Management of nicotine dependent inpatients An evidencebased treatment model Tobacco and Health Bran

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Management of nicotine dependent inpatientsAn
evidence-based treatment modelTobacco and
Health BranchNSW Centre for Health
PromotionJuly 2002
2
The purpose of this presentation is for use in
training clinicians working with inpatients who
smoke,in the context of the NSW Health Smoke
Free Workplace Policy (1999)
(please note all references for the content of
this presentation are included in the Guide for
the management of nicotine dependent inpatients
(page 19) except for lozenge study)
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In this presentation we will cover

• Tobacco use in the community
• Health policy
• Assessment of nicotine dependence
• Nicotine withdrawal
• Nicotine replacement therapy (NRT)
• Frequently asked questions
• Brief intervention
• Discharge referral

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Background to tobacco use in the community
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• The World Health Organisation describes smoking
  as an
• epidemic
• that will cause 1/3 of all adult deaths
  world-wide by 2020

(WHO 1999)
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Prevalence of smoking in Australian population

• Overall in 2001 daily smoking prevalence was
  19.5
• males 21
• females - 18
• Prevalence was higher among younger people,
  daily smoking rates peaked in the 20-29 year age
  group
• The mean number of cigarettes smoked per week
  increased with age peaking at 140 cigarettes by
  age 50-59

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Prevalence of smoking in Australian population
in 2001
of age group
Age groups
(Adapted from AIHW 2002 report)
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Prevalence of inpatient smoking in NSW

• Between 18 - 23 of patients admitted to NSW
  hospitals are current smokers (self-reported)
• The actual figure may be higher than this.
• In one study, a further 18 self-reported
  non-smokers tested positive for salivary
  cotinine, suggests theyre current smokers
• A Central Sydney study found that 1 in 5
  inpatients were highly dependent on nicotine
  (using Fagerstrom Test)

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Burden of disease caused by tobacco - NSW

• Tobacco is the major cause of drug-related
  death the single greatest preventable cause of
  premature death disease
• In 2000, smoking caused 4,316 male deaths
  2,255 female deaths (18.5 10.3 of all male
  female deaths respectively)
• In 1998/99 smoking caused 50,023
  hospitalisations among males and 30,045
  hospitalisations among females (5.7 3 of
  all male female hospitalisations respectively).

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Health Policy
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Recommends that- all health care facilities and
their immediate surroundings should be smoke
free. - and that hospital staff should - ask
about smoking status prior to or on
admission - offer brief advice
pharmacotherapy to those who need it and -
provide assistance to those interested in
stopping.
The World Health Organisation
WHO (2001)
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NSW Health Smoke Free Workplace Policy 1999

• Goal To prohibit smoking throughout all
  buildings, vehicles and property controlled by
  NSW Health
• Rationale
• To reduce the harm associated with smoking among
  staff, patients, visitors, especially exposure to
  passive smoking
• To provide a clear message to staff, patients,
  visitors, community about the health risks of
  smoking
• To provide leadership in the community about
  reducing harm associated with smoking

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The guide for the management of nicotine
dependent inpatients

• Developed within the context of the NSW Health
  Smoke Free Workplace Policy (1999)
• Aim to assist clinicians in the management of
  nicotine dependence in inpatients confined to
  smoke-free environment
• Two parts
• a laminated flowchart for use on the ward
• a booklet summarising the international evidence
• Is not about smoking cessation, although some
  patients may use the opportunity of
  hospitalisation to attempt to quit smoking

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Managing nicotine dependence

• The NSW Health Smoke Free Workplace Policy
  provides a supportive environment for abstinence
  during hospitalisation
• The guide proposes that hospital staff
• identify nicotine dependent patients
• give patients information about the smoke free
  policy
• provide prompt and appropriate treatment to
  patients experiencing nicotine withdrawal
• provide brief intervention for smoking
  cessation
• advise patients at discharge on options for
  permanent cessation

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Managing nicotine dependence

• Early identification of smoking status and
  swift provision of an adequate level of NRT may
  reduce the potential for a highly dependent
  smoker to become irritable or aggressive due to
  nicotine withdrawal
• Reduction of withdrawal symptoms may in turn
  reduce the amount of work and time required to
  manage the patient
• NSW Health recommends that AHSs develop
  specific protocols appropriate for local
  settings to clarify role delineation ensure
  prompt delivery of treatment to patients

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Recognising and AssessingNicotine Dependence
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Tobacco dependence is a chronic disease with
remission and relapseNicotine dependence
warrants medical treatment as does any drug
dependence disorder or chronic disease
Fiore et al, U.S. Dept of Health and Human
Services, June 2000
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• Indeed, it is difficult to identify any other
  condition that presents such a mix of lethality,
  prevalence, and neglect, despite effective and
  readily available interventions

