Hvordan gi effektiv hjelp til roykeavvenning Serena Tonstad, overlege OUS 22.11.12

Mest effektiv leveranse av nikotin

Røyking og type 2 diabetes 1.7 1.6 1.5 1.4 1.3 1.2 1.1 1.0 1.7 1.6 1.5 1.4 1.3 1.2 1.1 1.0 N=1.2 million Relativ risiko Tidligere røyker Lett røyker * Stor- røyker † Røyker BMI <25kg/m2 Røyker BMI ≥25kg/m2 *<20 sigaretter/dag †≥ 20 sigaretter/dag Willi C, et al. JAMA 2007;298:2654–64

Sammenheng mellom antall sigaretter/dag og CHD 2.0 Studier om aktiv røyking 1.5 Relativ risiko for CHD 1.3 Annenhånds røyk Null eksponering 1.0 5 10 15 20 25 30 Number of cigarettes per day Law M et al. Pro Card Dis 2003;46:31-8. 4 4

Smoking: Increased risk of acute nonfatal myocardial infarction 10 9 8 7 6 5 4 3 2 1 Odds Ratio (95% CI)* Key Point Overall, current smoking was associated with a 3-fold increase in the odds of having a nonfatal acute myocardial infarction (MI) compared with nonsmokers. Teo et al evaluated 12,133 cases of first acute MI and 14,435 age-matched and sex-matched controls in the international, multicenter INTERHEART study. Trained staff administered a questionnaire to both cases and controls in which participants were asked detailed questions about their smoking status. Overall, current smoking was associated with a 3-fold increase in the odds of having a non-fatal acute MI, compared with nonsmokers (odds ratio [OR] 2.95; 95% CI 2.77-3.14; P<.0001). Risk increased with the number of cigarettes smoked. The effect of current smoking was significantly greater in younger (OR, 3.53; 95% CI, 3.23-3.86) than in older participants (OR, 2.55; 95% CI, 2.35-2.76); P<.0001 for interaction. The effect of current smoking was markedly greater in younger subjects, particularly among the heaviest smokers (20 cigarettes per day) in whom ORs were 5.6 (95% CI, 5.1-6.2) for younger smokers and 3.6 (95% CI, 3.25-3.98) for older smokers (P<.0001 for interaction). Age <40 y Age 40-49 y Age 50-59 y Age 60-69 y Age >70 y Age >70 y Nonsmokers Ex-smokers 1-19 cigar- ettes 20 cigarettes 20 cigarettes Teo KK et al. Lancet 2006; 368:647-658. Reference Teo KK, Ounpuu S, Hawken S, et al; on behalf of the INTERHEART Study Investigators. Tobacco use and risk of myocardial infarction in 52 countries in the INTERHEART study: a case-control study. Lancet. 2006;368:647-658.

Impact of smoking cessation on cardiovascular risk reduction Blood pressure control Estimation of annual reduction of mortality related to coronary artery disease according to different primary prevention strategies in England and Wales between 1981 and 2000 Blood cholesterol reduction Smoking cessation 5000 10000 15000 20000 20000 Number of annual CHD-related deaths avoided or postponed Curr Opin Cardiol 25:469–477

