SOME NUMBERS:
Smoking is, in France, responsible for over 60,000 deaths annually. 4 18 year olds who smoke (currently 50% of 18 year olds are in this case), both continue to smoke for much of their lives, and one of them will die of the consequences of smoking. It is true that in two smokers will stop itself – “without help” – but after how long? Aid consultations weaning – too few – can not claim alone meet demand. The duty of all health professionals is to inform (not guilty) smokers of these risks, assess their motivation to stop, inform them of the possibilities to stop using.
MECHANISMS OF TOBACCO ADDICTION:
Smoking is a behavior maintained and amplified by pharmacological dependence (mainly nicotine) and / or psychobehavioural.
The cessation assistance must assess and take into account both aspects of addiction: psychobehavioural and pharmacological.
The relative importance of these two components is very variable from one smoker to another and we do not have very specific tests to quantify. While it is fairly easy to identify by the Fagerström test (Fig. 1) highly dependent smokers nicotine in those whose score is low (<4), there are enough addicts for withdrawal is difficult especially since it is not their a priori inclined to prescribe nicotine substitutes. The reliable way to assess the intake of nicotine a smoker would assaying urinary cotinine (nicotine metabolite), but this test is not widely used (cost problem for a withdrawal “mass”) . We must therefore be content with approximate average and overlap between the test (number of cigarettes smoked, CO measurement expired if possible trouble staying long without smoking) to evaluate the best profile of the dependence of each smoker.
APPROACH AID WITHDRAWAL:
Touch briefly on each consultation the tobacco problem:
Help smokers to stop is considered a long-term work that needs to stress the importance that the doctor committed to obtaining the judgment and value the benefits of quitting. This work aims to accelerate the cycle of Prochaska (Fig. 2). The GP is probably best placed to undertake this process. One or two questions about the position of the smoker from its smoking possible to locate the degree of motivation to quit. One can possibly help the Lagrue questionnaire and Légeron (Fig. 3). If motivation seems small, it is useless to insist (especially brandishing the dangers of smoking the smoker knows perfectly rule). It is limited in this case the minimum tip: stop consulting and providing documents about the risks of smoking and how to stop.It will réaborder the issue at a future consultation.
If the smoker seems hesitant, consider with him the disadvantages and advantages it derives from tobacco and the benefits it expects the arrest. We can propose a list of items but it is important to listen to his choice because it is from them that it will build its determination to stop.
It must be emphasized the benefits (faster for cardiovascular sphere) always obtained even if smoking is old. We must listen to and address their fears: loss of mental efficiency, “blues”, irritability, weight gain, etc.
The experience of a previous attempt is very instructive.Some major pitfalls stopped are often encountered, they are part of the “defense system” smokers: belief in the impossibility of stopping, has always lived with the cigarette, it seems impossible to live without.
Basing success on the will:
Make the success of weaning a challenge based solely on the desire disregarding the dependence phenomena, hence the need to place the attempt to stop the logic of a learning work: we will learn to live without smoking. This allows to play down a priori a possible “failure”: we managed to stop but not sustainable, however we experienced the stop at least a few days, it was noted the difficulties involved in the next attempt for which we will be better armed.
Do not equate to withdrawal a therapeutic injunction:
The attempt is left up to the smoker referee chooses the date that seem favorable to the judgment. We must suggest the smoker to develop a substitute reward system: notion of newfound freedom, a project through savings, benefits for their health and that of his entourage.
Before weaning, it is important to research a history of depression or current depressive mood (HAD questionnaires) and to ensure the absence of a personal problem (bereavement, separation, professional failure, etc.) which can lead to propose the patient to differ slightly from the withdrawal date and / or pre-treatment of mood disorders.
The subject decided to stop: how to help?
Fagerstrom score equal or greater than 4:
Nicotine replacement therapy is indicated if the subject agrees.
The higher the score, the higher the substitution dosage should be: at least one patch with 21 mg / d or more immediately if you have the notion of loss with this assay in an earlier weaning (we always the possibility of requesting an opinion from a smoking cessation consultation).
Among smokers who want to be active, gums 4 mg or use a nicotine inhaler on demand to control the intake of nicotine and have an oral substitute and / or sign language. It is possible for most addicts combine patch and gum or inhaler in small quantities to control the strongest point impulses (by asking the subject to try if possible to predict those moments so as to administer the substitute as soon as possible).
NRT is not against-indicated in patients with cardiovascular problems and can be administered quickly after a coronary event. It can also be used in pregnant women provided you follow a period of non-administration of at least 8 hours a day. If the subject “crack” and smoke, it is unnecessary to remove the patch (which continues to be one to two hours).Such an incident, if repeated, has to reassess upward the substitution dose and / or the subject’s motivation to stop.
The administration of nicotine not just the strategy of withdrawal and it is important to establish regular contact at least call for assessing whether the level of substitution is correct without signs of overdosage or more often under-dosing with persistence of strong drives to smoke, to verify the absence of mood disorders and / or eating. These contacts also help strengthen the patient’s motivation. Drinks (or sweet or alcoholic) should be abundant. Consumption of vitamin C sucking is also recommended. The patches are worn 24 hours (which avoids lack the morning upon waking) unless there is persistent sleep disorders. The substitution rule is continued quarter over quarter decreasing doses every month. The premature interruption increases the risk of resumption of smoking.
