The Ottawa Model for Smoking Cessation for Smokers with Cerebrovascular Disease

Robert D. Reid, Ph.D.

October 20, 2008

DisclosuresDisclosures

• I have received research support in I have received research support in the past 12 months from:the past 12 months from:

• PFIZERPFIZER

• I have received consulting fees in I have received consulting fees in the past 12 months from:the past 12 months from:

• PFIZER, MINISTRY OF HEALTH PFIZER, MINISTRY OF HEALTH PROMOTION, HEALTH CANADAPROMOTION, HEALTH CANADA

AcknowledgementsAcknowledgements

Smoking and StrokeSmoking and Stroke

Smoking contributes to Smoking contributes to 12% to 14% of all stroke deaths12% to 14% of all stroke deaths

Smoking may potentiate the effects Smoking may potentiate the effects of other stroke risk factorsof other stroke risk factors

Smoking increases stroke riskSmoking increases stroke risk– Acutely: effects on thrombus Acutely: effects on thrombus

formationformation– Chronically: increased burden Chronically: increased burden

of atherosclerotic diseaseof atherosclerotic disease

MRI of BrainWith an Acute Ischemic Stroke

Goldstein et al. Stroke. 2006;37:1583-1633; http://www.ucihs.uci.edu/stroke/whatisastroke.shtml. Accessed October 19, 2007.

20

30

40

50

Smoking: Increased Progression of Smoking: Increased Progression of Carotid AtherosclerosisCarotid Atherosclerosis BBoth active smoking and environmental tobacco smoke exposure are oth active smoking and environmental tobacco smoke exposure are

associated with increased progression of carotid atherosclerosis.associated with increased progression of carotid atherosclerosis.

aAdjusted for demographic characteristics, cardiovascular risk factors, and lifestyle variables (risk factor model and Keys score, education, leisure activity, body mass index, and alcohol use). bTo environmental tobacco smoke.Howard et al. JAMA. 1998;279(2):119-124.

Ex-smokers with

Exposureb

CurrentSmokers

Nonsmokerswithout

Exposureb

Pro

gre

ssio

n o

f In

tim

a-M

edia

l T

hic

knes

s, µ

m/3

y (

95%

CI)

a

Ex-smokerswithout

Exposureb

Nonsmokerswith

Exposureb

43.043.0

38.838.8

31.631.6 32.832.8

25.925.9

Smoking: Increased Risk of Fatal and Smoking: Increased Risk of Fatal and Nonfatal Stroke in WomenNonfatal Stroke in Women

1.0

3.8

2.92.5

0

1

2

3

4

5

6

1-14 15-24Nonsmokers

Rel

ativ

e R

isk

(95%

CI)

a

aThe probability of an event (developing a disease) occurring in exposed people compared with the probability of the event in nonexposed people. Adjusted for age, follow-up period, history of diabetes, hypertension, high cholesterol levels, and relative weight (in 5 categories).Colditz et al. N Engl J Med. 1988;318(15):937-941.

≥25

Cigarettes/DayCurrent Smokers

0

2

4

6

8

10

12

Smoking: Increased Risk of Hemorrhagic Smoking: Increased Risk of Hemorrhagic StrokeStroke

aThe probability of an event (developing a disease) occurring in exposed people compared with the probability of the event in nonexposed people.Adjusted for age, exercise, alcohol consumption, body mass index, history of hypertension, and history of diabetes. Kurth et al. Stroke. 2003;34:2792-2795.

Total Hemorrhagic Stroke

Rel

ativ

e R

isk

(95%

CI)

a

Intracerebral Hemorrhage

Subarachnoid Hemorrhage

Nonsmokers (n=20,339)

<15 Cigarettes/day (n=1914)

15 Cigarettes/day (n=3265)

2.062.06

3.433.43 2.392.39 2.892.891.741.74 4.044.04

Smoking: Increased Stroke MortalitySmoking: Increased Stroke Mortality

Cigarette smoking increases the risk of mortality from stroke in menCigarette smoking increases the risk of mortality from stroke in men

aTwenty-year age-adjusted mortality per 10,000 person-years for men. P<.014 for trend. Hart et al. Stroke. 1999;30:1999-2007.

