Jan 30, 2017
By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy
Long before former UKIP leader Nigel Farage became "Mr. Brexit" or signed on to becoming an "unofficial Trump Advisor", London had a stink to it. In 1858 the smell from the River Thames was so bad, that summer was called the "Great Stink of London". Not only did the river stink, people were dying. In 1853-1854 more than 10,000 Londoners were killed by cholera. Although at the time people thought these recurrent epidemics of cholera were caused by the stink itself, they weren't far off. Cholera is a water borne disease most often associated with a lack of sewage treatment. London needed a super hero. And the engineer, Joseph Bazalgette with his handle bar moustache swooped in to the rescue. Bazalgette designed the sewer system that connected most of London by 1866. With a proper sewage system, there were no more cholera outbreaks and no more stink for London.
I remember in University if you went out to the bar, when you came home your clothes stank of smoke even if you weren't a smoker. Going back farther, Myles remembers when the patients, pharmacists and doctors were all smoking all day long at the clinic. He remembers ashtrays built into the arm rests of the chairs in the waiting room. Things are different now. You can't smoke at most indoor workplaces at all. You can't smoke in restaurants, planes, malls or movie theaters. And taxes have made cigarettes very expensive. Just like Bazalgette designed sewers in London to greatly reduce the chance of cholera, various laws and regulations in Manitoba have made it very difficult to be a smoker.
From a public health point of view, less smokers are great. Smoking is the number 1 cause of premature death in North America. Name a body part, and we can tell you how smoking is bad for it. Other than the heart, lungs and cancer that everyone knows about, let's talk about some less discussed problems. Smoking decreases the blood flow to the skin, and this leads to leathery-looking skin and increased wrinkling. The more you smoke, the more likely you are to get cataracts -an eye problem that can lead to blindness. Smoking is the main reason people get cancer in the mouth. Smoking makes it harder for your saliva to remove germs in your mouth. You'll get stains, bad breath, and a higher chance of gum disease. Smokers are twice as likely as non-smokers to develop psoriasis - a disfiguring red and silver rash that can occur anywhere on your body. Smokers are more prone to stomach ulcers. The ulcers don't heal as fast, and they're more likely to recur. There's also growing evidence that smoking may increase the risk of chronic bowel disease. Finally, guys, smoking causes impotence. So, it is great that we have less smokers. However, since the anti-smoking regulations have worked so well, most of the people who could quit smoking without too much difficulty, already have. It seems like the people who are still smoking either really don't want to quit, or have a really hard time quitting.
What do you do with someone who kinda wants to quit smoking, but isn't quite ready right now? Usually, we tell people to think about it some more and come back and talk to us in the pharmacy when they are ready to quit within the next month. We might give them some info to take home to read about quitting smoking, but honestly, besides being encouragement, there isn't much we can do. Every heard, "You can lead a horse to water, but you can't make him drink?" The smoker must decide for themselves that they really want to quit.
But what if that isn't true. About 10 years ago, we were told about Reduce to Quit. It was different than what we usually tell smokers. We usually tell smokers to pick a quit date within the next month. Then we help them get ready. We may or may not give them a medication to help reduce their cravings, but after quit day passes, no more cigarettes. Period. In 2005, there was a study by Batra, et al. in Clinical Pharmacology and Therapeutics in which the researchers took 364 smokers and gave them either 4mg nicotine gum or a placebo for a year. The study participants were told to try to reduce the number of cigarettes they smoked and chew more gum. The researchers were mostly looking to see who reduced their cigarette consumption by 50%. Interestingly, at 13 months 12% of the nicotine gum users had actually quit smoking, while only 4.5% of the placebo group had. This study had several successful quitters by simply chewing more nicotine gum, smoking less cigarettes and not setting a quit date. This is the opposite approach to us telling smokers they must pick a quit date first, and not smoke after that date.
There is now an interesting new study talking about Reduce to Quit with a new drug. In 2015, Jon O. Ebbert et al. published a much larger trial in JAMA (the Journal of the American Medical Association), in which they looked at Reduce to Quit with varenicline or Champix. The researchers looked at 1510 smokers who were not willing to quit in the next month, but thought they might like to reduce how much they smoked over the next 3 months. Half the subjects were given varenicline 1 mg twice a day and the other half placebo for 24 weeks or about 6 months. The subjects were told to decrease the number of cigarettes they smoked by 50% about 1 month into the trial. Then they were told to decrease the number of cigarettes they smoked by 75% by 2 months and to try to quit by 12 weeks, or 3 months. The subjects were followed out to a year after starting their treatment. The subjects were asked to record how many cigarettes they smoked, but their carbon monoxide levels were checked to keep them honest.
How did the subjects do? I wasn't surprised to learn the subjects on varenicline smoked less cigarettes than the placebo group during the 24 week treatment peroid. Varenicline or Champix is a quit smoking drug. We have used it successfully for years. I must admit, I was surprised that at the 1 year follow up, which is 6 months after stopping the varenicline, 27% of the people who had used varenicline were still quit, versus only 10% of the placebo group. Reduce to Quit seems to be a reasonable plan whether it is with varenicline or nicotine gum. Reduce to Quit instead of picking a quite date and sticking to it might be a really good option for people who are having trouble quitting smoking. And because of all the cigarette bans in Manitoba, many of the people who are still smoking are by definition having trouble quitting.
Brandon was the first city in Manitoba to ban smoking. I remember going out in Brandon with my friend Joe after the ban and having my clothes not stink. It was amazing. Brandon's smoking ban was a brick in the well-designed regulations that reduced smoking in Manitoba and improved our public health. I wonder how long until Trump, Farage and cronies build a wall along the Canadian border to keep their stink out of our air?
As always if you have any questions or concerns about these or other products, ask your pharmacist.
The information in this article is intended as a helpful guide only. It is not intended to be used as a substitute for professional advice. If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.
We now have this and most other articles published in the Parkland Shopper on our Website. Please visit us at www.dcp.ca
History of London's sewer system - http://www.bbc.co.uk/history/historic_figures/bazalgette_joseph.shtml
Nicotine Gum Reduce to Quit - http://europepmc.org/abstract/med/16338284
Varenicline Reduce to Quit in JAMA - http://jamanetwork.com/journals/jama/fullarticle/2110968