Since the beginning of 2007, a new product can be offered in the cessation: varenicline (Champix®) is a partial agonist of the alpha-4 beta-2 receptors of the nicotinic acetylcholine receptors. She fixed them with greater affinity, in the brain that nicotine. By its partial agonist, varenicline stimulates the release of dopamine and firstly reduces the craving and withdrawal symptoms, and also blocks the binding of inhaled nicotine and its reinforcing effects.
Two studies, double-blind, compared the effect of bupropion (Zyban 150 mg twice a day, placebo and varenicline (1 mg twice per day) administered for 12 weeks period followed by a stop phase of 40 weeks. The stop percentage varenicline was 2.5 times higher than that observed with placebo (44.4% versus 17.7%) and 1.5 times higher than that observed bupropion at the end of 12 weeks. After one year, 22% of subjects who received varenicline remained abstinent. a third study assessed the benefit of treatment for another 12 weeks with varenicline. patients who stopped smoking week 12 were randomized to receive either 1 mg twice daily varenicline or placebo for an additional 12 weeks. Between week 13 and week 24, 71% of the varenicline patients were still abstinent against less than 50% on placebo . the interests of the product is its ability to be started shortly before complete stop smoking, make it easier this judgment and can be administered for a longer time than conventional nicotine replacement. The product is well tolerated rule (low intensity nausea, vivid dreams, headache). Given its mode of action, its association with nicotine replacement does not seem logical.
Fagerstrom score less than 4:
Dependence is rather psychobehavioural kind.
Help from behavioral and cognitive type must be in place:
The subject must identify “trigger” situations in order to develop alternative strategies, the need associated with making piecemeal gums or by the use of the inhaler. If nicotine dependence is very low and / or if the subject does not use the nicotine substitutes, the use of bupropion (Zyban) is possible. It is an antidepressant drug that acts on the encephalic centers of the award, which has proven its effectiveness in a controlled study against placebo.
It can only be prescribed if there is a history or risk of convulsion (seizure disorders, alcoholism) or in case of impaired liver function. It is desirable to administer the drug at increasing doses and the start two to three weeks before the start date of the withdrawal. This is not a “miracle product” (as tend to think some smokers) and the prescription is conceivable that if proven motivation of the subject.
The recommendations made in the previous paragraph on monitoring are in order, duration and quality of support are important success factors as outlined in the conclusions of the JNC VII (to improve adherence and treatment compliance of hypertension), “the most effective therapy prescribed by the most experienced doctor only reach its goal if the patient is motivated. Motivation increases when the patient had a positive contact with the doctor and trust him.
Empathy is a source of confidence and strong motivation. “
Other cessation counseling methods: homeopathy, acupuncture, hypnosis:
None of these methods has been able to demonstrate its long-term efficacy in controlled studies. However if the patient’s belief in the ability of these methods to help is strong, it is useless to dissuade however in urging him to associate it with an approach for which scientific evidence exists.
The results of group therapy are contradictory, they seem to at first interesting results unfortunately undermined by a high dropout rate at follow-up.
What about reducing consumption?
The decrease in the number of cigarettes is often used as an alternative to a complete stop by some smokers. Such an approach can be attempted – on a transitional basis
– Because it allows the smoker to gradually mourn cigarettes. However, we must bear in mind that this reduction is often overestimated by the smoker.
In case of strong dependence, the subject modifies his way of smoking and improves without being aware of the performance of the remaining cigarettes (this can be demonstrated by the assay of urinary cotinine or the CO levels in exhaled air). Finally, this strategy does not lead to a break with smoking and leaves the door open to a new increase in consumption.
In some very dependent subjects (despite the serious consequences of smoking: respiratory or vascular damage), the reduction in consumption – provided be limited to a very small number of cigarettes – may be a lower risk and an acceptable way of dealing with the patient.
In the future, new molecules interfering with the operation of the centers of the reward are in development.Rimonabant is a selective inhibitor of endocannabinoid receptor type 1. The results of the first Phase III studies show that this product is capable during the administration period to increase the success rate of smoking cessation without weight gain.
The impact of regulatory measures: Ministerial Decree (No. 2006- 1386 of 15 November 2006, Official Journal of 16 November 2006) prohibits smoking in places used for collective use. By restricting the use of tobacco, the imposed signage and fines for offenders, it is a strong signal of public authorities against smoking and its harmful consequences. This measure was generalized from January 2008.
CONCLUSION:
Smoking is a public health problem.
The cessation assistance is only one aspect of how to fight against this scourge. Medicated means available to help smokers in their quit attempt are limited for now and no one can claim to obtain a dramatic and sustainable rate of success. The systematic and renewed involvement of carers is to inform smokers about the risks of smoking, to speed up the cycle that allows them to reach an attempted withdrawal. This may require support in the most dependent smokers or problem. Minimal training allows caregivers to fulfill this mission in the majority of cases. smoking cessation consultation, due to their small number, should be reserved for the most difficult cases.