30.9

39.0

50.6

0

10

20

30

40

50

60

15-241-15

Mo

rtal

ity

Rat

ea

≥25

Cigarettes/DayCurrent Smokers

Summary: Smoking and StrokeSummary: Smoking and Stroke

Smoking contributes to 12% to 14% of all stroke deathsSmoking contributes to 12% to 14% of all stroke deaths

Increased risk ofIncreased risk of– Progression of carotid atherosclerosisProgression of carotid atherosclerosis– StrokeStroke– Hemorrhagic strokeHemorrhagic stroke– Intracerebral hemorrhageIntracerebral hemorrhage– Subarachnoid hemorrhageSubarachnoid hemorrhage

Increased stroke-related mortalityIncreased stroke-related mortality

…an exquisitely crafted drug delivery device

Nicotine Addiction

Nicotine rewardssmoking

Nicotine altersthe brain

Psychological andsocial forces are

at work

Dopamine releaseSignal to notice and

repeat

Acquired ‘drive’ (hunger)

Urge to smoke if abstinent for a whileReminders (cues)

increase urgePairing of stimuli

Beliefs aboutstress control

IdentityCamaraderie

‘‘‘‘Why do people smoke . . . to relax; for the Why do people smoke . . . to relax; for the taste; to fill the time; something to do with taste; to fill the time; something to do with my hands. . . . But, for the most part, people my hands. . . . But, for the most part, people continue to smoke because they find it too continue to smoke because they find it too uncomfortable to quit’’uncomfortable to quit’’

Philip Morris, 1984Philip Morris, 1984

Philip Morris. Internal presentation. 1984, 20th March; Kenny et al. Pharmacol Biochem Behav. 2001;70:531-549.

Nicotine WithdrawalNicotine Withdrawal

Restlessness or impatience

Increased appetite or weight gain

Withdrawal Syndrome

Anxiety(may increase

or decrease with quitting)

Dysphoric or depressed mood

Irritability, frustration,

or anger

Difficulty concentrating

Insomnia/sleep disturbance

Nicotine withdrawal syndrome consists of both somatic and affective Nicotine withdrawal syndrome consists of both somatic and affective symptomatologysymptomatology

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision. Washington, DC: American Psychiatric Association; 2000.

Nicotine Addiction: A Chronic Relapsing Medical ConditionNicotine Addiction: A Chronic Relapsing Medical Condition

1. O'Donnell DE et al. Can Respir J 2004;11(SupplB):3B-59B.2. Jarvis MJ. BMJ 2004;328:277-279.3. Foulds J. Int J Clin Pract 2006;60:571-576.4. Hughes JR. CA Cancer J Clin 2000;50:143-151.5. Optimal Therapy Initiative (University of Toronto). Smoking cessation guidelines: How to treat your patient's tobacco addiction, 2000.6. Fiore MC et al. JAMA 2002;288:1768-1771.

Nicotine addiction

is a chronic, relapsing

condition1-3

True drug addiction, similar to that of other drugs of abuse1,3

Requires long-term, repeated clinical intervention4

– Nicotine addiction needs to be viewed as a chronic disease5

– Remission can be achieved with the proper interventions and treatments5

Relapse is – Common2,4

– The nature of addiction, not the failure of the individual1

Long-term smoking abstinence in those who try to quit unaided = 5%6

Most relapse within the first 8 days4

A Comprehensive Approachto Smoking Cessation

A Comprehensive Approachto Smoking Cessation

Smoking addiction has two main components

that need to be addressed: one related to the

pharmacological action of inhaled nicotine and

the other related to behavioural factors1-3

Advice and behavioural support increase the

chances of quitting successfully4,5

Most effective methods of smoking cessation combine pharmacotherapy with advice and behavioural support2,4

1. Jarvis MJ. BMJ 2004;328:277-279.2. Coleman T. BMJ 2004;328:397-399.3. Rigotti NA. N Engl J Med 2002;346:506-512.4. Hughes JR. CA Cancer J Clin 2000;50:143-151. 5. O'Donnell DE et al. Can Respir J 2004;11(SupplB):3B-59B.

1. Identification of smokers2. Documentation3. Counseling

– Ready and not ready to quit, recently quit

4. Pharmacotherapy– Ready and not ready to quit

5. Self-help materials– Ready and not ready to quit

6. Long-term follow up (IVR)7. Linked to nurse counsel +/or

community resources

The Ottawa Model for Smoking Cessation

• > 6500 admissions/yr

• > 1400 smokers/yr

• Assistance provided to 96% of smokers

Long-term cessation rate pre-Ottawa Model: 35%

Long-term cessation rate with Ottawa Model: 50%!

