cessation facts SMOKING AND One year abstinence rates: CROHN’S DISEASE: • General population, no intervention — 3-6% Effectiveness of anti-smoking medications: THE FACTS • SR (Zyban) — RR 1.69 • Varenicline (Champix) — RR 2.27 The biggest modifiable risk Effectiveness of counselling: factor • Physician advice — RR 1.66 Smoking increases the risk of developing Crohn’s • Physician counselling — RR 1.86 disease, and for those with Crohn’s disease, smoking makes it worse: • Telephone counselling — RR 1.37 • increases the severity • Individual counselling — RR 1.39 • increases the number of flares • Group counselling — RR 1.98 • increases the need for steroids Effectiveness of the combination of anti-smoking medications and counselling: • increases the number of surgeries • General population — RR 1.82 in meta-analysis • increases the speed of relapse post-surgery of 40 trials; increased abstinence by 70-100% • increases the number of strictures, perforations, Cessation in specific subgroups: fistulas, and perianal disease • Pre-operative counselling and NRT — lower rate • increases the risk of extra-intestinal of overall postoperative complications compared manifestations with patients in the counselling-only group (18% • decreases the effectiveness of medications such vs 52%) as infliximab • Pre-operative counselling and varenicline — Additionally, patients with longstanding, active IBD improved one year abstinence rate (36.4% are at increased risk of cancer, and those who combination vs 25.2% counselling only, RR 1.45, smoke are at even higher risk of developing cancer. 95% CI: 1.01-2.07)

Bad for the budget Which patients to discuss Cost of in Canada is steadily increasing (2015 prices): with Every patient with Crohn’s disease who smokes. • Cost of a pack = $12-15 per day Rather than assessing readiness to quit, physicians • Pack per day, yearly cost = over $5,000 should proactively offer treatment, more in line with • Pack per day, 10 years = over $45,000 the treatment of other chronic diseases. • If invested at 5%, that money invested would A suggested approach is for the physician to grow to $57,000 over 10 years. That’s $13,000 in communicate three facts: interest alone • Stopping smoking can be difficult • The difference between costs of smoking • Effective treatment is available (-$45,000 over 10 years), and savings (+$57,000 over 10 years) is >$100,000 in 10 years. • Here is information on anti-smoking medications and counselling

Updated 2015 have not shown an increased risk of serious Anti-smoking medications neuropsychiatric events compared to placebo crash course • Contraindications — Allergy to varenicline Bupropion SR (Zyban): • Monitoring — No routine lab tests required • Mechanism of action — Weak - • When to stop therapy — Patients should be reuptake inhibitor treated for 12 weeks. For patients who have • When to quit cigarettes — Treatment is started successfully stopped smoking at the end of 12 while the patient is still smoking and a "target weeks, an additional course of 12 weeks at 1 mg stop date" set within the first two weeks of BID is recommended to further increase the treatment with Zyban, preferably in week 2 likelihood of long-term abstinence • Combination with NRT — Recommended • Dose —The initial dose is 150 mg daily for 3 replacement therapy options: days, increasing to 150 mg BID • Inhaler cartridges — good for breakthrough. Rx: • Most common side effects — is a very Cartridge inhaled PRN, m:100 cartridges common adverse event which is often transient. • Patch — steady nicotine delivery. Rx: Nicotine Insomnia may be reduced by avoiding dosing at patch 7 / 14 / 21 mg, on 0800 off 2000; m:14 bedtime or, if clinically indicated, dose reduction • Gum — causes dry mouth • Most serious side effects — Seizure; mania; • Mouth spray— causes dry mouth ; hypertension • Lozenge — causes dry mouth • Contraindications — Seizure disorder or history of seizures; Cirrhosis or severe liver disease; Renal impairment; Bipolar disorder; Uncontrolled Smoking cessation alone: hypertension • Most common side effects — Associated with: • Monitoring — No routine lab tests required insomnia, irritability, frustration or anger; anxiety; difficulty concentrating; change in appetite and • When to stop therapy — Patients should be weight gain treated for at least 7 weeks. Discontinuation should be considered if the patient has not made • Most serious side effects — Exacerbation of significant progress towards abstinence by the underlying psychiatric illness seventh week of therapy, since it is unlikely that they will stop smoking during that attempt Bottom line Varenicline (Champix): Take home messages for physicians: • Mechanism of action — Partial nicotine • Discuss smoking cessation (using the Smoking Cessation Action Plan and Smoking Fact Sheet • When to quit cigarettes — Treatment is started for patients) with all patients with Crohn’s disease while the patient is still smoking and a "target who smoke. stop date" set within the first two weeks of treatment with varenicline, preferably in week 2 • Recommend combination of counselling and anti-smoking medications. • Combination with NRT — Not recommended • If anti-smoking medications are prescribed by the • Dose — Days 1-3: 0.5 mg daily; Days 4–7: 0.5 gastroenterologist, varenicline is first line. Use mg BID; Day 8–End of Treatment: 1 mg BID bupropion SR as second line, plus NRT • Most common side effects — ; Abnormal cartridges if high . dreams • Most serious side effects — Case reports of seizures. Analyses of pooled data

Updated 2015