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Toronto Notes 2019 Health Promotion and Counselling Epidemiology
• 25%ofthepopulationexercisesregularly,50%occasionally,25%aresedentary
Management
• assesscurrentleveloffitness,motivation,andaccesstoexercise
• encourage warm up and cool down periods to allow transition between rest and activity and to avoid
injuries
• exercise with caution for patients with CAD, DM (risk of hypoglycemia), exercise-induced asthma
• patientswithknownCADshouldhavecardiacassessmentpriortocommencingexercise
• benefitsofexercise
■ reduces risk of premature death, heart disease, stroke, HTN, certain types of cancer, type 2 DM, osteoporosis, and overweight/obesity
■ leads to improved fitness, strength, and mental health (morale and self-esteem)
Smoking Cessation
Epidemiology
• smokingisthesinglemostpreventablecauseofprematureillnessanddeath
• 70%ofsmokersseeaphysicianeachyear
• 2012CanadianTobaccoUseMonitoringSurvey(CTUMS)onpopulationage≥15
■ 16% are current smokers (lowest since 1965)
■ highest prevalence in age group 20-24 (20%)
■ 11% of youth age 15-19 smoke (decreased from 25% in 2000): more males smoke than females;
number of cigarettes consumed per day also decreasing
Management
• generalapproach
■ identify tobacco users; elicit smoking habits, previous quit attempts, and results ■ 2012CAN-ADAPTTGuidelines
◆ tobacco use status should be updated for all patients regularly
◆ health care providers should clearly advise patients to quit
◆ health care providers should also monitor the patient’s mental health status/other addictions
while quitting smoking
◆ medication dosage should be monitored and adjusted as necessary
■ every smoker should be offered treatment
◆ combining counselling and smoking cessation medication is more effective than either alone
■ educate patient to watch for withdrawal symptoms
◆ low mood, insomnia, irritability, anxiety, difficulty concentrating, restlessness, decreased heart
rate, increased appetite
■ ≥4 counselling sessions >10 min each with 6-12 mo follow-up yields better results
■ 14% abstinent with counselling vs. 10% without counselling
■ approach depends on patient’s stage of change (see Motivational Strategies for Behavioural Change,
FM6)
• willingtoquit
■ provision of social support, community resources (self-help, group, helpline, web-based strategies) ■ pregnant patients: counselling is recommended as first line treatment
◆ nicotine replacement therapy (NRT) should be made available to pregnant women who are unable to quit using non-pharmacologic methods
◆ intermittent NRT use (lozenges, gum) is preferred over continuous dosing of the patch
◆ no strong evidence that either major positive or negative outcomes were associated with
gestational use of bupropion or varenicline; consider using only if benefits outweigh risks and
consult Motherisk Helpline • pharmacologictherapy
1. Nicotine Replacement Therapy
◆ 19.7% abstinent at 12 mo with NRT vs. 11.5% for placebo
◆ no difference in achieving abstinence for different forms of NRT
◆ reduces cravings and withdrawal symptoms without other harmful substances that are contained
in cigarettes
◆ use with caution: immediately post-MI, worsening angina, arrhythmia ◆ advise no smoking while using NRT
2. Antidepressants (mechanism of action appears to be independent of antidepressant effect) ◆ bupropion SR (Zyban®)
◆ 21% abstinent at 12 mo vs. 8% for placebo
◆ similar effectiveness of NRT vs. bupropion
3. Varenicline (Champix®)
◆ partial nicotinic receptor agonist (to reduce cravings) and partial competitive nicotinic receptor
antagonist (to reduce the response to smoked nicotine)
◆ more effective than bupropion (23% abstinent from 9-52 wk with varenicline vs. 16% with
bupropion vs. 9% with placebo)
◆ significant side effects may lower patient compliance
Family Medicine FM11
Antidepressants for Smoking Cessation
Cochrane Database Syst Rev 2014;1:CD000031
Purpose: To assess the efficacy and safety of antidepressants for
l o n g - t e r m s mo k i n g c e s s a t i o n .
Methods: Meta-analysis of RCTs comparing antidepressant medications to placebo or alternative medications for
smoking cessation. Studies comparing different doses, use of pharmacotherapy for relapse prevention or re-initiation of smoking cessation, or those targeting reduction in cigarette consumption by smokers, were also considered eligible. Eligible studies were required to have a minimum of 6 months follow-up.
Results: 90 trials were included. Antidepressants found to significantly increase long-termcessation included bupropion alone (risk ratio (RR) 1.62, 95% CI 1.49-1.76) and nortriptyline alone (RR 2.03, 1.48-2.78), which appeared equally effective to each other
and to nicotine replacement therapy (NRT). No significant additional long-term benefit was found with adding bupropion (RR 1.19, 0.94-1.51) or nortriptyline (RR 1.21, 0.94-1.55) to NRT. Significantly lowerquitrates (RR0.68,0.56-0.83)andincreasedadverseevents close to statistical significance (1.30, 1.00-1.69) were found with buproprion compared to varenicline. No evidence showed significant effectiveness for selective serotonin reuptake inhibitors alone (RR 0.93, 0.71-1.22) or in addition to NRT (RR 0.70-0.64-1.82), or with monoamine oxidase inhibitors alone (RR 1.29, 0.93-1.79), venlafaxine (RR 1.22, 0.64-2.32), St. John’s wort/hypericum (RR 0.81, 0.26-2.53) or SAMe dietary supplement (RR 0.70, 0.24-2.07).
Conclusion: The antidepressants bupropion and nortriptyline can
aid smoking cessation and have a similar efficacy to NRT. Bupropion is less effective than varenicline. Neither SSRIs (e.g. fluoxetine) nor MAOIs aid smoking cessation.
The 5 A’s for Patients Willing to Quit Ask if the patient smokes
Advise patients to quit
Assess willingness to quit
Assist in quit attempt Arrange follow-up
The 2-3 Pattern of Smoking Cessation
• Onset of withdrawal is 2-3 h after last cigarette
• Peak withdrawal is at 2-3 d
• Expect improvement of withdrawal
symptoms at 2-3 wk
• Resolution of withdrawal at 2-3 mo • Highest relapse rate within 2-3 mo
Assist Patient in Developing Quit Plan
STAR
Set quit date
Tell family and friends (for support) Anticipate challenges (e.g. withdrawal) Remove tobacco-related products (e.g. ashtrays/lighters)
Physician Advice for Smoking Cessation
Cochrane Database Syst Rev 2013;5:CD000165
Purpose: To assess the effectiveness of physician advice in promoting smoking cessation, compare minimal physician interventions with more intensive interventions, assess the effectiveness of various aids in smoking cessation, and determine the effect of anti-smoking advice on mortality.
Methods: Systematic review of RCTs of smoking cessation advice froma health care provider. Abstinence was assessed at least 6 months after advice was provided.
Results: 42 trials with over 31,000 smokers were identified. Most common setting for advice delivery was primary care. A significant increase in quitting rates was noted with advice versus no advice (relative risk (RR) 1.66, 95% CI 1.42-1.94), which was further increased where the intervention was considered more intensive (RR 1.84, 1.60-2.13; n.s.). Intensive advice showed a small advantage
to minimal advice when directly compared (RR 1.37, 1.20-1.56). A small benefit with follow-up visits was also found. No statistically significant difference in mortality at 20 yr follow-up was noted. Conclusion: Simple advice can increase cessation rates by 1-3%. More intensive advice and providing follow-up support may further increase quit rates.