A clinical flow chart for the treatment resistant smoker
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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).

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Background
Background Smoker”

  • 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 2005
WHO: International Framework Convention on Tobacco Control, 2005

The Framework Convention on Tobacco Control (FCTC): Article 1. Section D.

harmreduction strategies

to improve the health of a population by eliminating or reducing their consumption of tobacco products


Background to harm reduction
Background to harm-reduction 2005

  • 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
Benefits of using NRT for 2005Harm-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
Back ground to combination therapies 2005

  • Combination therapies show good outcomes in “hard-to-treat” smokers (Bittoun, 2005)



Application
Application management of the difficult smoking patient: from the disinterested to the poor responders

  • Apply strategies, both NRT and smoking---to mental health/intellectually disabled smokers

  • 90% comorbid COPD patients using combination/harm reduction


Some results
Some Results management of the difficult smoking patient: from the disinterested to the poor responders

  • 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
Reconciliation management of the difficult smoking patient: from the disinterested to the poor responders

  • 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
CONCLUSION management of the difficult smoking patient: from the disinterested to the poor responders

  • 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.


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