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A Clinical Flow-Chart for the “Treatment-Resistant Smoker”. Renee Bittoun. 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). - PowerPoint PPT Presentation
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A Clinical Flow-Chart for the “Treatment-Resistant Smoker”
Renee Bittoun
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)
WHO: International Framework Convention on Tobacco Control,
2005The 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
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)
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
Back ground to combination therapies
• Combination therapies show good outcomes in “hard-to-treat” smokers (Bittoun, 2005)
• 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
Application
• Apply strategies, both NRT and smoking---to mental health/intellectually disabled smokers
• 90% comorbid COPD patients using combination/harm reduction
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
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
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.