Smoking cessation

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Smoking cessation
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How do we stop people from smoking?

• Population measures

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The 5 basic ways to help smokers quitSchroeder
AS. JAMA 2005294482-7

• Increase the price of cigarettes
• Prohibit smoking in public places
• Create and disseminate effective counter
  marketing messages about smoking (media, pack
  displays)
• Ban tobacco advertising and promotion
• Provide cessation aids
• Counselling / Behavioural therapy
• Pharmacotherapy
• NRT
• Bupropion
• Varenicline
• Nortriptyline, Clonidine

Population measures (Government initiatives)
Individual measures (NHS Stop Smoking
Services)
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How do you stop people smoking?

• Changing behaviour

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Changing behaviour"Giving up smoking is easy
I've done it a hundred timesMark Twain

• Most smokers want to stop
• 90 of the practice populations will visit the
  surgery during a three-year period (and more will
  see other health professionals)
• This provides a good opportunity to change
  behaviour
• Theories of
  behaviour change
• - Health Belief
  Model (Becker, 1974)
• - Theory
  of Reasoned Action
• (Ajzen
  Fishbein 1980)
• - Stages of
  Change
• 
  (Prochaska DiClemente 1984)
• -
  Catastrophe pathway
• (West
  Sohal, 2006)

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Communicate effectively when giving advice to
stop smokingRCN Clearing the Air 2

• Listen to the reasons the patient gives you for
  their smoking and paraphrase them e.g. I can
  hear that it would be very hard for you to give
  up smoking at the moment because.. or right
  now continuing smoking is important to you even
  though you know you risk having another heart
  attack
• When a patient hears the things they have said
  summarised back in this way it helps them reflect
  on the consequences of their current choice. The
  yes but may become I know I should stop
  smoking or but I do really want to give up
• Try to ask questions that will help them work out
  for themselves, why they smoke and why they
  should stop. This person focused approach will
  help smokers much more than advice

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Summary Changing behaviour

• Most smokers want to quit, but changing behaviour
  is difficult
• People need to recognise that their health is
  threatened, and that the benefits of giving up
  outweigh the benefits they obtain from smoking
  (Health Belief Model)
• Intention to change behaviour is influenced by
  personal attitudes and by the behaviour and
  attitudes of people around them (Theory of
  Reasoned Action and Planned Behaviour)
• Smokers go through a series of distinct phases in
  their attitudes towards smoking cessation
  (Stages of Change model)
• Many people get to the stage of wanting to quit
  without formal planning of their quit date
  responding to immediate needs (e.g. by providing
  NRT and/or behavioural support) may be
  appropriate (Catastrophe Model)

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Public Health Intervention Guidance 1NICE March
2006. Brief Interventions and referral for
smoking cessation in primary care and other
settings

• Everyone who smokes should be advised to quit
• Advice to stop smoking should be sensitive to the
  individuals preferences, needs and circumstances
• Those who want to stop should be offered a
  referral to an intensive support service
• The smoking status of those who are not ready to
  stop should be recorded and reviewed with the
  individual once a year

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Hard to reach and high smoking prevalence
groups NICE Public Health Guidance 10. Smoking
Cessation Services February 2008

• Managers and providers of NHS Stop Smoking
  Services should ensure services are responsive to
  the needs of people who smoke from minority
  ethnic and disadvantaged communities
• Consider developing links with local community
  groups
• Wherever possible provide people with advice,
  counselling and support in their first language

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Smoking cessation servicesNICE Public Health
Guidance 10. Smoking Cessation Services February
2008

• Interventions proven to be effective for smoking
  cessation
• Brief interventions
• Individual behavioural counselling
• Group behaviour therapy
• Pharmacotherapies
• Self-help materials
• Telephone counselling and quitlines
• Mass media campaigns

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Smoking cessation PharmacotherapyNICE Public
Health Guidance 10. Smoking Cessation Services
February 2008

• Nicotine replacement therapy (NRT), bupropion and
  varenicline can be used to help people quit
  smoking
• All pharmacotherapy options can be offered to
  smokers with cardiovascular or respiratory
  disease, according to clinical judgement
• Neither varenicline or bupropion should be
  offered to people under 18 years nor to pregnant
  or breastfeeding women
• Normally treatment should only be prescribed as
  part of an abstinent-contingent treatment (ACT),
  in which the smoker makes a commitment to stop
  smoking on or before a particular date (target
  stop date)