Fiore et al, U.S. Dept of Health and Human
Services, June 2000
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Identification of smoking status

• Swift identification of smokers on admission
  increases rates of intervention and guides
  appropriate treatment
• The Alcohol and Other Drugs Policy for Nursing
  Practice in NSW Clinical Guidelines recommends
  recording a patients substance use history
  (including tobacco) upon admission
• Moderate to heavily dependent smokers should
  also be screened for depression
• Patients with depressed mood and a history of
  problem drinking are more likely to be nicotine
  dependent and may have greater difficulty in
  abstaining during hospitalisation

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Nicotine

• A psychoactive drug affecting mood and
  performance
• The source of addiction to tobacco
• More addictive than heroin or cocaine (WHO)
• Binds to nicotinic cholinergic receptors found
  on cell bodies and at nerve terminals in the
  brain and autonomic ganglia
• Activation (smoking) facilitates release of
  neurotransmitters- acetylcholine,
  norephinephrine, dopamine, serotonin,
  B- endorphin and glutamate

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Manipulation of dose

• Arterial blood nicotine concentrations may be
  up to 100ng/mL - venous concentrations typically
  20-30 of this
• Concentrations in the heart and brain may be up
  to 200-300 ng/mL immediately after a cigarette
• Regular cigarette smoking plateaus at daily
  plasma concentrations of 20-35 ng/mL ( 5
  -10 carboxyhemoglobin)
• Smoker can titrate the dose of nicotine to
  regulate a particular level
• Intake of nicotine from a given product depends
  on puff volume, depth of inhalation, rate and
  intensity of puffing
• Smokers titrate higher levels of nicotine from
  light cigarettes or reduced number by
  breathing in deeper holding smoke in lungs
  longer
•  

(Ng/mL nannograms per millilitre)
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Nicotine dependence

• Tobacco use produces tolerance to nicotine,
  withdrawal symptoms and difficulty in
  controlling future use
• The bolus of nicotine to the brain achieved by
  smoking is one of the key reinforcers of
  dependence
• Nicotine in blood in 4 seconds, in brain in 7
  seconds
• Nicotine dependence and withdrawal can develop
  with use of all forms of tobacco
• Neuro-adaptation (tolerance) can occur within a
  few doses of the drug, depending on rate and
  route of dosing

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Nicotine dependence (DSM-IV)

• Features of nicotine dependence include
• smoking soon after waking
• smoking when ill
• difficulty refraining from smoking
• reporting the first cigarette of the day to be
  the one most difficult to give up
• smoking more in the morning than in the
  afternoon

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Assessment of nicotine dependence

• The Fagerstrom Test for Nicotine Dependence
  (FTND) is based on criteria in DSM-IV (6
  questions)
• (for questions scoring see page
  9 of Guide)
• 2 questions consistently match valid biochemical
  indicators of dependence
• how soon after waking up do you smoke?
• how many cigarettes per day do you smoke?
• (for scoring see page 10 of
  Guide)

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Time to first cigarette (TTFC)

• Due to widespread smoking restrictions, many
  highly dependent smokers may not be able to
  smoke as many cigarettes per day as they need to
  get adequate nicotine
• Smoke fewer cigarettes but smoke them more
  thoroughly ie suck harder, deeper,
  down to filter etc.
• Wake up extremely nicotine deprived
• 1 question may suffice to determine level of
  dependence
• how soon after waking up do you smoke?
• First cigarette within or 30 minutes after
  waking high dependence
• More than 30 minutes after waking low dependence

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Time to first cigarette (TTFC)

Wake up 0
TTFC Less than or equal to 30 minutes after
waking HIGH DEPENDENCE
TTFC More than 30 minutes after waking
LOW DEPENDENCE
30 minutes
(Adapted from presentation by Saul Shiffman)
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Nicotine Withdrawal
Usually worst in the first 24 - 48 hours, then
decline in intensity gradually over next 2 weeks.
Symptoms may include four (or more) of the
following within 24 hours of cessation, often
causing significant distress

• Dizziness
• Coughing
• Tingling sensations in extremities
• Appetite changes
• Constipation
• Decreased heart rate
• Insomnia

• Craving for tobacco
• Depressed mood
• Increased appetite or weight gain
• Irritability, frustration or anger
• Anxiety
• Difficulty in concentrating
• Restlessness

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Pharmacotherapy
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Nicotine Replacement Therapy (NRT)

• Available in gum, lozenge, patch and inhaler
• Aims to replace the nicotine obtained from
  cigarettes, reducing withdrawal symptoms when
  stopping smoking
• Use of NRT is preferable to smoking, because it
  does not
• contain non-nicotine toxic substances such as
  carbon monoxide and 'tar'
• produce dramatic surges in blood nicotine
  levels
• produce strong dependence

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Nicotine Replacement Therapy (NRT) (cont.)

