SMOKING CESSATION

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SMOKING CESSATION

• Vici Ripley

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Costly business

• Treatment of smoking related disease is estimated
  to cost NHS 1.4-1.7 billion per annum
• Providing smoking cessation advice is one of the
  quality outcome measures in GMS contract

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Some effects of smoking

• IHD, CVD, COPD, asthma, cancers, blindness
  (cataract, AMD, thrombus), PVD/amputations,
  osteoporosis, childhood ailments (eg glue ear,
  chest infections), low birth weight, cot death,
• skin effects
• Poverty/poor health
• Addiction
• Etc

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• 1951 famous cohort study of 40 000 UK doctors
• Divided into 4 groups depending on smoking habit
  (length/amount)
• Proved strong link between cigarette smoke and
  lung cancer
• Showed that stopping smoking at any time
  worthwhile in terms of mortality and morbidity

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Random facts

• Advise on healthy eating/exercise most smokers
  gain 3-4 kg after quitting
• 1 in 2 lifetime smokers will die from habit
• ½ these deaths will be in middle aged
• 14 of all deaths in Scotland attributable to
  smoking
• Low tar cigarettes just as bad
• Cutting down ineffective in reducing long term
  complications (death rate increased in women!)
• UK wide indoor public places ban on smoking by
  July 1st 2007

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Must want to change first! Stages of change

• Pre-contemplation
• Contemplation
• Preparation
• Action
• Maintenance
• Relapse
• (keep repeating until succeed!)

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Options for kicking the habit

• WILLPOWER
• Most opted for method
• Highest rate of failure
• 1 year quit rate of only 2-3 (compared to 20-30
  with pharmacotherapy and input from trained
  smoking cessation counsellors)
• More likely to succeed if stop abruptly rather
  than cutting down

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NRT

• PATCH, GUM, LOZENGE, MICROTAB, INHALATOR, NASAL
  SPRAY
• effective widely accepted
• None of 6 formulations best
• Pt choice most important (usually patch)
• Dose depends on level of nicotine addiction
• Determine by using time between waking and first
  morning cigarette
• lt30min high addiction
• 30min-2hrs moderate addiction
• gt2hrs low addiction
• Combination of NRT useful if more addicted
• Nicotine relatively safe. NRT should be taken for
  min 2-3 months

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PATCHES

• Transfer small, steady amounts
• of nicotine into bloodstream
• Discreet, easy to use, 24 hr patch available (to
  reduce morning cravings)
• Can cause skin irritation avoid in chronic
  generalised dermatology conditions
• 24 hr patches can cause strange dreams and sleep
  disturbances
• Step-down approach or pts can remain on most
  appropriate patch dose for their level of
  addiction for treatment duration

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GUM LOZENGES

• Both used when urge to smoke occurs
• Gum chew-park-chew method
• (chew piece slowly until flavour fades, rest in
  buccal cavity to allow absorption, chew again
  after flavour has gone, repeat etc for 30 min)
• May use up to 15-25 pieces per day
• Difficult to chew with dentures
• May cause indigestion
• Lozenges may also cause throat irritation

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MICROTABS

• 1-2 tabs placed under tongue when urge to smoke
  occurs
• V discreet
• Dose easily adjusted
• Max 40 tabs per day
• Ineffective if swallowed or chewed
• Least palatable oral preparation
• Can cause throat irritation

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INHALATOR

• Addresses habit of holding cigarette
• Nicotine released by inhaling through holder
• Each cartridge lasts for 20 min intense use
• 6-12 cartridges per day
• Often used in combination with
• other forms of NRT
• Attracts attention in public
• Can cause throat irritation

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NASAL SPRAY

• Offers smokers hit of nicotine
• Closest treatment option to a real cigarette in
  terms of speed and potency
• Useful in high levels of nicotine addiction
• Can sting insides of nose and throat and cause
  eyes to water
• Potential for dependence

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NRT dosage summary
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BUPROPION (ZYBAN)

• At least as effective as NRT
• Side effects include insomnia, headache, dry
  mouth, GI upset
• 11000 chance of seizure (! Pts livelihood may
  depend on driving/operating machinery)
• Not for use in pregnancy, breast feeding pts lt 18
  yrs
• Use with caution in elderly, pts with hepatic
  impairment or renal insufficiency
• Useful in pts who failed to quit on NRT

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BUPROPION contd

• Keep smoking for 1st 8-14 days
• 150mg od for 6 days increase to 150mg bd for
  remainder of course
• Second dose in day should be at least 8 hrs after
  1st - but as far from bedtime as possible
  (insomnia)
• Continue course for 7-9 weeks depending on effect
• Zyban can be used together with NRT (if no CI)
  and if BP monitored

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VARENICLINE (CHAMPIX)

• Exciting new drug
• Increases odds of quitting 3 fold compared to
  placebo
• Higher number of quitters than with Bupropion and
  lower risk of serious adverse effects
• Main SE is nausea (mild- moderate, subsides)
• Does not appear to interact with other drugs
• High pt satisfaction
• Not licensed in under 18s, in pregnancy or
  breastfeeding

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VARENICLINE contd

• Pts need to pre-emptively set a stop date 1-2
  weeks after starting on course
• ie 1st dose taken 1-2 weeks before set stop date
• Days 1-3 0.5mg od
• Days 4-7 0.5mg bd
• Day 8 end of treatment 1mg bd
• Course lasts up to 12 weeks

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Other options

• Hypnosis acupuncture have no proven active
  effect in helping people quit
• ...but offer support, which is why they may
  appear to work over no intervention

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and if all else fails
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