Thursday, September 26, 2013

Nicotine Addiction

Nicotine Addiction
-Dr. Milan Khara MBChB CCFP
Clinical Director VGH SMoking Cessation Clinic

Lecture given at the Canadian Society of Addiction Medicine Annual Conference in the Hyatt Regency, Sept. 26, 2013, Vancouver, BC. 

I actually had not planned to attend this lecture as I thought I knew all there was to know about tobacco addiction and treatment. I am glad I did attend bcause Dr. Milan Khara knows far more than I do and gave a fascinating presentation, not only comprehensive and clinically relevant but also very cutting edge.  These are my rough notes which hopefully will encourage someone to quit smoking or at least seek Dr. Milan Khara’s help and wisdom.

Nicotine Addiction
changing prevalence and ‘hardening’ of remaining populations of smokers
tobacco dependence as chronic disease
evidence based interventions for tobacco dependence
the future - “Electronic Cigarettes” (ENDS)

Psychiatric and Substance Use Disorder
  • Am. J. Addict 14 106 to 123 - Kalman, Morisset and George 2005
  • intensive smoking cessation works with concurrent treatment and doesn’t destabilize or make treatment of other psychiatric disorders less.

Disease Burden
  • leading preventable cause of death in Canada
  • 1 in 2 smokers die prematurely
  • 44% of tobacco consumption by mentally ill

What’s new in Tobacco control-
-Australian - generic package - Smoking Causes Blindness - Brand Variant
-packaging sludgy green - no longer red and white and no longer styllized brand

What’s in a cigarette?
  • tobacco smoke - greater 4000 chemicals - greater than 50 are carcinogenic

Smoking cigarettes with lower tar and nicotine provides no health benefit?

WHO - tobacco deadly in any form or disguise 2006

Effects - nucleus accumben and ventral tegmental area
-nicotine bines to nicotinic acetylcholine (nACh) - primar a4B2 nAch receptor of the VTA (ventral tegmental area)
-after nicotine bines to a4B2 a4B2 nACh receptor in the nicotiniic /TA it result in releasteof dopamine in the nucleus accumbens.

Most smokers using NRT were underdosing
If they are not getting sufficient amount they’re fill that with cigarettes

10 key recommendations
-recognise tobacco dependence as chronic disease
  • document smoking status and willingness on a regular basis
  • supper every patient identified as willing to quit with counselling and medications
  • - tobacco dependence treatments work across a broad range of populations
  • understand that een brief tobacco dependence treatment can be effective
  • use individual, group and telephone counselling
  • -more intenstive treatment increases coeffectively
  • --practical tips on how to quit and providing social support
  • counselling and medication are evidence based treatments- not hypnotherapy, not acupuncture, not massage , not herbs - counselling and medication modalities work across broad populations and are the proven treatments of choice
  • prescribe recommended cessation medication
  • combine counseeling and effective medications
  • encourage use of telephone quit lines
  • support every patient willing to quit
Brief smoking cessation
Ask - about tobbaco
Advise - they can quit and will be healthier
Assess - readiness to quit
Assist - self help, pharmacotherapy, counselling/quit
Arrange - follow up or referral

I’m not going to talk about treating ambivalence - we have tools but treating ambivalent patients is beyond this time 

First line pharmacotherapies

-nicotine replacement patch, gum, inhaler etc
-safe (Hubbard 2005)
Moste effective when combined with therapy
Minimize withdrawal symptons
Role for forced or temporary abstinence - ie in hospital stay

Zyban (Buproprion)
-hypothesize it works by non competitive inhibition of nicotine receptors
blocks reuptake of dopamine
-doubles ones chances of quitting
‘cochrane - 2009 - increases sz rates for quitting without affecting their mental state negatively

a4B2 nicotinic acetylcholine receptor partial agonist and antagonist

prevents binding of nicotine

probably our most effective treatment

BMJ 2012 meta analysis ‘no significent or clinically meaningful CVS risks’
Despite labelling - many studies emerging suggesting safe and efficacious amongst most populations 
CMAJ 20011 meta analysis - 72% increase in CVS events compared to placebo’.

Gibbons et al, APA - 8000 n - no evidence of varenicline is associated with neuropsychiatric events - in individuals with or without a history of recent psychiatric disorder

Electronic Nicotine Delivery System ENDS
McCarthy - Playmate - face of ENDS brand advertising
  • debate - makes safe - harm reduction - 

(I was sorry I didn’t have time to ask Dr. Khara his opinion on the increasing production of aboriginal cigarettes marketting tobacco to the already marginalized and sick as “100% natural’ and having none of the normal warnings required of other tobacco cigarettes.  I’ve noticed these all over the downtown east side Vancouver and couldn’t help but be impressed by the contrast to this slick advertising compared to the direction the Australians were taking)

VGH SMoking Cessation Clinic

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