Experience in Sweden I, A - NCBI

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periods. Non-smokers. 60 1 Month. 40. 3 Months. 20. 0. 1. 2. 3. 4. Years. Fig. 6. Percent of patients using the nicotine chewing gum in relation to time. Subjects.
Lars Wilhelmsen Agneta Hjalmarsson

Smoking Cessation Experience in Sweden SUMMARY Studies of post-infarct patients and healthy controls in Sweden show that likelihood of stopping smoking is greater in better informed patients, in those who suffer a sudden bout of serious disease, and those who stop smoking completely, rather than cutting down. (Can Fam Physician 26:737-743, 1980). Dr. Wilhelmsen is on the medical

staff, and Ms. Hjalmarsson is a psychologist at Ostra Hospital in Goteborg, Sweden. Reprint requests to: Lars Wilhelmsen, Dept. of Medicine, Ostra Hospital, CK, Plan 2, S-416 85 Goteborg, Sweden. TNFORMATION ABOUT known associations between smoking and diseases is obviously important when trying to help people stop smoking. However, at least in Sweden, dissemination of this information seems to have been rather badly done. In spite of many newspaper articles,

I, A

radio and TV programs, we fQund the level of knowledge to be poor, much worse than we thought before we analyzed the situation. However, we also know that smokers have a tendency to reject this message because it increases their psychological conflict. Figure 1 shows the associations between smoking and fatal diseases in our prospective population study of about 8,000 randomly selected middle-aged men in Goteborg, Sweden. Total death, cancer death, coronary heart disease -and especially lung cancer increase very rapidly with increasing tobacco consumption. Lung

Fig. 1. Incidence of fatal events during seven years' follow up among a random population sample of men aged 47-54 years at entry to the study. 14 % Total death

