% prevalence in Russian/Chinese men
WHO 2013, The Tobacco Atlas 2012
Leading cause of preventable death
20% of deaths in men >30
5% of deaths in women >30
Up to 1/2 of current users will die of tobacco related disease
6 million deaths annually attributed to tobacco worldwide
~600K from second-hand smoke
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CANADIAN TRENDS
Tobacco Use in Canada: Patters and Trends 2013
Following widespread recognition of the
harms of smoking & public health efforts to combat tobacco use, smoking rates
have steadily declined
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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
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COUNSELING, QUIT AIDS, & RESOURCES
Approach to cessation counseling
Assessment of nicotine dependance
Pharmacologic quit aids
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OVERVIEW OF CESSATION COUNSELINGA. 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
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THE 5 A’S
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TRANSTHEORETICAL MODEL(STAGES OF CHANGE)
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FAGERSTROM TEST FOR NICOTINE DEPENDANCE & HSI
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PHARMACOTHERAPY
NicotineReplacement
Therapy(NRT)
Antidepressant Buproprion
(Zyban)
Nicotine Acetylcholine Receptorpartial agonist - Varenicline
(Champix)
MUST be dosed based onestimates of nicotinedependance and dailynicotine requirements(coming up in 2 slides!)
150mg daily x 3d150mg BID x 7-12wks
initiate quit after 1st week
0.5mg daily x 3d0.5mg BID x 4d
0.5-1mg BID x 12wksInitiate quit after 1 week
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NICOTINE REPLACEMENT THERAPY (NRT)
Reduces physiologic withdrawal symptoms
Avoids carcinogens, mutagens, chemicals, and toxins present in tobacco smoke
Requires TITRATION to effect
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NRT AND CARDIOVASCULAR 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)
Isn’t NRT unsafe in patients with CVS disease? Doesn’t it increase cardiac
events?
Mayo Clin Rev 2015
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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
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VARENICLINE (CHAMPIX)
Partial ⍺4β2 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?
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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
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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
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VARENICLINE AND NEUROPSYCHIATRIC EVENTS
Meta-analysis of 39 trials, ~11,000 patients
No significant increase in:
Suicide / attempted suicide / suicidal ideation
Depression / irritability / aggression
Death
There WAS a significant increase in insomnia, abnormal
dreams, and fatigue!
BMJ 2015
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E-CIGS?
We get it,you vape…
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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
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BENEFITS IN SURGICAL & PERIOPERATIVE PATIENTS
Mechanism of harm
Plastic surgery
Major surgery
Cardiac surgery
Cancer surgery
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tissue hypoxia
CO toxicityendothelial dysfunction
catecholamine releasevasoconstriction
thromboxane A2
polycythemia
increased blood viscosity
thrombogenesis
systemic inflammation
impaired ciliary function
accelerated atherosclerosisimpaired gas exchange
increased platelet activation
impaired immune response
carcinogenesis
increased oxygen free-radicals
MORE COMPLICATIONS!!!!
J Am Coll Surg 2012
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HOLD ON A MINUTE……
Doesn’t quitting immediately before surgery increase complications??
NO! This is out-dated and false.
Patients should ALWAYS be advised to quit
“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
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STILL NOT CONVINCED?
Arch Int Med 2011, Can J Anes 2012, Anes Analg 2011
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PLASTIC SURGERY
Ann Plastic Surg 2013
necrosis of the woundOR 3.61 (CI 2.78-4.68)
wound dehiscenceOR 2.86 (CI 2.78-4.68)
surgical site infectionOR 2.12 (CI 1.56-2.88)
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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
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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
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CANCER SURGERY
VASQIP database study including 20,413 patients
Gastrointestinal, lung/thoracic, and Urologic cancer surgeries
Divided into current, prior, or never smokers
Ann Surg Onc 2014
Current smokers had significantly more surgical site infections, compared to non smokers
OR 1.20 (CI 1.05 - 1.38)
Current smokers had significantly more pulmonary complications, compared to non smokers
OR 1.96 (CI 1.68 - 2.29)
Current smokers had significantly higher mortality, compared to non smokers
OR 1.41 (CI 1.08 - 1.42)
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EFFICACY OF INTERVENTIONS IN PERIOPERATIVE PATIENTS
Counseling + NRT
Verenicline
Bupropion
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COUNSELING + NRT
Anaesthesia 2009, Anes Analg 2013
patients randomized to counseling & free supply of NRT vs brief / no specific smoking intervention
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COUNSELING + NRT
Anes Analg 2013, Anes Analg 2015
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.
Fast forward one year…
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COUNSELING + NRT
Anaes 2009
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)
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SPH - NRT
We have PPO’s for NRT for inpatients!
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VARENICLINE
286 patients booked for elective surgery enrolled in PAC
randomized to varenicline or placebo
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
12mo. abstinence rate of 36.4% vs 25.2% in the
treatment group vs placeboRR 1.45 (CI 1.01 - 2.07)
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COCHRANE
Cochrane 2014
13 trials, 2010 patients enrolled
Behavioral therapy (counseling)
Scheduled quit date
NRT
Varenicline
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COCHRANE
Authors conclude:
Cochrane 2014
Intensive counseling + NRT appears to have the greatest
periop effect
Behavioral support + NRT increases abstinence
Behavioral support + NRT may reduced complications
Varenicline does not increase periop abstinence or reduce complications
Varenicline increases long-term quitting
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CAS Stop Smoking For Safer Surgery pagehttp://www.cas.ca/English/Stop-Smoking
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ASA Be Smoke Free for Surgery pagehttp://www.asahq.org/resources/clinical-information/asa-stop-smoking-initiative
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THE BOTTOM LINE
“As the traditional practice of anaesthesia changes and the scope of anaesthetic practice
expands beyond the operating theatre to include peri-operative medicine, it is time for anaesthetists to participate actively in
interventions of peri-operative smoking cessationas part of a ‘pre-habilitation’ programme.”
Anaesthesia 2015
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PAC Friday afternoon…. Next patient is for an
elective TKA Monday AM. Should we proceed?
Hgb 84(No prior Hgb avail)BP 190/95
(No current anti-HTN Rx)
3x pre-syncopein last month
III/VI SEM (No prior echo)
1 PPD x 40 yrs
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QUESTIONS?