2. The Ottawa Model for Smoking Cessation for Smokers with Cerebrovascular Disease Robert D. Reid, Ph.D. October 20, 2008

3. Disclosures I have received research support in the past 12 months from: I have received research support in the past 12 months from: PFIZER PFIZER I have received consulting fees in the past 12 months from: I have received consulting fees in the past 12 months from: PFIZER, MINISTRY OF HEALTH PROMOTION, HEALTH CANADA PFIZER, MINISTRY OF HEALTH PROMOTION, HEALTH CANADA

4. Acknowledgements

5. Smoking and Stroke  Smoking contributes to 12% to 14% of all stroke deaths  Smoking may potentiate the effects of other stroke risk factors  Smoking increases stroke risk –Acutely: effects on thrombus formation –Chronically: increased burden of atherosclerotic disease MRI of Brain With an Acute Ischemic Stroke Goldstein et al. Stroke. 2006;37:1583-1633; http://www.ucihs.uci.edu/stroke/whatisastroke.shtml. Accessed October 19, 2007.

6. Smoking: Increased Progression of Carotid Atherosclerosis  Both active smoking and environmental tobacco smoke exposure are associated with increased progression of carotid atherosclerosis. a Adjusted for demographic characteristics, cardiovascular risk factors, and lifestyle variables (risk factor model and Keys score, education, leisure activity, body mass index, and alcohol use). b To environmental tobacco smoke. Howard et al. JAMA. 1998;279(2):119-124. Ex-smokers with Exposure b Current Smokers Nonsmokers without Exposure b Progression of Intima-Medial Thickness, µm/3 y (95% CI) a Ex-smokers without Exposure b Nonsmokers with Exposure b 43.0 38.8 31.6 32.8 25.9

7. Smoking: Increased Risk of Fatal and Nonfatal Stroke in Women 1-1415-24 Nonsmokers Relative Risk (95% CI) a a The 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/Day Current Smokers

8. Smoking: Increased Risk of Hemorrhagic Stroke a The 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 Relative Risk (95% CI) a Intracerebral Hemorrhage Subarachnoid Hemorrhage Nonsmokers (n=20,339) <15 Cigarettes/day (n=1914)  15 Cigarettes/day (n=3265) 2.06 3.43 2.39 2.89 1.74 4.04

9. Smoking: Increased Stroke Mortality  Cigarette smoking increases the risk of mortality from stroke in men a Twenty-year age-adjusted mortality per 10,000 person-years for men. P<.014 for trend. Hart et al. Stroke. 1999;30:1999-2007. 15-24 1-15 Mortality Rate a ≥25 Cigarettes/Day Current Smokers

10. Summary: Smoking and Stroke  Smoking contributes to 12% to 14% of all stroke deaths  Increased risk of –Progression of carotid atherosclerosis –Stroke –Hemorrhagic stroke –Intracerebral hemorrhage –Subarachnoid hemorrhage  Increased stroke-related mortality

11. …an exquisitely crafted drug delivery device

12. Nicotine Addiction Nicotine rewards smoking Nicotine alters the brain Psychological and social forces are at work Dopamine release Signal to notice and repeat Acquired ‘drive’ (hunger) Urge to smoke if abstinent for a while Reminders (cues) increase urge Pairing of stimuli Beliefs about stress control Identity Camaraderie

13. ‘‘Why do people smoke... to relax; for the taste; to fill the time; something to do with my hands.... But, for the most part, people continue to smoke because they find it too uncomfortable to quit’’ Philip Morris, 1984 Philip Morris. Internal presentation. 1984, 20th March; Kenny et al. Pharmacol Biochem Behav. 2001;70: 531-549.

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

15. Nicotine 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 condition 1-3  True drug addiction, similar to that of other drugs of abuse 1,3  Requires long-term, repeated clinical intervention 4 –Nicotine addiction needs to be viewed as a chronic disease 5 –Remission can be achieved with the proper interventions and treatments 5  Relapse is –Common 2,4 –The nature of addiction, not the failure of the individual 1  Long-term smoking abstinence in those who try to quit unaided = 5% 6  Most relapse within the first 8 days 4

16. A Comprehensive Approach to 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 factors 1-3  Advice and behavioural support increase the chances of quitting successfully 4,5 Most effective methods of smoking cessation combine pharmacotherapy with advice and behavioural support 2,4 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.

17. 1.Identification of smokers 2.Documentation 3.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

18. > 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

19. Implementation of the Ottawa Model in Canadian Hospitals

20. Abstract submitted to SRNT 2009 (Dublin) Ottawa Model effectiveness in 9 hospitals: 6-month continuous abstinence rate pre- vs. post-implementation Unadjusted OR = 1.9 (1.2 to 3.1) p=.008

21. Ottawa Model for Smoking Cessation - Outpatient

22. 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

23. 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

24. Pharmacotherapy for Nicotine Dependence 1-4  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.

25. Effectiveness of various medications and combinations vs. placebo MedicationNumber of armsEstimated odds ratio Estimated abstinence rate Placebo801.013.8 Varenicline (2 mg/d) 53.1 (2.5-3.8)33.2 (28.9-37.8) Nicotine patch321.9 (1.7-2.3)23.4 (21.3-25.8) Nicotine gum151.5 (1.2-1.7)19.0 (16.5-21.9) Bupropion SR262.0 (1.8-2.2)24.2 (22.2-26.4) Patch + Gum (ad lib) 33.6 (2.5-5.2)36.5 (28.6-45.3) Patch + Bupropion 32.5 (1.9-3.4)28.9 (23.5-35.1)

26. 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

27. Hospital Workstations Counselor Laptops Internet TelASK Servers Patients TelASK IVR Call

28. IVR follow-up appears to be useful 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

29. Social Norms and Tobacco …transform your clinical practice!

30. Developing a Quit Plan Set a quit dateSet a quit date –Ideally within 2 weeks Tell family, friends and coworkersTell family, friends and coworkers –Request understanding and support Anticipate challengesAnticipate challenges –First 2 weeks critical; nicotine withdrawal Sx Remove tobacco productsRemove tobacco products –Prior to quitting, avoid smoking in places where you spend a lot of time. Make home smoke-free

31. Practical Counseling AbstinenceAbstinence –Strive for total abstinence; not even a puff Past Quit ExperiencePast Quit Experience –What helped and what hurt before. Build on success Anticipate Triggers and Challenging SituationsAnticipate Triggers and Challenging Situations –Overcome through delay, avoidance and substitution AlcoholAlcohol –Common trigger for relapse Other SmokersOther Smokers –Quit together or at least avoid smoking in their presence Provide supplementary material including information on quitlinesProvide supplementary material including information on quitlines

32. Enhancing motivation to quit RelevanceRelevance –Encourage patient to indicate why quitting is personally relevant RisksRisks –Ask the patient to identify potentially negative consequence of continued smoking RewardsRewards –Ask the patient to identify potential benefits of quitting RoadblocksRoadblocks –Ask the patient to identify barriers to quitting and providing treatment RepetitionRepetition –Repeat the intervention during each visit