• Odds ratio for abstinence with NRT compared to
  control is 1.73 (patch 1.76, gum 1.66, inhaler
  2.08) (4mg lozenge 3.69)
• Odds are independent of intensity of additional
  support provided to smoker or setting in
  which NRT offered
• In highly dependent smokers there is significant
  benefit of 4mg gum over 2mg gum (odds ratio
  2.67) (NBlozenge also)
• Increases quit rates 1.5 - 2 fold, regardless of
  setting
• NRT is safe, should be routinely recommended to
  smokers, product choice depends on practical
  personal considerations
• (Cochrane review)
• ( large RCT)

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Level of nicotine dependence and NRT dosage

• As a general rule, smokers who are nicotine
  dependent will have less intense withdrawal
  symptoms if provided with an adequate dosage of
  NRT
• For example
• The trial for the nicotine lozenge used the
  TTFC (time to first cigarette) measure of
  dependence to allocate dosage
• those who smoke within 30 mins of waking - 4mg
  lozenge
• those who wait longer than 30 mins - 2mg
  lozenge
• (Note the lozenge provides 25 more nicotine
  than the gum as it dissolves completely)

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Nicotine Toxicity

• Recent quitters using NRT often confuse
  withdrawal with nicotine toxicity
• Nicotine withdrawal symptoms similar to toxic
  effects of nicotine
• Extremely rare in smokers more likely not
  enough nicotine
• Rapid tolerance to nicotine (within several
  cigarettes or few days of smoking) toxicity
  symptoms would not occur in smoker
• NRT only provides the body with nicotine levels
  close to the low trough level reached between
  cigarettes when smoking

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Smoking produces much higher nicotine
levels than NRT
14
12
10
8
Increase in nicotine concentration ( ng/ml )
Cigarette Gum 4 mg Gum 2 mg Inhaler Patch
6
4
2
0
5 10 15 20 25 30
Minutes
Source Balfour DJ Fagerström KO. Pharmacol
Ther 1996 7251-81.
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NRT Dosage

• Plasma nicotine levels significantly lower from
  NRT than smoking
• MIMS recommended dosages
• Gum maximum 40 per day
• Lozenge maximum 15 per day
• Patch healthy people gt 10 cigs/day gt45 kgs
  one patch daily 2 1mg/24 hr or
  15mg/16hr
•        cardiovascular disease lt10 cigs/day, lt45
  kgs one patch daily 14mg/24hr or 10mg/16hr
• Inhaler Self-titrate dose, according to
  withdrawal symptoms. 6-12 cartridges/day.

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Directions for use of NRT products
Gum nicotine absorbed through oral mucosa, chew
till a peppery/tingling feeling, flatten gum
and park between gum cheek, or under
tongue Lozenge nicotine absorbed through oral
mucosa, move around mouth from time to time
and suck until dissolved (takes 20-30
minutes) Patch nicotine absorbed through skin,
place on clean, non-hairy site on chest or
upper arm on waking, place new patch on new
site each day to prevent skin reaction Inhaler
nicotine absorbed through oral mucosa, inhale air
through cartridge for 20 minutes
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Bupropion (Zyban)

• First non-nicotine medication shown effective
  for cessation
• Blocks neural re-uptake of dopamine and/or
  noradrenaline
• Start one week prior to quit day, limited
  application for inpatients
• An option for patients after discharge and
  patients can be referred to their GP to discuss
  their options
• The only pharmacotherapy available on PBS
• Contraindications include patients with seizure
  disorder, current or prior bulimia or anorexia
  nervosa, use of a MAO inhibitor within the
  previous 14 days

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Combination therapy

• Highly dependent smokers may benefit from
  combining patch with self- administered form of
  NRT (lozenge/gum/inhaler)
• More effective than single form of NRT
• Use combined treatments if unable to remain
  abstinent or if still experiencing withdrawal
  symptoms using single therapy
• Increased success depends on the use of two
  distinct delivery systems one passive (ie
  patch) one active or at liberty (ie
  gum/lozenge/inhaler)

