Nicotine replacement therapy … - Carlos A ... - Entretiens du Carla

(15) Fiore MC, Jaen CR
et al. Treating Tobacco
use and dependence:
2008 Update. Clinical
Practice Guideline.
Department of Health
and Human Services.
Public Health Service.
2008.
(16) McBride CM et al.
Understanding the
potential of teachable
moments. The case of
smoking cessation.
Health Educ Res 2003
18: 156-170.
(17) France EK et al.
Smoking cessation
interventions among
hospitalized patients.
Whta have we
learned?. Prev Med
2001; 32: 376-388.
(18) Niaura R et al.
Relevance of cue
reactivity to
understanding alcohol
and smoking relapse. J
Abnorm Psychol 1988;
97: 133-152.
(19) Rigotti N, Munafo
M et al. Interventions
for smoking cessation
in hospitalized patients.
Cochrane Database
System Review. Issue 4.
2007.
(20) Cropley et al. The
effectiveness of
smoking cessation
interventions prior to
surgery. A sytematic
review. Nic Tob &Res
2008 10: 407-412.
In which cases should we
recommend NRT for
temporary abstinence?
NRT for temporary abstinence can be
recommeded in three different cases:
a) in those smokers who are forced to live
in smoke-free enviromments during a period
of time that is as large as causing them craving
or nicotine withdrawal syndrome (among
these patients we have to consider those who
are travelling frequently in public transports,
those who work in smoke-free worplaces,
those who like or are force to keep smoke-free
enviromment at home and those who visit
smoke-free recreational venues: discos, bars,
restaurants and so on),
b) in those smokers who are hospitalized
for different reasons and,
c) in those smokers who are going to be
operated on (“elective surgery”).
Which benefits can
produce temporary
abstinence in hospitalized
patients?
Hospitalization is a excellent “teachable
moment” for smokers. A “teachable moment”
is an event that motivates individuals to
change health behaviours that increase risk
(16). There is strong evidence that
hospitalization is associated with an increased
rate of spontaneous smoking cessation
compared with the general population. It has
been found that 1-year self-reported tobacco
abstinence rates after general hospitalization
tend to be higher than the rate of
spontaneous quitting in the general
population( approximately 10% to 15% vs 3%
to 5%, respectively (17).
On the other hand, we have to consider
that the hospitalized smoker is living in a
smoke-free enviromment that can help
him/her to maintain abstinence. Nevertheless,
nicotine is highly addicitve, and abstinence
from nicotine can causes withdrawal
symptoms and craving that could present a
barrier to quitting. In this context, using NRT in
hospitalized smokers in order to help them to
maintain abstinence should be strongly
recommended.
Probably, quitting smoking while
hospitalization can be easier than in other
enviromment. Smoking behaviour is modified
to a substantial degree by envirommental cues
that become associated with smoking.
Withdrawal symptoms may be accentuated in
the smokers natural enviromment because
these smoking related cues elicit withdrawal
syndrome. When the smoker s enviromment is
modified, such as cues may not be operative
and withdrawal symptoms may be better
controlled by NRT (18).
A recent meta-analysis in hospitalized
patients has found that intensive counselling
which is provided to the patient while he/she
is hospitalized and which is prolonged during
at least one month after discharge, is the only
intervention that can increase significantly
smoking cessation rates after discharge. OR:
1.65 (1.44-1.90) (19). Nevertheless, authors
conclude that although combining NRT with
intensive counselling has not increased
significantly the smoking cessation rates, the
evidences of benefits from using NRT have
increased with respect to the last revision (19).
Moreover, in a recent systematic review of 7
randomized controlled trials that included 870
patients hospitalized for surgery, Cropley et al
concluded that all interventions ( most of
them counselling plus NRT) were effective
with the short term quit rates as high as 95%
and averaging 55% (20). Nevertheless, authors
agree with the need to prolonged
interventions after discharge.
So taking into account all of these
considerations, we can conclude that
hospitalization is an excellent “teachable
moment” and represents a unique
opportunity for health professionals to advice
their patients to quit. Those, who in spite of
that, do not want to quit definitely should be
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