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中国临床戒烟指南——解读

2008/09/28

    中国是WHO《烟草控制框架公约》的签署国,公约明确提出,每一缔约方应考虑国家现状和重点,制定和传播以科学证据和最佳实践为基础的适宜、综合和配套指南,并应采取有效措施以促进戒烟和对烟草依赖的适当治疗。为了履行公约,WHO烟草或健康合作中心等推出了《中国临床戒烟指南》。该指南可供各级各专业临床医生特别是全科医生、护士以及公共卫生医生在实践中使用。2008年新版《中国临床戒烟指南》的制定正在进行中。
    要点1 烟草依赖是一种慢性病
    ·WHO已将烟草依赖作为一种疾病列入国际疾病分类,确认烟草是目前对人类健康的最大威胁。
    ·烟草依赖是一种慢性高复发性疾病,只有少数吸烟者第一次戒烟就完全戒掉,大多数吸烟者均需要多次尝试才能最终戒烟。
   
要点2 控烟是医生义不容辞的责任
    ·医生与烟草是不相容的。
    很多国家的医生没有把烟草控制当做职业责任的一部分,而只是单纯治疗因吸烟引起的各种疾病。
    ·医生,应该首先不吸烟。
    但在高吸烟率的国家,医生甚至比一般公众吸烟更严重,这与医生的责任和形象明显冲突。
    要点3 烟草是医生职业生涯中面对的最大的可预防的致病因素
    ·医生帮助降低烟草危害的最直接方法就是帮助患者戒烟。
    ·医生劝导戒烟的效果与劝导的程度成正比。
    ·医生要帮助每个吸烟者朝着戒掉最后一支烟的目标努力,每次至少解决吸烟者戒烟中的一点问题。
  要点4 要宣传吸烟之害戒烟之益
  ·早戒比晚戒好,戒比不戒好。
  30岁前戒烟能使肺癌风险减少90%;戒烟5年后由吸烟所致的口腔和食管肿瘤风险减少一半;戒烟后心脏病风险降低更为迅速,1年内吸烟所致的死亡就将减半,15年内绝对风险与从未吸烟者类似;戒烟能轻度升高肺功能,逆转肺功能降低的速度。
  ·无论何时戒烟,戒烟者的寿命都长于持续吸烟者。
  一项对英国男医生为期50年的随访队列研究发现,吸烟者与不吸烟者相比平均早死亡约10年,60、50、40或30岁戒烟分别可赢得约3、6、9或10年的预期寿命。
  ·尼古丁最大的危害在于它的成瘾性,且作用极为迅速,吸烟者只需7.5秒就可到达大脑(静脉注射需13.5秒)。它还是一种抗焦虑药物,过量吸入可引起抑制或麻痹作用。
  要点5 对愿意戒烟者采取5A法
  ·询问(ask) 询问吸烟者的基本情况,执行问诊制度,最好使用统一的记录系统。
