Smoking CessationSmoking Cessation

Dr Victoria ScobieDr Victoria Scobie

BackgroundBackground

Biggest single cause of preventable Biggest single cause of preventable chronic illness, disability and chronic illness, disability and premature death in Scotlandpremature death in Scotland

30% adults smoke30% adults smoke Average smoker will lose 10 years of Average smoker will lose 10 years of

life because of smokinglife because of smoking 250 people in Scotland die every 250 people in Scotland die every

week from their smokingweek from their smoking

Role of Primary CareRole of Primary Care

93% GPs thought helping a patient to 93% GPs thought helping a patient to stop smoking was the best thing they stop smoking was the best thing they could do for their healthcould do for their health

BUTBUT - 63% didn’t have time- 63% didn’t have time- 61% thought input was ineffective61% thought input was ineffective- 40% felt they lacked skills40% felt they lacked skills- 23% thought it wasn’t their job23% thought it wasn’t their job

Number Needed to TreatNumber Needed to Treat

Best practice gives long term quit rate of Best practice gives long term quit rate of 20%20%

50% long term smokers die of smoking 50% long term smokers die of smoking related illnessrelated illness

So if 10 smokers attempt to quitSo if 10 smokers attempt to quit• 2 stop long term2 stop long term• 1 would have died of smoking related disease1 would have died of smoking related disease• Therefore NNT for smoking cessation = 10Therefore NNT for smoking cessation = 10

NNT-comparisonNNT-comparison

InterventionIntervention OutcomeOutcome NNTNNT

Statin as Statin as primary primary preventionprevention

Prevent 1 death over Prevent 1 death over 5yrs (from MI, stroke 5yrs (from MI, stroke or other cause)or other cause)

107107

AntihypertensivAntihypertensive therapy in e therapy in mild mild hypertensionhypertension

Prevent 1 stroke, MI or Prevent 1 stroke, MI or death over 1 yrdeath over 1 yr

700700

Screening for Screening for cervical cancercervical cancer

Prevent 1 death over Prevent 1 death over 10 yrs10 yrs

11401140

30-second approach30-second approach

1.Do you smoke?1.Do you smoke?

2.Are you aware of the risks?2.Are you aware of the risks?

3.Would you like to stop?3.Would you like to stop?

4.Would you like my/our help to stop 4.Would you like my/our help to stop smoking?smoking?

Health RisksHealth Risks StrokeStroke Ca of mouth, throat, oesophagusCa of mouth, throat, oesophagus Ca of larynxCa of larynx Coronary heart diseaseCoronary heart disease COPDCOPD Asthma exacerbationsAsthma exacerbations Lung CaLung Ca Pancreatic CaPancreatic Ca Peptic ulcerPeptic ulcer Bladder CaBladder Ca OsteoporosisOsteoporosis Cervical CaCervical Ca Peripheral artery diseasePeripheral artery disease

Other effects of smokingOther effects of smoking

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

Benefits of QuittingBenefits of Quitting

Time after last cigaretteTime after last cigarette• 20mins20mins -BP+HR return to normal, -BP+HR return to normal,

circulation circulation improves in hands + feetimproves in hands + feet• 8hrs8hrs -O2 levels in blood return to normal-O2 levels in blood return to normal• 24hrs24hrs -CO is eliminated from body-CO is eliminated from body• 48hrs48hrs -nicotine no longer detected in body, -nicotine no longer detected in body,

ability to taste + smell improvedability to taste + smell improved• 2-12wks2-12wks -circulation improves- walking easier-circulation improves- walking easier• 3-9months3-9months -lung function improved by 5-10%-lung function improved by 5-10%• 1year1year -50% reduction coronary heart disease-50% reduction coronary heart disease• 10years10years -risk of MI similar to non-smoker-risk of MI similar to non-smoker

Assess MotivationAssess Motivation

Number of previous attempts to quitNumber of previous attempts to quit Previous NRT usePrevious NRT use Willingness to attend individual Willingness to attend individual

counselling or group sessionscounselling or group sessions >10 cigs/day>10 cigs/day Prepared to stop in next 2 weeks?Prepared to stop in next 2 weeks? Encouraged to stop through use of will Encouraged to stop through use of will

power and smoking cessation clinics.power and smoking cessation clinics.

