SMOKING CESSATIONPANBC

Conference

Nov 5, 2016——————————

Steve Petrar

AnesthesiologistSt. Paul’s Hospital

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

EPIDEMIOLOGY & TOBACCO ADDICTION

Global epidemiology

Canadian patterns

Attributable harms

Mechanisms of addiction

Age-standardized smoking prevalence among men, 2012

GLOBAL EPIDEMIOLOGY

Age-standardized smoking prevalence among women, 2012

JAMA 2014

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

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

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

COUNSELING, QUIT AIDS, & RESOURCES

Approach to cessation counseling

Assessment of nicotine dependance

Pharmacologic quit aids

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

THE 5 A’S

TRANSTHEORETICAL MODEL(STAGES OF CHANGE)

FAGERSTROM TEST FOR NICOTINE DEPENDANCE & HSI

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

NICOTINE REPLACEMENT THERAPY (NRT)

Reduces physiologic withdrawal symptoms

Avoids carcinogens, mutagens, chemicals, and toxins present in tobacco smoke

Requires TITRATION to effect

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

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

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?

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

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

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

E-CIGS?

We get it,you vape…

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

BENEFITS IN SURGICAL & PERIOPERATIVE PATIENTS

Mechanism of harm

Plastic surgery

Major surgery

Cardiac surgery

Cancer surgery

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

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

STILL NOT CONVINCED?

Arch Int Med 2011, Can J Anes 2012, Anes Analg 2011

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)

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

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

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)

EFFICACY OF INTERVENTIONS IN PERIOPERATIVE PATIENTS

Counseling + NRT

Verenicline

Bupropion

COUNSELING + NRT

Anaesthesia 2009, Anes Analg 2013

patients randomized to counseling & free supply of NRT vs brief / no specific smoking intervention

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…

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)

SPH - NRT

We have PPO’s for NRT for inpatients!

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)

COCHRANE

Cochrane 2014

13 trials, 2010 patients enrolled

Behavioral therapy (counseling)

Scheduled quit date

NRT

Varenicline

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

CAS Stop Smoking For Safer Surgery pagehttp://www.cas.ca/English/Stop-Smoking

ASA Be Smoke Free for Surgery pagehttp://www.asahq.org/resources/clinical-information/asa-stop-smoking-initiative

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

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

QUESTIONS?