a clinical flow chart for the treatment resistant smoker
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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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  • 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
  • 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 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
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
  • Apply strategies, both NRT and smoking---to mental health/intellectually disabled smokers
  • 90% comorbid COPD patients using combination/harm reduction
some results
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
  • 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
  • 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.