12

10 All cancer

8

6 4

~~~~~~~Coronal~heart disease

22

E

uLung cancer

E

0 N =2410 Never

smoked

1655

Stopped smoking

CAN. FAM. PHYSICIAN Vol. 26: MAY 1980

2733 1-14

1232

15-24 Smoking g/day

208

ยข 25

Si

S

SEPTRA* SUSPENION bid. * broad-spectrum activity provides bactericidal coverage against most common causa-

tive organisms in both urinary and respiratory tract infections * discourages development of resistance * achieves rapid. high urine and blood levels * well tolerated by most patients * licorice flavor well accepted by children * Septra* (Trimethoprim + Sulfamethoxazole) PX Summary NID TIONS: Indicated for the following infections when caused by susceptible organisms: UPPER AND LOWER RESPIRATORY TRACT INFECTIONS-particularly chronic bronchitis and acute and chronic otitis media. URINARY TRACT INFECTIONS-acute, recurrent and chronic. GENITAL TRACT INFECTIONS-uncomplicated gonococcal urethritis. GASTROINTESTINAL TRACT INFECTIONS. SKIN AND SOFT TISSUE INFECTIONS. SEPTRA is also indicated in the treatment of infants and children with a diagnosis of Pneumocystis carinii pneumonitis, especially if they are immunosuppressed. SEPTRA is not indicated in infections caused by Pseudomonas, Mycoplasma or viruses. This drug has not yet been fully evaluated in streptococcal infections. CONTRANDICATIONS: Patients with evidence of marked liver parenchymal damage, blood dyscrasias, known hypersensitivity to trimethoprim or sulfonamides, marked renal impairment where repeated serum assays cannot be carried out, premature or newborn babies during the first few weeks of life. For the time being SEPTRA is contraindicated during pregnancy. ADVERSE REACTIONS: Most frequent: nausea; vomiting; gastric intolerance; and rash. Less frequent: diarrhea; constipation: flatulence: anorexia; pyrosis; gastritis; gastroenteritis; urticaria; headache: and liver changes (abnormal elevations in alkaline phosphatase and serum

transaminase). Occasionally reported: glossitis; oliguria; hematuria; tremor; vertigo; alopecia; and elevated BUN, NPN, and serum creatinine. Hematological changes occurring particularly in the elderly, are mostly transient and reversible (primarily, neutropenia and thrombocytopenia: less frequently, leukopenia, aplastic or hemolytic anemia, agranulocytosis, and bone marrow depression). PRECAUTlONS: As with other sulfonamide preparations, critical appraisal of benefit versus risk should be made in patients with liver damage, renal damage, urinary obstruction, blood dyscrasias. allergies or bronchial asthma. The possibility of a superinfection with a non-sensitive organism should be borne in mind. DOSAGE AND ADMINISTRATION: Adults and children over 12 years. Standard dosage: 2 Septra tablets or 1 Septra DS tablet twice daily. Minimum dosage and dosage for long-term treatment: 1 Septra tablet or l/2 Septra DS tablet twice daily. Maximum dosage: Overwhelming infections: 3 Septra tablets or 11'2 Septra DS tablets twice daily. Uncomplicated gonorrhea: 2 Septra tablets or 1 Septra DS tablet four times daily for 2 days. Pneumocvstis carinii pneumonitis: 20 mg/kg/day trimethoprim and 100 mg/kg/day sulfamethoxazole in four divided doses for 14 days. Children 12 years and under.t Young children should receive a dose according to biological age: Children under 2 years: 2.5 ml of suspension twice daily. Children 2 to 5 years: 2.5-5 ml of suspension twice daily. Children 6 to 12 years: 5-10 ml of suspension twice daily. tIn children this corresponds to an approximate dose of 6 mg trimethoprim/kg body weight/day, plus 30 mg sulfamethoxazole/kg body weight/day, divided into two equal doses.

cancer is as common as a cause of death among those smoking more than 25 cigarets as is coronary heart disease. There are six times as many moderate smokers- 15-25 cigarets a day-and the total number of fatal events is greater in this group than in the group with the higher tobacco consumption. This means that the "population-attributable risk" is higher in the group with moderate tobacco consumption as compared to the group

with the highest consumption. This fact is not always kept in mind when the impact of smoking on the community is discussed. The moderate smokers are at least as important in the antismoking program as the heavy smokers. Coronary heart disease is the most common cause of death in the group of moderate smokers. We found that especially the randomly selected selected men from the general population knew very little

Fig. 2. Percent yes-answers to the question: "Do you think that an association between smoking and the following diseases is shown?" The percent non-smokers in the random samples of doctors (n=1011), student nurses (n=170) and of men aged 50 (n =137) and aged 60 (n =536) are also shown. The studies were undertaken between 1969 (doctors) and 1974 (random population samples of men). 1 00 %

80

% Non-smokers

20in i

60 40

..

0

Myocardial

Chronic bronchitis

Pulmonary carcinoma

Student nurses (n

I1011)

Swedish doctors (n Men aged 50 (n

=

infarction

Men aged 60 (n = 536) (random samples)

137)

