Pre-operative Smoking Cessation Special Therapeutic Situations

the฀risks฀of฀peri-฀and฀post-operative฀tobacco-associated฀complications฀ [217] .฀This฀study฀in฀ 120฀patients฀indicates฀that฀an฀effective฀smoking฀intervention฀programme฀6–8฀weeks฀before฀ surgery฀reduces฀postoperative฀morbidity:฀the฀overall฀complication฀rate฀was฀18฀in฀the฀ smoking฀intervention฀group฀and฀52฀in฀the฀control฀group฀p฀=฀0.0003.฀The฀median฀length฀ of฀ hospital฀ stay฀ was฀ 11฀ 7–57฀ vs.฀ 13฀ 8–69฀ days฀ intervention฀ vs.฀ controls฀ [217] .฀ According฀to฀estimates฀in฀one฀series฀of฀studies,฀smoking฀cessation฀should฀be฀implemented฀ 8฀weeks฀prior฀to฀surgery฀ [218] .฀The฀period฀before฀and฀after฀surgery฀is฀a฀good฀time฀to฀insti- tute฀interventional฀measures฀with฀regard฀to฀smoking฀cessation.฀In฀particular,฀peri-operative฀ complications฀can฀be฀reduced฀by฀pre-operative฀smoking฀cessation.฀Alongside฀behavioural฀ therapy฀interventions,฀NRT฀is฀probably฀the฀method฀of฀choice.