Ottawa Model at the University of Ottawa Heart Institute

Implementation of the Ottawa Model in Canadian Hospitals

1

8

18

27

38

0

5

10

15

20

25

30

35

40

2004 2005 2006 2007 2008

Year

Nu

mb

er o

f h

osp

ital

s

April 19, 2023 Abstract submitted to SRNT 2009 (Dublin)

Ottawa Model effectiveness in 9 hospitals: 6-month continuous abstinence rate pre- vs. post-implementation

14.9%

25.1%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

Pre-Ottawa ModelImplementation

Post-Ottawa ModelImplementation

Per

cen

tag

e o

f p

atie

nts

sm

oke

-fre

e at

6-m

on

ths

Unadjusted OR = 1.9 (1.2 to 3.1) p=.008

Ottawa Model for Smoking Cessation - Outpatient

Patient Waiting Room Survey

• Tobacco use– Past 6 months– Past 7 days

• Smoking history

• Time to first cigarette

• Importance and confidence

• Concerns

• Past use of medications

Smoking Cessation Consult Form

• Physician and nurse complete• Advise• Assess willingness to quit• Assist

– Patient preferences– Contraindications– Select pharmacotherapy– Set quit date

• Arrange follow-up

Pharmacotherapy for Nicotine Dependence1-4

Pharmacotherapy for Nicotine Dependence1-4

Nicotine replacement therapy (NRT)– Long acting

Patch

– Short acting Gum Inhaler

Bupropion SR

Varenicline– A new smoking cessation aid

1. O'Donnell DE et al. Can Respir J 2004;11(SupplB):3B-59B.2. Foulds J. Int J Clin Pract 2006;60:571-576.3. Challenge Quit to win. Pharmacological Aids. February 20, 2007.4. CHAMPIX Product Monograph, Pfizer Canada Inc., January 2007.

Effectiveness of various medications and combinations vs. placebo

Medication Number of arms Estimated odds ratio

Estimated abstinence rate

Placebo 80 1.0 13.8

Varenicline (2 mg/d) 5 3.1 (2.5-3.8) 33.2 (28.9-37.8)

Nicotine patch 32 1.9 (1.7-2.3) 23.4 (21.3-25.8)

Nicotine gum 15 1.5 (1.2-1.7) 19.0 (16.5-21.9)

Bupropion SR 26 2.0 (1.8-2.2) 24.2 (22.2-26.4)

Patch + Gum (ad lib) 3 3.6 (2.5-5.2) 36.5 (28.6-45.3)

Patch + Bupropion

3 2.5 (1.9-3.4) 28.9 (23.5-35.1)

Quit Smoking Plan

• Medications

• Quit date

• Quit smoking follow-up program– - 7, 5, 14, 30, 60, 90, 180 days around quit

date

• Preparing for your quit date

Hospital

Workstations

Counselor Laptops

Internet

TelASK Servers

PatientsTelASK IVR CallTelASK IVR Call

IVR follow-up appears to be useful

37 35

4246

05

101520253035404550

12 weeks 52 weeks

% A

bst

inen

t

Usual CareGroup

IVR Group

Adjusted* OR = 2.27 (0.92-5.62; p=.07)*adjusted for age, LOS, quit attempts in past year, reason for

hospitalization

(2N=99)

Reid et al, Pat Educ Counsel, 2007

Social Norms and

Tobacco

…transform your clinical practice!

Developing a Quit PlanDeveloping a Quit Plan

• Set a quit dateSet a quit date– Ideally within 2 weeksIdeally within 2 weeks

• Tell family, friends and coworkersTell family, friends and coworkers– Request understanding and supportRequest understanding and support

• Anticipate challengesAnticipate challenges– First 2 weeks critical; nicotine withdrawal SxFirst 2 weeks critical; nicotine withdrawal Sx

• Remove tobacco productsRemove tobacco products– Prior to quitting, avoid smoking in places where you Prior to quitting, avoid smoking in places where you

spend a lot of time. Make home smoke-freespend a lot of time. Make home smoke-free

Practical CounselingPractical Counseling

• AbstinenceAbstinence– Strive for total abstinence; not even a puffStrive for total abstinence; not even a puff

• Past Quit ExperiencePast Quit Experience– What helped and what hurt before. Build on successWhat helped and what hurt before. Build on success

• Anticipate Triggers and Challenging SituationsAnticipate Triggers and Challenging Situations– Overcome through delay, avoidance and substitutionOvercome through delay, avoidance and substitution

• AlcoholAlcohol– Common trigger for relapseCommon trigger for relapse

• Other SmokersOther Smokers– Quit together or at least avoid smoking in their presenceQuit together or at least avoid smoking in their presence

• Provide supplementary material including information on Provide supplementary material including information on quitlinesquitlines

Enhancing motivation to quitEnhancing motivation to quit

• RelevanceRelevance– Encourage patient to indicate why quitting is personally relevantEncourage patient to indicate why quitting is personally relevant

• RisksRisks– Ask the patient to identify potentially negative consequence of Ask the patient to identify potentially negative consequence of

continued smokingcontinued smoking

• RewardsRewards– Ask the patient to identify potential benefits of quittingAsk the patient to identify potential benefits of quitting

• RoadblocksRoadblocks– Ask the patient to identify barriers to quitting and providing Ask the patient to identify barriers to quitting and providing

treatment treatment

• RepetitionRepetition– Repeat the intervention during each visitRepeat the intervention during each visit