NRT OptionsNRT Options

What Type of smoker?

Regular IrregularIrregular + high behavioural

dependence

PATCHES GUM INHALATOR

PatchesPatches

24hr patch if 124hr patch if 1stst cigarette within 20mins of cigarette within 20mins of waking up. Smokes >10/day.waking up. Smokes >10/day.

6/52 21mg high strength, 2/52 14mg med strength, 2/52 6/52 21mg high strength, 2/52 14mg med strength, 2/52 7mg low strength7mg low strength

16hr patch-doesn’t need cigarette within 16hr patch-doesn’t need cigarette within 20mins waking or vivid dreams with 24hr 20mins waking or vivid dreams with 24hr patchpatch

6/52 15mg high strength, 2/52 10mg med strength, 2/52 6/52 15mg high strength, 2/52 10mg med strength, 2/52 5mg low strength5mg low strength

Irregular smokersIrregular smokers

GumGum <20cigs/day - <20cigs/day - 2mg gum, 15 2mg gum, 15 pieces a day for 8 weeks, reduce by half for 2 pieces a day for 8 weeks, reduce by half for 2 weeks, then reduce to zero over 2 weeksweeks, then reduce to zero over 2 weeks..

GumGum >20cigs/day – >20cigs/day – 4mg gum, 15 4mg gum, 15 pieces a daypieces a day

Nicotine inhalator – inhale when urge Nicotine inhalator – inhale when urge to smoke –to smoke – inhale 12 cartridges/day 8 weeks, inhale 12 cartridges/day 8 weeks, 6 cartridges/day for 2 weeks, 3 cartridges/day for 6 cartridges/day for 2 weeks, 3 cartridges/day for 2 weeks2 weeks

NRTNRT

Aims to blunt nicotine withdrawal Aims to blunt nicotine withdrawal symptomssymptoms

NRT is not addictiveNRT is not addictive NRT may reduce weight gain on quitting NRT may reduce weight gain on quitting

smokingsmoking

Contra-indications – under 18yrs, severe hepatic/renal Contra-indications – under 18yrs, severe hepatic/renal impairment. impairment.

Caution - pregnancy, breast-feeding, cardiovascular Caution - pregnancy, breast-feeding, cardiovascular disease, active PU disease, hyperthyroidism, DM.disease, active PU disease, hyperthyroidism, DM.

Problems-GI upset, dry mouth, skin irritation, nose/throat Problems-GI upset, dry mouth, skin irritation, nose/throat irritationirritation

Bupropion (Zyban)Bupropion (Zyban)

Antidepressant- selectively inhibits Antidepressant- selectively inhibits reuptake of dopamine + reuptake of dopamine + noradrenalinenoradrenaline

150mg daily for 6 days150mg daily for 6 days 150mb BD for 6-8 weeks (150mg OD elderly)150mb BD for 6-8 weeks (150mg OD elderly) Stop date 1-2 weeks after start treatmentStop date 1-2 weeks after start treatment

Zyban contdZyban contd

C/I- pregnancy, breastfeeding, C/I- pregnancy, breastfeeding, bipolar disorder, severe renal bipolar disorder, severe renal /hepatic impairment/hepatic impairment

Risks- seizure in 1/1000 ptsRisks- seizure in 1/1000 pts Assess risk factors- history of seizure, Assess risk factors- history of seizure,

alcohol abuse, head trauma, concomitant alcohol abuse, head trauma, concomitant use of drugs which lower seizure thresholduse of drugs which lower seizure threshold

Anaphylactic reaction 1/1000 ptsAnaphylactic reaction 1/1000 pts Other-mild allergic reaction, Other-mild allergic reaction,

insomnia, dry mouthinsomnia, dry mouth

Varecicline (Champix)Varecicline (Champix)