11.6 Concluding Remarks

It฀is฀assumed฀that,฀despite฀pharmacotherapy,฀medical฀counselling฀of฀the฀smoker฀is฀neces- sary฀but฀that฀this฀achieves฀independent฀smoking฀cessation฀in฀a฀fraction฀of฀smokers฀only. • ฀ Among฀ the฀ pharmacological฀ options,฀ numerous฀ studies฀ indicate฀ that฀ treatment฀ with฀ nicotine฀products฀appears฀to฀be฀a฀reliable฀method,฀leading฀to฀successful฀smoking฀cessa- tion฀in฀30–40฀of฀cases฀see฀Table฀ 11.9 ฀for฀list฀of฀products. • ฀ The฀level฀of฀the฀nicotine฀dose฀administered฀initially฀is฀a฀critical฀problem฀area฀simulta- neous฀combination฀of฀two฀or฀three฀formulations฀may฀be฀required฀in฀the฀initial฀phase฀of฀ treatment. • ฀ Depending฀ on฀ the฀ level฀ of฀ dependence,฀ NRT฀ should฀ be฀ continued฀ for฀ 4–12฀ weeks,฀ decreasing฀the฀nicotine฀dose฀over฀time. • ฀ Nicotine฀chewing฀gum฀4฀mg,฀nasal฀spray฀and฀inhaler฀are฀more฀suitable฀than฀the฀nico- tine฀patch฀for฀the฀relief฀of฀craving. Agent Formulation Daily฀dose฀[mg] Nicotine Patch฀maximum฀release฀1.5฀mgh Maximum฀21 a Chewing฀gum,฀2฀mg Maximum฀32 a Chewing฀gum,฀4฀mg Maximum฀64 a Sublingual฀tablet,฀2฀mg Maximum฀60 a Nasal฀spray฀10฀mgml 1–2฀mgh,฀maximum฀30 a Inhaler฀10฀mg฀cartridge 20–40 a Lozenge,฀2฀mg Maximum฀18–30 a Lozenge,฀4฀mg Maximum฀36–60 a Bupropion Sustained-release฀tablets Maximum฀2฀´฀150 Table 11.9 ฀฀฀A฀selection฀of฀agents฀used฀as฀aids฀to฀promote฀smoking฀cessation,฀together฀with฀dosage฀ details a Irrespective฀of฀bioavailability • ฀ Treatment฀with฀nicotine฀products฀makes฀an฀independent฀contribution฀to฀smoking฀cessation,฀ and฀to฀a฀large฀extent฀is฀therefore฀effective฀independently฀of฀medical฀counselling.฀The฀two฀ interventions฀have฀an฀additive฀effect. • ฀ Currently฀available฀studies฀indicate฀that฀bupropion฀is฀not฀more฀effective฀than฀nicotine฀ [239] ,฀but฀the฀likely฀incidence฀of฀serious฀adverse฀effects฀has฀not฀yet฀been฀established฀ conclusively.฀Because฀of฀its฀smaller฀risk-beneit฀ratio,฀bupropion฀should฀be฀used฀as฀a฀ second-line฀ option฀ where฀ NRT฀ has฀ failed฀ or฀ where฀ the฀ patient฀ insists฀ on฀ bupropion฀ despite฀medical฀advice฀to฀the฀contrary. • ฀ On฀the฀basis฀of฀data฀currently฀available,฀other฀agents฀such฀as฀nortriptyline,฀clonidine,฀ lobeline,฀mecamylamine,฀opioid฀antagonists฀and฀antidepressants฀including฀buspirone฀ are฀not฀to฀be฀recommended฀for฀the฀treatment฀of฀people฀who฀wish฀to฀stop฀smoking. • ฀ In฀ pregnant฀ women,฀ smoking฀ cessation฀ with฀ NRT฀ should฀ be฀ instituted฀ if฀ structured฀ counselling฀does฀not฀achieve฀the฀desired฀goal. • ฀ All฀smokers฀with฀cardiovascular฀disease฀should฀use฀NRT฀because฀nicotine฀in฀therapeu- tic฀doses฀does฀not฀cause฀vasospasm. • ฀ In฀the฀case฀of฀“hopeless”฀smokers฀who฀are฀simultaneously฀risk฀patients,฀consideration฀ should฀be฀given฀in฀the฀near฀future฀as฀to฀whether฀longer-term฀administration฀of฀NRT฀ preparations฀“harm฀reduction”฀might฀not฀help฀to฀lower฀daily฀cigarette฀consumption,฀ and฀thus฀reduce฀the฀risk฀of฀tobacco-associated฀morbidity฀and฀mortality. • ฀ Nicotine฀receptor฀antagonists฀increase฀the฀chances฀of฀successful฀long-term฀smoking฀cessa- tion฀between฀two-฀and฀threefold฀compared฀with฀pharmacologically฀unassisted฀quit฀attempts.฀ However,฀there฀is฀a฀need฀for฀larger,฀independent฀community-based฀trials฀to฀test฀the฀eficacy฀ of฀treatment฀extended฀beyond฀12฀weeks฀and฀to฀assess฀potential฀adverse฀reactions. • ฀ Nicotine฀vaccines฀are฀still฀under฀development.฀Some฀preliminary฀studies฀were฀promis- ing.฀First฀compounds฀might฀appear฀on฀the฀market฀in฀2011. References ฀ 1.฀Haustein฀ KO฀ 2000฀ Pharmacotherapy฀ of฀ nicotine฀ dependence.฀ Int฀ J฀ Clin฀ Pharmacol฀ Ther฀ 386:273–290 ฀ 2.฀The฀Tobacco฀Use฀and฀Dependence฀Clinical฀Practice฀Guideline฀Panel,฀Staff,฀and฀Consortium฀ Representatives฀2000฀A฀clinical฀practice฀guideline฀for฀treating฀tobacco฀use฀and฀dependence.฀ JAMA฀283:3244–3254 ฀ 3.฀Anonym฀2000฀Treating฀tobacco฀use฀and฀dependence.฀U.S.Department฀of฀Health฀and฀Human฀ Services,฀Public฀Health฀Service,฀Washington ฀ 4.฀The฀Cochrane฀Library฀2002฀The฀Cochrane฀Collaboration฀฀Update฀Software฀Ltd,฀editor.฀ [Update฀2002,฀Issue฀1],฀Oxford,฀UK ฀ 5.฀Silagy฀C,฀Lancaster฀T,฀Stead฀L,฀Mant฀D,฀Fowler฀G฀2002฀Nicotine฀replacement฀therapy฀for฀ smoking฀cessation.฀Cochrane฀Database฀Syst฀Rev฀1:CD000146 ฀ 6.฀Blondal฀T฀1989฀Controlled฀trial฀of฀nicotine฀polacrilex฀gum฀with฀supportive฀measures.฀Arch฀ Intern฀Med฀1498:1818–1821 ฀ 7.฀Bolliger฀ CT฀ 2000฀ Practical฀ experiences฀ in฀ smoking฀ reduction฀ and฀ cessation.฀ Addiction฀ 95suppl฀1:19–24 ฀ 8.฀Blondal฀T,฀Franzon฀M,฀Westin฀A฀1997฀A฀double-blind฀randomized฀trial฀of฀nicotine฀nasal฀ spray฀as฀an฀aid฀in฀smoking฀cessation.฀Eur฀Respir฀J฀107:1585–1590