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Smoking cessation PharmacotherapyNICE Public
Health Guidance 10. Smoking Cessation Services
February 2008

• Initial prescription should be sufficient to last
  only until 2 weeks after the target stop date
  (normally 2 weeks of NRT, and 3-4 weeks of
  varenicline or bupropion therapy)
• Second prescriptions only given if demonstrated
  that quit attempt is continuing on re-assessment
• If a smokers attempt to quit is unsuccessful
  with treatment using either NRT, varenicline or
  bupropion, the NHS should normally fund no
  further attempts within 6 months, unless special
  circumstances hampered the initial attempt

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Smoking cessation PharmacotherapyNICE Public
Health Guidance 10. Smoking Cessation Services
February 2008

• Do not offer NRT, varenicline or bupropion in any
  combination
• There is insufficient evidence to conclude that
  one form of NRT is more effective than another
• Combinations of NRT patches and other fast
  release formulations such as gum can be
  considered for people with high level of
  dependence, or have found single forms inadequate
• People receiving pharmacotherapy should also be
  offered advice encouragement and support,
  including referral to NHS Stop Smoking Service

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What about combinations of NRT?NRT MHRA QA
document December 2005

• And agreement from NICE
• NICE Public Health Guidance 10. Smoking Cessation
  Services February 2008

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Nicotine Assisted Reduction to Stop (NARS)NICE
Public Health Guidance 10. Smoking Cessation
Services February 2008

• Smokers who want to stop smoking but not
  immediately can consider NRT to help them to cut
  down with a view to stopping at a later date
• NICE state this strategy should only be used if
  part of a properly designed and conducted
  research study for people who have failed
  repeatedly to quit smoking abruptly
• Suggested reduction programme from CKS Smoking
  Cessation 2006

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CSM advice for bupropionCSM 2002

• CSM advice (bupropion). The CSM has issued a
  reminder that bupropion is contra-indicated in
  patients with a history of seizures or of eating
  disorders, a CNS tumour, or who are experiencing
  acute symptoms of alcohol or benzodiazepine
  withdrawal. Bupropion should not be prescribed to
  patients with other risk factors for seizures
  unless the potential benefit of smoking cessation
  clearly outweighs the risk. Factors that increase
  the risk of seizures include concomitant
  administration of drugs that can lower the
  seizure threshold (e.g. antidepressants,
  antimalarials such as mefloquine and
  chloroquine, antipsychotics, quinolones,
  sedating antihistamines, systemic
  corticosteroids, theophylline, tramadol), alcohol
  abuse, history of head trauma, diabetes, and use
  of stimulants and anorectics.

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Europe-wide review recommends updates to product
information for varenicline?MHRA December 2007

• Doctors are already aware of the risk of using
  Champix in patients who have an underlying mental
  illness. They also need to be aware of the
  possibility that patients who are trying to stop
  smoking can develop symptoms of depression, and
  they should advise their patients accordingly
• Patients who are taking Champix and develop
  suicidal thoughts should stop their treatment and
  contact their doctor immediately

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KEY POINTS

• Smoking cessation

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Pharmacotherapy Key points

• Pharmacotherapy e.g. NRT/ bupropion/ varenicline,
  can be prescribed, if appropriate, by trained
  professionals but are most effective when used
  with other forms of support
• Abrupt smoking cessation is desirable, however a
  NARS strategy with NRT can be considered for
  those who are unwilling or unable to stop
  completely, if part of a research study
• Safety and efficacy data for bupropion and
  varenicline are limited
• NRT is a less harmful alternative to smoking and,
  where non-drug approaches alone are not
  sufficient, can now be considered for
  adolescents, women who are pregnant or
  breastfeeding

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Smoking cessation Key points

• Advising and effectively assisting a person to
  stop smoking is the single most important thing
  that can be done for their health
• All health professionals should take the
  opportunity to advise smokers to stop smoking,
  and consider referral to the NHS Stop Smoking
  Service