Fig. 3. Percent of Swedish doctors who considered an association between smoking and disease proven. Percent smokers also given.

+4 > Welicome Medical Division Burroughs Welicome Inc. t 6'LLCO~ LaSalle, Que. IPAABI

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Fig. 4. Survival during five years' follow up of male patients having survived a first myocardial infarction related to stopping smoking and continuing smoking after the infarction. % Survival rate

100 80

%Chroni~c br0flchi'5

100 90 l go

Lun~fgCa == ~~

Ii, l~~~~~~~~~t S

n9

DOSAGE FORMS: SEPTRA DS TABLETS, each containing 160 mg trimethoprim and 800 mg sulfamethoxazole, and coded WELLCOME 02C. Bottles of 50 and 250. SEPTRA TABLETS, each containing 80 mg trimethoprim and 400 mg sulfamethoxazole, and coded WELLCOME Y2B. Bottles of 100 and 500. and unit dose packs of 100. SEPTRA PEDIATRIC TABLETS, each containing 20 mg trimethoprim and 100 mg sulfamethoxazole, and coded WELLCOME H4B. Bottles of 100. SEPTRA PEDIATRIC SUSPENSION, each teaspoonful (5 ml) containing 40 mg trimethoprim and 200 mg sulfamethoxazole. Bottles ot 100 and 400 ml. Product monograph available on request. wTrade Mark W-7o21

170) L

40

"?OkX

70 Pe

20

okers

60

ir

0

1969

1972

Study Years

1977

0

'1

1

2

4

5

212

159

85

133

98

44

3

Follow up years No. Stopped 276 352 433 No. Continued 327 248 191

CAN. FAM. PHYSICIAN Vol. 26: MAY 1980

about the associations between pulmonary carcinoma, chronic bronchitis, myocardial infarction and smoking. There was also a relationship between present smoking status and the knowledge of these facts (see Fig. 2). We have performed studies of smoking habits and known associations between smoking and these diseases in random samples of Swedish doctors at three times since 1969 (Fig. 3). It can be seen that attitudes and smoking habits have changed rather markedly during these few years. Physicians themselves may be fully aware of the deleterious effects of smoking but they do not convey them to their patients, presumably because they think that patients are already well informed. The lack of personal advice to stop smoking from the physician in charge will, not only rob a patient of important advice but may result in a more positive attitude towards smoking: "My doctor didn't say anything, so it can't be too dangerous even though the newspaper says it is". Different diseases associated with smoking tend to influence the possibility of a sudden behavioral change to different degrees. Diseases which strike the patient suddenly also seem to cause sudden changes in behavior. This group of diseases includes lung cancer and myocardial infarction. Other diseases are just as strongly associated with smoking but usually take a more gradual course and modify behavior in the same way. Examples are chronic bronchitis and intermittent claudication. In our experience patients from the first group stop smoking far more easily than those in the

second group. There is, however, one very important prerequisite for this result. Stopping smoking has to take place in close association with the onset of the acute disease, or with the patient's becoming aware of the lifethreatening condition. Once post-infarct patients have been discharged from hospital, the prognosis for cessation of smoking is not much better than for patients of the second group. Patients in the second group often easily detect improvement of the symptoms with decreasing consumption, and this is usually found even if they have not cut down to zero. Thus, hypothetically, this relief seems to encourage decreased consumption but the slow progression of disease does not encourage the patient to stop completely. He or she might soon increase his consumption again.

In our work we have been able to Fig. 5. Percent of 224 patients still not smoking after various follow up periods. Non-smokers

60

1 Month

*

3 Months

40

*

20 1

3

2

4

40

20 I-

3

4

5

Months CAN. FAM. PHYSICIAN Vol. 26: MAY 1980

6

'-

-U

60

2

-~~

Years

N = 224

1

6

0

80

0

-p

Practical Considerations in an Anti-smoking Clinic

Fig. 6. Percent of patients using the nicotine chewing gum in relation to time. Subjects 100 %

p

7

8

,

9

10 11

12 20 40

Sinemef*

ANTIPARKINSON AGENT Comnon adverse resctons that can occur with SINEMET* are abnormal involuntary movements and, less frequently, mental changes. These usually can be diminished by dosage reduction. INDICATIONS Treatment of Parkinson's syndrome with exception of drug induced parkinsonism. CONTRAINDICATIONS When a sympathomimetic amine is contraindicated; with monoamine oxidase inhibitors, which should be discontinued two weeks prior to starting SINEMET*; in uncompensated cardiovascular, endocrine, hematologic, hepatic, pulmonary or renal disease; in narrowangle glaucoma; in patients with suspicious, undiagnosed skin lesions or a history of melanoma. WARNINGS When given to patients receiving levodopa alone, discontinue levodopa at least 12 hours before initiating SINEMET* at a dosage that provides approximately 20% of previous levodopa. Not recommended in drug-induced extrapyramidal reactions; contraindicated