1. A Clinical Flow-Chart for the “Treatment-Resistant Smoker” Renee Bittoun

2. 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)

3. WHO: International Framework Convention on Tobacco Control, 2005 The Framework Convention on Tobacco Control (FCTC): Article 1. Section D. harmreduction strategies to improve the health of a population by eliminating or reducing their consumption of tobacco products

4. 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 you’ll die” dogma of abrupt quitting (Warner, 2005)

5. 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

6. Back ground to combination therapies • Combination therapies show good outcomes in “hard-to-treat” smokers (Bittoun, 2005)

7. 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

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

10. 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

11. 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 control=addictive behaviour) (Aristotle, 4BCE; Heather, 1998; Ainslie, 2001) • Harm-reduction may be a softer option

12. CONCLUSION • Don’t abandon the “hard-to-treat” “can’t 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 You’ll Die” Dogma.