  ·建议(advice) 强化吸烟者的戒烟意识,用清晰的、强烈的、个性化的方式,敦促吸烟者戒烟,让他们知晓吸烟的危害,并走出误区。
  ·评估(assess) 明确吸烟者戒烟的意愿。
  ·帮助(assist) 包括帮助吸烟者树立正确观念、审查戒烟的理由、确定开始戒烟日期、签署戒烟协议、选择适当的戒烟方法、使用戒烟药物、处理戒断症状、提醒持续戒烟者防止复吸、提供戒烟科普材料和电话咨询等。
  ·随访(arrange) 在吸烟者开始戒烟后安排长期随访,随访时间最好6个月。
  要点6 掌握适宜的戒烟方法
  ·治疗生理依赖(躯体依赖)方法:戒烟药物。
  ·治疗心理依赖方法:心理支持。
  ·烟草依赖治疗最佳方案:药物和行为治疗结合。
  要点7 鼓励使用戒烟辅助药 
  ·WHO建议:一线戒烟药物包括尼古丁替代疗法的相应制剂,如尼古丁贴片、咀嚼胶、鼻喷剂、吸入剂和舌下含片以及盐酸安非他酮。伐尼克兰(Varenicline) 在美国已被列为一线用药。
  ·在一线药物无效的情况下,临床医生可采纳二线药物,如可乐定等(但现临床基本不用)。
  尼古丁替代疗法(NRT)
  ·治疗原理:以非烟草形式提供部分原来从烟草中获得的尼古丁,而治疗量的尼古丁远远低于从烟草中的获得量。既减轻戒断症状,提高戒烟成功率,又避免吸烟产生的有害物质对身体的毒害。
  ·疗效:NRT经广泛临床研究证实能有效控制烟瘾,缓解戒断症状,戒烟成功率是安慰剂的2倍。
  ·使用方法:要参照烟碱依赖量表进行评估。
  盐酸安非他酮  是一种具有多巴胺和去甲肾上腺素能的抗抑郁剂,于1997年被用于戒烟。它是口服药,在戒烟前1~2周开始服用,疗程为7~12周。副作用有口干、易激惹、失眠、头痛和眩晕。可降低癫痫发作阈,故癫痫患者禁用。
  伐尼克兰(Varenicline酒石酸盐)  在美国和欧洲上市,用于帮助成年烟民戒烟。是一种选择性尼古丁乙酰胆碱受体的部分激动剂,可减轻烟瘾和戒断症状。在治疗期间,它的拮抗性又可以减少吸烟时的满足感,从而减少复吸的可能性。在戒烟日之前的1~2周开始治疗,疗程2周,也可再治疗12周,同时考虑减量。副作用有失眠、恶心、胃肠胀气及便秘等。目前我国已完成该药的三期临床试验,近期有望上市。
    链  接
    美国:2000年出版的戒烟指南在2008年更新,戒烟咨询采取5A、5R法,其他国家指南多以此为依据。新西兰:2007年8月版戒烟指南推荐ABC方案(Ask,Brief advice, Cessation support); 澳大利亚、英国等亦有自己国家的戒烟指南。