in management of intention tremor and Huntington's chorea. Levodopa related central effects such as involuntary movements may occur at lower dosages and sooner, and the 'on and off' phenomenon may appear earlier with combination therapy. Monitor carefully all patients for the development of mental changes, depression with suicidal tendencies, or other serious antisocial behaviour. Cardiac function should be monitored continuously during period of initial dosage adjustment in patients with arrhythmias. Upper gastrointestinal hemorrhage is possible in patients with history of peptic ulcer. Safety of SINEMET* in patients under 18 years ot.age not established. Pregnancy and lactation: In women of childbearing potential, weigh benefits against risks. Should not be given to nursing mothers. Effects on human pregnancy and lactation unknown.

PRECAUTIONS General: Periodic evaluations of hepatic, hematopoietic, cardiovascular and renal function recommended in extended therapy. Treat patients with history of convulsions cautiously. Physical Activity: Advise patients improved on SINEMET* to increase physical activities gradually, with caution consistent with other medical considerations. In Glaucoma: May be given cautiously to patients with wide angle glaucoma, provided intraocular pressure is well controlled and can be carefully monitored during therapy. WithAntihypertensive Therapy: As symptomatic postural hypotension has been reported occasionally, give cautiously to patients on antihypertensive drugs, checking carefully for changes in pulse rate and blood pressure. Dosage adjustment of antihypertensive drug may be required. With Psychoactive Drugs: If concomitantadministration is necessary, administer psychoactive drugs with great caution and observe patients for unusual adverse reactions. With Anesthetics: Discontinue SINEMET* the night before general anesthesia and reinstitute as soon as patient can take medication orally. ADVERSE REACTIONS Most Common: Abnormal Involuntary Movements-usually diminished by dosage reduction-choreiform, dystonic and other involuntary movements. Muscle twitching and blepharospasm may be earlysigns of excessive dosage. OtherSerious Reactions: Oscillations in performance: diurnal variations, independent oscillations in akinesia with stereotyped dyskinesias, sudden akinetic crises related to dyskinesias, akinesia paradoxica (hypotonic freezing) and 'on and off' phenomenon. Psychiatric: paranoid ideation, psychotic episodes, depression with orwithout development CAN. FAM. PHYSICIAN Vol. 26: MAY 1980

of suicidal tendenciesand dementia. Levodopa may produce hypomania when given regularly to bipolar depressed patients. Rarely convulsions (causal relationship not established). Cardiac irregularities and/or palpitations, orthostatic hypotensive episodes, anorexia, nausea, vomiting and dizziness. Other adverse reactions that may occur: Psychiatric: Increased libido with serious antisocial behaviour, euphoria, lethargy, sedation, stimulation, fatigue and malaise, confusion, insomnia, nightmares, hallucinations and delusions, agitation and anxiety. Neurologic: ataxia, faintness, impairment of gait, headache, increased hand tremor, akinetic episodes, "akinesia paradoxica", increase in the frequency and duration of the oscillations in performance, torticollis, trismus, tightness of the mouth, lips or tongue, oculogyric crisis, weakness, numbness, bruxism, priapism. Gastrointestinal: constipation, diarrhea, epigastric and abdominal distress and pain, flatulence; eructation, hicc.ips, sialorrhea; difficulty in swallowing, bitter taste, dry mouth; duodenal ulcer; gastrointestinal bleeding; burning sensation of the tongue. Cardiovascu/ar: arrhythmias, hypotension, non-specific ECG changes, flushing, phlebitis. Hematologic: hemolytic anemia, leukopenia, agranulocytosis. Dermatologic: sweating, edema, hair loss, pallor, rash, bad odor, dark sweat. Musculoskeletal: low back pain, muscle spasm and twitching, musculoskeletal pain. Respiratory: feeling of pressure in the chest, cough, hoarseness, bizarre breathing pattern, postnasal drip. Urogenital: urinary frequency, retention, incontinence, hematuria, dark urine, nocturia, and one report of interstitial nephritis. Special Senses: blurred vision, diplopia, dilated pupils; activation of latent Horner's syndrome. Miscellaneous: hot flashes, weight gain or loss. Abnormalities in laboratory tests reported with levodopa alone, which may occur with SINEMET*: Elevations of blood urea nitrogen, SGOT, SGPT, LDH, bilirubin, alkaline phosphatase or protein bound iodine. Occasional reduction in WBC, hemoglobin and hematocrit. Elevations of uric acid with colorimetric method. Positive Coombs tests reported both with SINEMET* and with levodopa alone, but hemolytic anemia extremely rare.