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Contraindications (MIMS 2001)
NRT is currently contraindicated for some patient
groups and use by these patients requires special
consideration Gum non-tobacco users,
pregnancy, lactation, children (lt 12 yrs) Patch
non-tobacco users, acute MI, unstable angina,
severe arrhythmias, recent CVA, skin disease,
children (lt 12 years) pregnancy,
lactation Inhaler non-tobacco users,
hypersensitivity to menthol, pregnancy,
children (lt 12 years) Lozenge non-tobacco users,
phenylketonurics, pregnancy, lactation, recent
heart attack or stroke, severe irregular
heartbeat unstable or resting angina, (from
pack info) (NB while NRT is contraindicated
during pregnancy, if patient unable to abstain,
then gum, lozenge or inhaler are preferable to
smoking)
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Frequently asked questions
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Is NRT suitable for cardiovascular patients?

• No evidence of increased cardiovascular risk
  with NRT
• NRT delivers plasma nicotine concentrations
  below those produced by smoking and does not
  expose the smoker to carbon monoxide or other
  harmful substances
• Clinical trials of NRT in patients with
  underlying, stable coronary disease suggest that
  nicotine does not increase cardiovascular risk
• The health risks of using NRT to assist such
  patients to stop, or significantly reduce,
  smoking far outweigh any treatment-related risks

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Is NRT safe for pregnant or lactating women?

• NRT should be considered when a pregnant woman
  is otherwise unable to quit
• Potential benefits of quitting outweigh the
  risks of the NRT potential continued smoking
• NRT less harmful than smoking during pregnancy
  - lower total nicotine dose and no exposure to
  carbon monoxide other toxic substances
• NRT clearly beneficial to highly dependent
  smokers, more at risk of adverse reproductive
  outcome less likely to quit when pregnant
•  

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Is NRT safe for pregnant or lactating women?
(cont.)

• A maternal 10 blood carboxyhemoglobin level
  (40 cigs per day) can cause 10 -15 higher
  carboxyhemoglobin level in the foetus than in
  the mother ( 60 reduction in foetal blood flow)
• If clinician and patient decide to use NRT,
  consider forms that yield intermittent nicotine
  (lozenge/inhaler/gum) rather than continuous
  drug exposure (patch) due to potential
  neurotoxicity in the foetus of continuous
  exposure to nicotine   
• A pregnant smoker should receive encouragement
  and assistance in quitting throughout her
  pregnancy

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Is pharmacotherapy safe for patients with
psychiatric comorbidity?

• Always in patients best interests to quit
  smoking
• Tobacco use is associated with affective
  disorders and depressive symptoms
• Depression decreases likelihood that abstinence
  will be successful and depressed mood is a
  common symptom of nicotine withdrawal
• Antidepressants may aid abstinence in those
  with symptoms of depression
• Possible that smoking increases risk of
  depression perhaps by affecting
  neuro-transmitter systems
•  

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Is pharmacotherapy safe for patients with
psychiatric comorbidity? (cont)

• Patients with a history of major depression who
  quit may be 7 times more likely to have a
  recurrence of major depression than people who
  continue to smoke  
• Current smokers have higher rates of anxiety
  disorders may find it more difficult to remain
  abstinent. Evidence suggests that anxiolytics
  are not effective smoking cessation aids  
• Quitting may affect the pharmacokinetics of
  psychiatric medications (eg anti-psychotic
  medications)
• Monitor actions or side effects of psychiatric
  medications in smokers attempting abstinence
• Mental health patients demonstrate a preference
  for nicotine inhaler over the transdermal patch

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Is NRT safe for adolescents?

• Young people can become addicted to tobacco
  very quickly
• NRT provides lower dose of nicotine than
  smoking, no carbon monoxide and other toxins
• While there are no LEGAL restrictions, the info
  on the NRT pack states Do not use if you are
  under 18 years of age a condition of
  registration of product by Commonwealth
•   When treating adolescents, clinicians may
  consider pharmacotherapy when there is evidence
  of nicotine dependence
• Factors such as degree of dependence, number
  of cigarettes per day and body weight should be
  considered  
• Prescription guidelines from pharmaceutical
  companies recommend 21 mg patch if gt45 kilos, 14
  mg patch if lt45 kilos

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How long should NRT be used for?

• Clinicians advising clients in smoking cessation
  should tailor the dosage and duration of therapy
  to fit the needs of patients
• Patch - 8 weeks of continuous use has been shown
  to be as effective as longer treatment periods
  (no need to taper)
• Gum generally should be used for up to 12
  weeks
• Inhaler up to 6 months, tapering off during
  final 3 months
• Lozenge trial suggests 24 weeks of treatment
  using same product in diminishing doses (however,
  similar period of use to gum likely to be
  effective due to similar absorption method)
• (Fiore et al, 2000)

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What is best to prevent weight gain?