Effekten av røykeslutt på blodplater Key Point Smoking abstinence is associated with reduced platelet aggregability. In an attempt to evaluate the impact of smoking cessation on intracellular oxidative stress and platelet aggregability in long-term smokers, Morita et al evaluated 27 male smokers. Subjects smoked a minimum of 15 cigarettes per day for more than 5 years. Participants were divided into 2 groups: group A abstained from smoking for 28 days, and group B abstained from smoking initially, but resumed smoking after 14 days. Bloodwork was assessed at baseline followed by days 7, 14, 21, and 28. Adenosine diphosphate (ADP) and collagen-induced platelet aggregation were assessed by adding ADP and collagen to washed platelet suspensions and light transmission was monitored using a platelet aggregometer. Agonist (ADP or collagen)-induced platelet aggregations were similar between the 2 groups at baseline. In group A, agonist-induced platelet aggregations were significantly reduced throughout the period of abstinence. In group B, agonist-induced platelet aggregation significantly decreased through day 14; however, aggregability rapidly returned to baseline with reinitiation of smoking. A - Quit smoking for 28 days. B - Resumed smoking after quitting for 14 days. ADP=adenosine diphosphate. ADP is a platelet aggregation agonist. Morita et al. J Am Coll Cardiol. 2005;45:589-594. Reference Morita JH, Ikeda H, Haramaki N, Eguchi H, Imasizumi T. Only two-week smoking cessation improves platelet aggregability and intraplatelet redox imbalance of long-term smokers. J Am Coll Cardiol. 2005;45:589-594. 7

Avhengighetensmakt Bare ~2–3% lykkes i å slutte årlig Alle røykere 100% Prøver å slutte ~30% Ønsker å slutte ~70%

Effekten av røyking på det mesolimbiske system Benowitz N. N Engl J Med 2010;362:2295-2303

Nervecelle reseptorer for nikotin 4 Nikotin Åpning av kanaler Reseptor enheter Celle-membran Nikotinske acetylkolinreseptorer

Nikotin reseptor aktivitet Start av røyking = aktivert = sensitiv = ikke sensitiv 11

Nikotin reseptor aktivitet Oppregulering ved røyking = aktivert = sensitiv = ikke sensitiv 12

Nikotin reseptor aktivitet Røykeslutt = aktivert = sensitiv = ikke sensitiv 13

Tobakk-avhengighet passer til en sykdomsmodell Organ Tobakk-avhengighet passer til en sykdomsmodell hos mange pasienter ÅRSAK Forstyrrelse* Abstinens *Forstyrrlese i hjernens belønningssystem

Medikamentell behandling Nikotinerstatning Korttidsvirkende Tyggegummi Inhalator Sugetabletter Sublingvaltabletter Langtidsvirkende Plaster Antidepressiva Bupropion SR Nortriptylin (ikke godkjent) Vareniklin Første medikament som ikke inneholder nikotin og utviklet spesifikkt for røykeavvenning 16

US Public Health Service Meta-analysis (2008) 6-måneders sluttrater sammenliknet med placebo Medication Estimated odds ratio (95% CI) Est. abstinence rate Placebo 1.0 13.8 Varenicline (2 mg/day) 3.1 (2.5–3.8) 33.2 (28.9–37.8) Nicotine nasal spray 2.3 (1.7–3.0) 26.7 (21.5–32.7) Nicotine inhaler 2.1 (1.5–2.9) 24.8 (19.1–31.6) Bupropion SR 2.0 (1.8–2.2) 24.2 (22.2–26.4) Nicotine patch (6–14 weeks) 1.9 (1.7–2.2) 23.4 (21.3–25.8) Nicotine gum (6–14 weeks) 1.5 (1.2–1.7) 19.0 (16.5–21.9) Fiore MC, et al. Clinical Practice Guideline. Treating Tobacco Use and Dependence: 2008 Update. USDHHS. PHS. Rockville, MD. 2008. 17

Binding av vareniklin til nikotin-reseptor Receptor Subunits b2 b2 b2 V N V Cell membrane 4 4 4 4

Resultater av vareniklin vs placebo hos pasienter med HKS OR: 6.11 (95% CI: 4.18–8.93) P<0.0001 Varenicline (n=355) Placebo (n=359) 50 47.0 OR: 3.92 (95% CI: 2.55–6.03) P<0.0001 40 OR: 3.14 (95% CI: 1.93–5.11) P<0.0001 30 28.2 Continuous abstinence (%) 20 19.2 13.9 9.5 10 7.2 Weeks 9–12 (Primary endpoint) Weeks 9–24 Weeks 9–52 (Key secondary endpoint) Rigotti NA et al. Circulation; 121: 221-9. 19