DOSAGE SUMMARY In order to reduce the incidence of adverse reactions and achieve maximal benefit, therapy with SINEMET* must be individualized and drug administration continuously matched to the needs and tolerance of the patient. Conbined therapy with SINEMET* has a narrower therapeutic range than with levodopa alone because of its greater milligram potency. Therefore, titration and adjustment of dosage should be made in small steps and recommended dosage ranges not be exceeded. Appearance of involuntary movements should be regarded as a sign of levodopa toxicity and an indication of overdosage, requiring dose reduction. Treatment should, therefore, aim at

maximal benefit without dyskinesis Therapy in Patients not receiving Levodopa: Initially Y2 tablet once or twice a day, increase by Y2 tablet every three days if desirable. An optimum dose of 3 to 5 tablets a day divided into 4 to 6 doses.

Therapy in Patients receiving Levodopa: Discontinue levodopa for at least 12 hours, then give approximately 20% of the previous levodopa dose in 4 to 6 divided doses. FOR COMPLETE PRESCRIBING INFORMATION, PARTICULARLY DETAILS OF DOSAGE AND ADMINISTRATION, PLEASE CONSULT PRODUCT MONOGRAPH WHICH IS AVAILABLE ON REQUEST. HOW SUPPLIED Ca8804-Tablets SINEMET* 250, dapple-blue, oval, biconvex, scored, compressed tablets coded MSD 654, each containing 25 mg of carbidopa and 250 mg of levodopa. Available in bottles of 100 and 500. *"Trademark [PAAB

CMERCK & DOHME CANADA LIMITED P0O

BOX 10D5. POINTE-CLIRE, DORVAL H9R 4P8

TABLE 1 Result in Relation to Mode of Cessation: Follow-up 44-50 Months

Abrupt Reduced consumption

Ex-smokers Smokers n n 101 51 0

24

x2= 9.76 p < 0.005 follow post-infarct patients who have stopped smoking. We have also worked at a special anti-smoking clinic with patients referred from other physicians, patients asking for help in stopping smoking even if they have no direct symptoms, and men invited to stop smoking in association with a special primary preventive trial comprising 10,000 men aged 47-54 in the intervention group of the trial. We have with few exceptions advocated abrupt discontinuation of the smoking habit. Smoking cessation of this type differs from various other changes of habit, like diet and physical exercise, which require more gradualchanges but also more long-lasting concern. There are several reasons for recommending a complete stop. The smoking habit is more easily forgotten with complete discontinuation. We have repeatedly seen people having cut down to two or three cigarets a day, who have later increased their consumption to the original level. A true nonsmoker is more easily accepted as a non-smoker by his friends than a person who only cuts down his consumption. In general we have used group therapy, but we have also some experience from individual therapy. Whatever method has been used, we have always informed the patient about adverse effects of the smoking habit, and also positive effects of stopping smoking. The information has also been quite extensive concerning theories of the smoking habit, nicotine addiction and methods of stopping. Information about side effects of stopping has also been offered quite extensively as well as support when problems arise. We think that the support during the first weeks up to three months after having stopped smoking is probably the most important work at an anti-smoking clinic. It is also im741

Librax' (chlordiazepoxide HCI -

clidinium bromide'Roche') Rx Summary

Indications

TABLE 2 Results of Stopping Smoking In Relation to Duration of Nicotine Chewing Gum Use (n = 185)

Adjunctive management of irritable bowel

syndrome, peptic ulcer and other gastrointestinal disorders associated with hypersecretion, hypermotility and spasm and accompanied by anxiety or tension states.

Ex-smokers Smokers Total (n)

0 % 30 % 70 20

Weeks Using Chewing Gum 1-160 1-3 4-12 16-160 27 7 23 68 73 93 77 32 165 44 88 33

Contralndlcatlons Hypersensitivity to chlordiazepoxide and/ or clidinium bromide.

Glaucoma, prostatic hypertrophy and benign bladder neck obstruction.

Precautions In elderly or debilitated patients limit the initial dose to the smallest effective to preclude the development of oversedation or ataxia.

Use with caution in severely depressed patients and in those who may increase the dosage on their own accord. Advise patients against concomitant ingestion with alcohol or other CNS depressants and caution against engaging in activities requiring complete mental alertness or physical coordination. Use only in women who are or who may become pregnant when benefits have been weighed against possible hazards to mother and fetus.

Use with caution in patients with impaired renal or hepatic function; periodic blood counts and liver and renal function tests may be advisable during prolonged therapy Adverse Effects As for chlordiazepoxide. In addition, clidinium bromide may cause dryness of the mouth, blurred vision, urinary hesitancy; constipation particularly when combined with other spasmolytics and/or low residue diet.

Dosage Adults - 1 to 2 capsules 3 or 4 times daily, before meals and at bedtime.

Supply Each capsule contains chlordiazepoxide HCI - 5 mg, and clidinium bromide 2.5 mg; green opaque body and cap with ROCHE and LIBRAX (black ink) alternating between body and cap. Bottles of 100 and 500.

Complete prescribing information available on request. H offmann-La Roche Limited H/H \ *