附:1: Respir Care. 2000 Oct;45(10):1200-62.  

US public health service clinical practice guideline: 
treating tobacco use and dependence.

Fiore MC.

Treating Tobacco Use and Dependence, a Public Health Service-sponsored Clinical Practice Guideline, is a product of the Tobacco Use and
Dependence Guideline Panel ("the panel"), consortium representatives, consultants, and staff. These 30 individuals were charged with the responsibility of identifying effective, experimentally validated tobacco dependence treatments and practices. The updated guideline was sponsored by a consortium of seven Federal Government and nonprofit organizations: the Agency for Healthcare Research and Quality (AHRQ), Centers for Disease Control and Prevention (CDC), National Cancer Institute (NCI), National Heart, Lung, and Blood Institute, National Institute on Drug Abuse, Robert Wood Johnson Foundation, and University of Wisconsin Medical School’s Center for Tobacco Research and Intervention. This guideline is an updated version of the 1996 Smoking Cessation Clinical Practice Guideline No. 18 that was sponsored by the Agency for Health Care Policy and Research (now the AHRQ), United States Department of Health and Human Services. The original guideline reflected the extant scientific research literature published between 1975 and 1994. The updated guideline was written because new, effective clinical treatments for tobacco dependence have been identified since 1994. The accelerating pace of tobacco research that prompted the update is reflected in the fact that 3,000 articles on tobacco were identified as published between 1975 and 1994, contributing to the original guideline. Another 3,000 were published between 1995 and 1999 and contributed to the updated guideline. These 6,000 articles were screened and reviewed to identify a much smaller group of articles that served as the basis for guideline data analyses and panel opinion. This guideline contains strategies and recommendations designed to assist clinicians, tobacco dependence treatment specialists, and health care administrators, insurers, and purchasers in delivering and supporting effective treatments for tobacco use and dependence. The recommendations were made as a result of a systematic review and analysis of the extant scientific literature, using meta-analysis as the primary analytic technique. The strength of evidence that served as the basis for each recommendation is clearly indicated in the guideline. A draft of the guideline was peer-reviewed prior to publication, and the comments of 70 external reviewers were incorporated into the final document. The key recommendations of the updated guideline, Treating Tobacco Use and Dependence, based on the literature review and expert panel opinion, are as follows: 1. Tobacco dependence is a chronic condition that often requires repeated intervention. However, effective treatments exist that can produce long-term or even permanent abstinence. 2. Because effective tobacco dependence treatments are available, every patient who uses tobacco should be offered at least one of these treatments: Patients willing to try to quit tobacco use should be provided with treatments identified as effective in this guideline. Patients unwilling to try to quit tobacco use should be provided with a brief intervention designed to increase their motivation to quit. 3. It is essential that clinicians and health care delivery systems (including administrators, insurers, and purchasers) institutionalize the consistent identification, documentation, and treatment of every tobacco user seen in a health care setting. 4. Brief tobacco dependence treatment is effective, and every patient who uses tobacco should be offered at least brief treatment. 5. There is a strong dose-response relation between the intensity of tobacco dependence counseling and its effectiveness. Treatments involving person-to-person contact (via individual, group, or proactive telephone counseling) are consistently effective, and their effectiveness increases with treatment intensity (eg, minutes of contact). 6. (ABSTRACT TRUNCATED)

2: Am J Prev Med. 2008 Aug;35(2):158-76. 

A clinical practice guideline for treating tobacco use and dependence:
2008 update. A U.S. Public Health Service report.

American Journal of Preventive Medicine
Volume 35, Issue 2, August 2008, Pages 158-176

Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update Panel, Liaisons, and Staff.
Collaborators (37) 

Fiore M, Jaén CR, Baker TB, Bailey WC, Bennett G, Benowitz NL, Christiansen BA, Connell M, Curry SJ, Dorfman SF, Fraser D, Froelicher ES, Goldstein MG, Hasselblad V, Healton CG, Heishman S, Henderson PN, Heyman RB, Husten C, Koh HK, Kottke TE, Lando HA, Leitzke C, Mecklenburg RE, Mermelstein RJ, Morgan G, Mullen PD, Murray EW, Orleans CT, Piper ME, Robinson L, Stitzer ML, Theobald W, Tommasello AC, Villejo L, Wewers ME, Williams C.

OBJECTIVE: To summarize the U.S. Public Health Service guideline Treating Tobacco Use and Dependence: 2008 Update, which provides recommendations for clinical interventions and system changes to promote the treatment of tobacco dependence. PARTICIPANTS: An independent panel of 24 scientists and clinicians selected by the U.S. Agency for Healthcare Research and Quality on behalf of the U.S. Public Health Service. A consortium of eight governmental and nonprofit organizations sponsored the update. EVIDENCE: Approximately 8700 English-language, peer-reviewed articles and abstracts, published between 1975 and 2007, were reviewed for data that addressed assessment and treatment of tobacco dependence. This literature served as the basis for more than 35 meta-analyses.
CONSENSUS PROCESS: Two panel meetings and numerous conference calls and staff meetings were held to evaluate meta-analyses and relevant literature, to synthesize the results, and to develop recommendations. The updated guideline was then externally reviewed by more than 90 experts, made available for public comment, and revised. CONCLUSIONS: This evidence-based, updated guideline provides specific recommendations regarding brief and intensive tobacco-cessation interventions as well as system-level changes designed to promote the assessment and treatment of tobacco use. Brief clinical approaches for patients willing and unwilling to quit are described.

 


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下一篇: 附:2007年版临床戒烟指南(讨论稿)参考文献

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