PANBC Conferenc e Nov 5, 2016 Steve Petrar Anesthesiologist - - PowerPoint PPT Presentation

SMOKING CESSATION

PANBC Conferenc e

Nov 5, 2016 ——————————

Steve Petrar

Anesthesiologist

• St. 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 COUNSELING

• A. Pharmacotherapy + psychosocial treatment
• ffered 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

Nicotine Replacement Therapy (NRT) Antidepressant Buproprion (Zyban) Nicotine Acetylcholine Receptor partial agonist - Varenicline (Champix) MUST be dosed based on estimates of nicotine dependance and daily nicotine requirements (coming up in 2 slides!) 150mg daily x 3d 150mg BID x 7-12wks initiate quit after 1st week 0.5mg daily x 3d 0.5mg BID x 4d 0.5-1mg BID x 12wks Initiate 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 toxicity endothelial dysfunction catecholamine release vasoconstriction thromboxane A2 polycythemia increased blood viscosity thrombogenesis systemic inflammation impaired ciliary function accelerated atherosclerosis impaired 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 wound

OR 3.61 (CI 2.78-4.68)

wound dehiscence

OR 2.86 (CI 2.78-4.68)

surgical site infection

OR 2.12 (CI 1.56-2.88)

MAJOR SURGERY

NSQIP data corresponding to ~142K patients who underwent

• ne of 16 “major” surgeries

Primary outcome was occurrence of a predefined adverse post-

• perative 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

• f 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 placebo RR 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 page

http://www.cas.ca/English/Stop-Smoking

ASA Be Smoke Free for Surgery page

http://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 cessation as 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-syncope in last month III/VI SEM

(No prior echo)

1 PPD x 40 yrs

QUESTIONS?