• Smokers weigh on average 4 kg less than
  non-smokers
• When smoker stops, gains average of 2.3kg in
  next year
• Brings quitters up to similar weights to sex
  age matched never- smokers
• Of great concern to some smokers, especially
  women and adolescents, can act as motivator to
  start or continue smoking
•   NRT (particularly gum lozenge) bupropion
  delay, but don't prevent post-cessation weight
  gain
• Advise that health risks of moderate weight
  gain are small compared to risks of continued
  smoking - concentrate on cessation till
  confident will not return to smoking
• Recommend regular exercise program healthy
  eating to control weight

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Brief Intervention
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Brief Intervention

• The World Health Organisation encourages
  provision of brief opportunistic interventions
  delivered by all health professionals in the
  course of their routine work
• The purpose of brief intervention for smoking
  cessation is to increase motivation to quit
• Same technique can be used during provision of
  information for management of dependence while
  hospitalised
• Hospitalisation is a time when the adverse
  consequences of smoking are highlighted for
  the individual a window of opportunity for a
  teachable moment

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Brief Intervention (cont.)

• Brief advice (approx 3 minutes) by doctors,
  nurses and other health care workers is
  effective
• More intensive interventions only marginally
  increase the efficacy of brief advice
• Personalised, non-critical feedback that helps
  them understand the impact of smoking on their
  health
• Motivational interventions most likely to
  succeed when clinician is empathetic, promotes
  patient autonomy, encourages self- efficacy
  identifies previous successes in behaviour change
  efforts

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Discharge referral
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Discharge and referral

• Every patient identified as a smoker should be
  assessed prior to discharge to determine their
  interest in quitting
• 80 of smokers have made past attempts to quit,
  50 of male female current smokers plan to
  quit in next 6 months (NSW
  Health Surveys)
• Patients planning to quit should receive
• at least 3 days supply of NRT
• treatment summary in discharge plan
• a Quit Kit
• advice to seek support from GP/pharmacist/Quitli
  ne 131 848
• Patients not planning to quit should be
  encouraged to make a future quit attempt

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Quit plan

• For those patients ready to quit, a few key
  points can increase their chance of success 
• Set a date to stop and stop completely on that
  day
• Use pharmacotherapy (whichever product suits
  best)
• Review past periods of abstinence (what helped
  -what hindered?)
• Identify future problems and make a plan to
  deal with them (problem-solving)
• Enlist support (family, friends, colleagues)
          
• Avoid alcohol for first 2 weeks
• Reduce caffeine consumption by half (more
  caffeine is absorbed)
•  

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Relapse

• Any smoking within the first 2 weeks is a
  reliable predictor of failure in the quit
  attempt (95 probability of returning to smoking)
• Other predictors include
• short periods of abstinence in previous quit
  attempts
• low motivation to quit
• low confidence in ability to quit
• smokers in subject's environment
• high pre-cessation alcohol consumption
• Common triggers for relapse include
• other people smoking
• alcohol
• stressful or negative events
• depression

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Prevention of relapse

• Relapse prevention should include
• discussion of high-risk situations
• developing coping strategies (e.g. using
  pharmacotherapy, reducing alcohol consumption)
• reinforcing total abstinence (but relapse is
  not failure, continue quit attempt)
• most people make several quit attempts before
  success
• Many smokers cannot stop without more intensive
  help (often heavier smokers more at risk of
  smoking related disease)
• refer to specialist treatment service, such as
  AHS DA Services, their GP or the Quitline for
  telephone counselling
• outpatient clinics should be advised of
  hospital treatment
•  

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Useful web sites

• Resources about tobacco for non-English speaking
  patients
• www.mhcs.health.nsw.gov.au/health-public-affairs/m
  hcs/publications/5885.html
• Tobacco control super site (Sydney University)
• www.health.usyd.edu.au/tobacco/
• US Surgeon General clinical practice guideline
• www.surgeongeneral.gov/tobacco/treating_tobacco_us
  e.pdf
• UK clinical practice guideline
• www.bmj.com/cqi/contents/full/318/7177/182
• Tobacco in Australia Facts and Issues
• www.quit.org.qu/quit/FandI/welcome.htm
• Encyclopaedia on tobacco
• www.tobaccopedia.org/

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For more information

• If you have any queries about
• The NSW Smoke Free Workplace Policy (1999)
• The guide for the management of nicotine
  dependent inpatients
• This PowerPoint presentation
• Please contact
• Elayne Mitchell [phone]
  emitc_at_doh.health.nsw.gov.au

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