1. A Clinical Flow-Chart for the “Treatment-Resistant Smoker”
Renee Bittoun

2. Background Most smokers want to quit (Fong, 2004)
Very few do not (about 6% in Australia)
Many/most fail at quit attempts with or without pharmacotherapies (Cohrane Reviews)

3. WHO: International Framework Convention on Tobacco Control, 2005
The Framework Convention on Tobacco Control (FCTC): Article 1. Section D.
harm reduction strategies
to improve the health of a population by eliminating or reducing their consumption of tobacco products

4. Background to harm-reduction
Using pharmacotherapies while smoking  inhaled toxicants (Fagerstrom,2002)
Potential gateway to quitting (Fagerstrom, 2005; Hughes, 2005)
Harm-reduction agenda a softer,
not the “stop smoking or you’ll die”
dogma of abrupt quitting (Warner, 2005)

5. Benefits of using NRT for Harm-reduction and Temporary Abstinence
Relief of craving and other withdrawal symptoms
Reduced cigarette consumption and prevention of compensatory smoking
Smokers may learn that they can manage without tobacco for several hours 
 motivation to quit

6. Back ground to combination therapies
Combination therapies show good outcomes in “hard-to-treat” smokers (Bittoun, 2005)

7. A flow chart has been developed for clinicians that directs management of the difficult smoking patient: from the disinterested to the poor responders
The flow-chart shows increasing therapies as required, using clinical signs and symptoms (withdrawal) to guide treatment choices

9. Application
Apply strategies, both NRT and smoking---to mental health/intellectually disabled smokers
90% comorbid COPD patients using combination/harm reduction

10. Some Results 16% no pharmacotherapies 16% oral NRT (gum,lozenge)
16% on 2 X 21mg patch
21% on 2 X 21mg patch plus oral NRT
5% on 3 X 21mg patch
5% on Bupropion
1% on Bupropion plus 21mg patch
20% lost to follow-up

11. Reconciliation Many do not have the “wherewithal” to quit as:-
too hard (overwhelming withdrawals)
pharmacotherapies too expensive
limited understanding of withdrawals
Akrasia (lack of will-power, inability to reconcile your want/need with your action, loss of control=addictive behaviour) (Aristotle, 4BCE; Heather, 1998; Ainslie, 2001)
Harm-reduction may be a softer option

12. CONCLUSION Don’t abandon the “hard-to-treat” “can’t quit” smoker
Develop a hierarchy of strategies for smokers that begins with permanent cessation using increasing combinations as required but----
Consider harm-reduction for resistant smokers
?? Unethical to exclude recommending harm reduction behaviours to resistant smokers as an alternative to the “Quit or You’ll Die” Dogma.