Binds to nicotinic acetylcholine receptors Binds to nicotinic acetylcholine receptors in brainin brain• Partial agonist-reduces cravings + withdrawal symptomsPartial agonist-reduces cravings + withdrawal symptoms• Antagonist- reduces satisfaction asso smokingAntagonist- reduces satisfaction asso smoking

500mcg OD 3 days, 500mcg BD 4 days, 500mcg OD 3 days, 500mcg BD 4 days, 1mg BD for 11 weeks1mg BD for 11 weeks

Stop smoking after 1-2 weeks treatmentStop smoking after 1-2 weeks treatment

Champix contdChampix contd

C/I pregnancyC/I pregnancy Caution-renal impairment, Caution-renal impairment,

breastfeeding, hx psychiatric illnessbreastfeeding, hx psychiatric illness Avoid abrupt withdrawal-relapse, Avoid abrupt withdrawal-relapse,

irritability, depression, insomniairritability, depression, insomnia Problems-GI upset, dry mouth, sleep Problems-GI upset, dry mouth, sleep

disturbance, abnormal dreamsdisturbance, abnormal dreams

Percentage of quit attempts achieving 6 Percentage of quit attempts achieving 6 months continuous abstinencemonths continuous abstinence

No treatmentNo treatment5%5%

NRT/bupropion plus limited support 13%NRT/bupropion plus limited support 13% Behavioural support only 13%Behavioural support only 13% Behavioural support with NRT/buproprion 21% Behavioural support with NRT/buproprion 21%

Prescribe 1 month supply-dispense 2 Prescribe 1 month supply-dispense 2 weeklyweekly

Advise ongoing support Advise ongoing support Max 3 months treatment offeredMax 3 months treatment offered If patient has not stopped or If patient has not stopped or

significantly reduced by one month- significantly reduced by one month- discontinue Zyban/Champixdiscontinue Zyban/Champix

Relapse-no further prescribing of Relapse-no further prescribing of smoking cessation products in a 6 smoking cessation products in a 6 month period month period

Target groups Target groups

Pregnant smokersPregnant smokers Young smokersYoung smokers Low income smokersLow income smokers Hospital patients who smokeHospital patients who smoke Psychiatric patients who smokePsychiatric patients who smoke Smokers with cardiovascular diseaseSmokers with cardiovascular disease Smokers with chest conditionsSmokers with chest conditions

ConclusionConclusion

Opportunistic advice to smokers in Opportunistic advice to smokers in GP surgeryGP surgery

Offer support to those who wish to Offer support to those who wish to quitquit

Best results with behavioural support Best results with behavioural support plus NRT/zyban/champixplus NRT/zyban/champix

ReferencesReferences BMJ ABC of Smoking Cessation Molyneux,A 2004;328:454-456BMJ ABC of Smoking Cessation Molyneux,A 2004;328:454-456 Smoking Cessation Guidelines for Scotland 2004 Update.Health Smoking Cessation Guidelines for Scotland 2004 Update.Health

Scotland and ASH Scotland.Scotland and ASH Scotland. Encouraging Smokers to Stop-A Guide for Health Professionals-Encouraging Smokers to Stop-A Guide for Health Professionals-

www.healthscotland.comwww.healthscotland.com A Simple and Time Effective Intervention in Smoking Cessation-A Simple and Time Effective Intervention in Smoking Cessation-

The 30 Second Approach. GlaxoSmithKlineThe 30 Second Approach. GlaxoSmithKline Guidance for Smoking Cessation in Tayside 2001. Tayside Drug Guidance for Smoking Cessation in Tayside 2001. Tayside Drug

and Therapeutics Committeeand Therapeutics Committee Simply Stop Smoking-A Practical Pocket Guide.British Thoracic Simply Stop Smoking-A Practical Pocket Guide.British Thoracic

Society 1999.Society 1999. Smoking Cessation with NHS Tayside Community Pharmacy 2005Smoking Cessation with NHS Tayside Community Pharmacy 2005 www.bnf.orgwww.bnf.org www.nice.org.ukwww.nice.org.uk