Røykeavvennings ABC A. Røyker du? B. Hva synes du om din røyking? C. Jeg kan hjelpe deg å slutte 20

Ask and Act www.aafp.com

Effekten av minimal intervensjon på røykeslutt Forest plot of the effect of minimal clinical intervention on the incidence of smoking abstinence. Smoking abstinence is defined by the most rigorous criterion. (1) In addition to a minimal clinical intervention arm, patients were randomized to a telephone counselling arm. Mottillo S et al. Eur Heart J 2009;30:718-730

Endringens stige Aksjonerer Begynner å tenke på å endre røykevaner 10 9 Begynner å tenke på å endre røykevaner 8 7 6 Tenker på å slutte men ikke helt klar 5 4 3 Tenker på at en dag må jeg slutte 2 1 Ingen tanker om å slutte Biener et al. Health Psychology 1991; 10: 360-5. 23

Behandling i klinikken Avtale strategien Visitt (Dag 2 or 3) Telefonsamtale Visitt eller telefonsamtale Visitt eller telefonsamtale Oppfølgingsvisitt 1 2 3 4 5 6 7 8 9 10 11 12 Antall uker siden første besøk

Redskaper - kalendar Nov 2011 Des 2011 Jan 2012 Sluttdato Su M Tu W Th F Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Begynner å få virksomme blodverdier Des 2011 Su M Tu W Th F Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1/Jorenby/p 62/Table 4 2/Gonzales/p 53/Table 4 3/Tonstad/Slide 10 Kanskje ikke merker noe? Jan 2012 Su M Tu W Th F Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 15 16 17 18 20 21 22 23 24 25 26 27 28 29 30 Sluttdato 1/Jorenby/p 62/Table 4 2/Gonzales/p 53/Table 4 3/Tonstad/Slide 10, Slide 11 Siste behandlings-dag, 12 uker senere Planlegg oppfølging Reference Champix Prescribing Information. Pfizer Inc, New York, NY. (May 2006) 25

Adferdsendring i praksis Gjenkjenne faresituasjoner – tristhet, sinne, tretthet, stress, alkohol Utvikle evnen til å forutsi, unngå, distrahere, redusere stress Gi informasjon om sug, abstinens, reseptorer www.ahrq.gov

Adferdsendring i praksis Det er lettere å planlegge å gjore noe enn IKKE å gjøre noe (f eks ikke røyke) Planlegg hva man vil gjoere istedenfor Utvikle nye assosiasjoner Samme situasjon, ny adferd Når jeg stresser, ringer jeg en venn Bytt med adferd som møter samme behov og er belønnende Når jeg ringer en venn, stresser jeg ned og det fører til hyggelig sosialt samvær O´Connor KP & Stravynski A. Behav Res Ther. 1982; 20:279-88. 28

Reduser kaffe

Hva med lette sigaretter? Ventilasjonshull Low tar cigarettes were once held up as a sound approach to reducing the harm caused by smoking. This approach is now entirely discredited. Such products make little difference to the total exposure to toxins experienced by smokers. However, they carry the additional risk that smokers will draw false reassurance from what is branded to appear less dangerous, and tastes less strong. This could easily lead smokers that would otherwise have quit to continue smoking – this American advert even made that choice explicit. RCP Tobacco Advisory Group PowerPoint Files. Available at: www.rcplondon.ac.uk/pubs/books/tag/index.asp. 30 30

Hvor mye overvekt tilsvarer risiko ved røyking? Økning i BMI på15.9 enheter hos menn og15.8 enheter hos kvinner tilsvarer risiko ved å røyke 10 sigaretter/dag Gjennomsnittlig vektøkning er 2-5 kg Smoking, body weight, and CHD mortality in diverse populations. Preventive Medicine 2004; 38: 834-40.

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