A Clinical Flow-Chart for the

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A Clinical Flow-Chart for the Treatment-Resistant
Smoker

• Renee Bittoun

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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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WHO International Framework Convention on
Tobacco Control, 2005

• The Framework Convention on Tobacco Control
  (FCTC) Article 1. Section D.
• harm reduction strategies
• to improve the health of a population by
  eliminating or reducing their consumption of
  tobacco products

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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 youll die
• dogma of abrupt quitting (Warner, 2005)

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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

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Back ground to combination therapies

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

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• 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

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Application

• Apply strategies, both NRT and smoking---to
  mental health/intellectually disabled smokers
• 90 comorbid COPD patients using combination/harm
  reduction

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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

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Reconciliation

• 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 controladdictive behaviour) (Aristotle, 4BCE
  Heather, 1998 Ainslie, 2001)
• Harm-reduction may be a softer option

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CONCLUSION

• Dont abandon the hard-to-treat cant 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 Youll Die Dogma.