Smoking Cessation

1
Smoking Cessation

• Dr Victoria Scobie

2
Background

• Biggest single cause of preventable chronic
  illness, disability and premature death in
  Scotland
• 30 adults smoke
• Average smoker will lose 10 years of life because
  of smoking
• 250 people in Scotland die every week from their
  smoking

3
Role of Primary Care

• 93 GPs thought helping a patient to stop smoking
  was the best thing they could do for their health
• BUT - 63 didnt have time
• 61 thought input was ineffective
• 40 felt they lacked skills
• 23 thought it wasnt their job

4
Number Needed to Treat

• Best practice gives long term quit rate of 20
• 50 long term smokers die of smoking related
  illness
• So if 10 smokers attempt to quit
• 2 stop long term
• 1 would have died of smoking related disease
• Therefore NNT for smoking cessation 10

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NNT-comparison
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30-second approach

• 1.Do you smoke?
• 2.Are you aware of the risks?
• 3.Would you like to stop?
• 4.Would you like my/our help to stop smoking?

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Health Risks

• Stroke
• Ca of mouth, throat, oesophagus
• Ca of larynx
• Coronary heart disease
• COPD
• Asthma exacerbations
• Lung Ca
• Pancreatic Ca
• Peptic ulcer
• Bladder Ca
• Osteoporosis
• Cervical Ca
• Peripheral artery disease

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Other effects of smoking

• Yellowing of teeth/fingers
• Hair, skin, breath and clothes smell of tobacco
• Skin around eyes and mouth wrinkled
• Reduced fertility
• Increase risk LBW baby
• Increased risk spontaneous abortion
• Increased risk premature labour
• Cost (20 cigs/day costs 1000 per year)
• Increased premiums for life insurance

9
Benefits of Quitting

• Time after last cigarette
• 20mins -BPHR return to normal, circulation
  improves in hands feet
• 8hrs -O2 levels in blood return to normal
• 24hrs -CO is eliminated from body
• 48hrs -nicotine no longer detected in body,
  ability to taste smell improved
• 2-12wks -circulation improves- walking easier
• 3-9months -lung function improved by 5-10
• 1year -50 reduction coronary heart disease
• 10years -risk of MI similar to non-smoker

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Assess Motivation

• Number of previous attempts to quit
• Previous NRT use
• Willingness to attend individual counselling or
  group sessions
• gt10 cigs/day
• Prepared to stop in next 2 weeks?
• Encouraged to stop through use of will power and
  smoking cessation clinics.

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NRT Options
12
Patches

• 24hr patch if 1st cigarette within 20mins of
  waking up. Smokes gt10/day.
• 6/52 21mg high strength, 2/52 14mg med strength,
  2/52 7mg low strength
• 16hr patch-doesnt need cigarette within 20mins
  waking or vivid dreams with 24hr patch
• 6/52 15mg high strength, 2/52 10mg med strength,
  2/52 5mg low strength

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Irregular smokers

• Gum lt20cigs/day - 2mg gum, 15 pieces a day for 8
  weeks, reduce by half for 2 weeks, then reduce to
  zero over 2 weeks.
• Gum gt20cigs/day 4mg gum, 15 pieces a day
• Nicotine inhalator inhale when urge to smoke
  inhale 12 cartridges/day 8 weeks, 6
  cartridges/day for 2 weeks, 3 cartridges/day for
  2 weeks

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NRT

• Aims to blunt nicotine withdrawal symptoms
• NRT is not addictive
• NRT may reduce weight gain on quitting smoking
• Contra-indications under 18yrs, severe
  hepatic/renal impairment.
• Caution - pregnancy, breast-feeding,
  cardiovascular disease, active PU disease,
  hyperthyroidism, DM.
• Problems-GI upset, dry mouth, skin irritation,
  nose/throat irritation

15
Bupropion (Zyban)

• Antidepressant- selectively inhibits reuptake of
  dopamine noradrenaline
• 150mg daily for 6 days
• 150mb BD for 6-8 weeks (150mg OD elderly)
• Stop date 1-2 weeks after start treatment

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Zyban contd

• C/I- pregnancy, breastfeeding, bipolar disorder,
  severe renal /hepatic impairment
• Risks- seizure in 1/1000 pts
• Assess risk factors- history of seizure, alcohol
  abuse, head trauma, concomitant use of drugs
  which lower seizure threshold
• Anaphylactic reaction 1/1000 pts
• Other-mild allergic reaction, insomnia, dry mouth

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Varecicline (Champix)

• Binds to nicotinic acetylcholine receptors in
  brain
• Partial agonist-reduces cravings withdrawal
  symptoms
• Antagonist- reduces satisfaction asso smoking
• 500mcg OD 3 days, 500mcg BD 4 days, 1mg BD for 11
  weeks
• Stop smoking after 1-2 weeks treatment

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Champix contd

• C/I pregnancy
• Caution-renal impairment, breastfeeding, hx
  psychiatric illness
• Avoid abrupt withdrawal-relapse, irritability,
  depression, insomnia
• Problems-GI upset, dry mouth, sleep disturbance,
  abnormal dreams

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Percentage of quit attempts achieving 6 months
continuous abstinence

• No treatment 5
• NRT/bupropion plus limited support 13
• Behavioural support only
  13
• Behavioural support with NRT/buproprion 21
  
  

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• Prescribe 1 month supply-dispense 2 weekly
• Advise ongoing support
• Max 3 months treatment offered
• If patient has not stopped or significantly
  reduced by one month- discontinue Zyban/Champix
• Relapse-no further prescribing of smoking
  cessation products in a 6 month period

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Target groups

• Pregnant smokers
• Young smokers
• Low income smokers
• Hospital patients who smoke
• Psychiatric patients who smoke
• Smokers with cardiovascular disease
• Smokers with chest conditions

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Conclusion

• Opportunistic advice to smokers in GP surgery
• Offer support to those who wish to quit
• Best results with behavioural support plus
  NRT/zyban/champix

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References

• BMJ ABC of Smoking Cessation Molyneux,A
  2004328454-456
• Smoking Cessation Guidelines for Scotland 2004
  Update.Health Scotland and ASH Scotland.
• Encouraging Smokers to Stop-A Guide for Health
  Professionals-www.healthscotland.com
• A Simple and Time Effective Intervention in
  Smoking Cessation-The 30 Second Approach.
  GlaxoSmithKline
• Guidance for Smoking Cessation in Tayside 2001.
  Tayside Drug and Therapeutics Committee
• Simply Stop Smoking-A Practical Pocket
  Guide.British Thoracic Society 1999.
• Smoking Cessation with NHS Tayside Community
  Pharmacy 2005
• www.bnf.org
• www.nice.org.uk