Smoking cessation facts

Cigarette smoking is the single most important cause of preventable death in UK. 120 000 deaths/yr.
Chronic, relapsing problem which warrants repeated clinical intervention.
Smoking related illness (COPD, lung cancer, CHD, stroke, cancers of mouth, pharynx, larynx, oesophagus & bladder) costs NHS £1.7 billion/yr.
> ¼ of adults smoke (more in deprived areas). 2/3 of these would like to give up.
Nicotine-highly addictive, as much as heroin, cocaine and alcohol. Dopaminergic pathways-feeling of well-being.
About ½ of smokers will have given up for 6/12 at an attempt.
½ of all smokers will eventually give up.
Most smokers will have 5-7 attempts at giving up before succeed.
Most relapses within first 3/12 and in fact most in first 2/7. (Implications for F/U).
Stopping smoking benefits = slows down COPD progression; reduces risk of lung cancer; risk of CHD reduced by 50% by 1 yr post quitting and after 3-5 yrs approaches lifetime risk of non-smoker; if previous MI reduces risk of re-infarction.
S/E of stopping smoking = wt gain (4-6kg), anxiety, insomnia, low mood, poor concentration, cravings.
Cost per life-year saved smoking cessation programmes compare favourably with other NHS –funded interventions. Between April 01 and March 02 – increase in quitters from 64 000 to 120 000, at cost of £21.4 million.
Most smokers say want to quit on their own- but only 5-10% of these attempts are successful.
Assistance can more than double the chance of success.
Quitting gradually is as successful as ‘’cold turkey’’.

Treatments that work

Simple advice on uitting (by GP, nurse) improves rates of uitting by 2% at 1 year. Light smokers benefit most from GP advice (Silagy Cochrane review 2000)
With intensive support-rate increased to 4% at 1 year.
Pregnancy-good time to target people, 8% will stop spontaneously, can be increased to 16% if given cessation advice/support.
When offering advice-5 A’s – ask, assess interest, advise against smoking, assist (set date, plan, enlist family/friends, counselling), arrange F/U.
DiClemente & Prochaskas cycle of readiness to change (1991) lends it self well to smoking cessation. Precontemplation, Contemplation (70% 0f smokers at this stage), Preparation, Action, Maintenance, Relapse.
Tailor the advice depending on their motivation level and where in cycle.
Help 2 uit programme- a simplified version of ‘’stages to change’’ (see BMJ 13/4/04).
Are new Read codes describing the 3 categories of smoker’s motivations used by Help 2 uit – ready, thinking about it and not interested. Will enable GP to audit/monitor interventions.
Counselling, group support and teaching coping skills. If such support is given for at least 4/52 to smokers who actively want to uit, about 5% who would not have otherwise have done so are able to uit for at least 6/12 (Lancaster Cochrane review 2000).
When to refer to a formal counselling programme- smokers with little confidence in own ability or partner who smokes, also if lots of previous attempts. Also smokers with alcohol / substance misuse, depression or psychiatric disorder.
If this intensive behavioural support is combined with NRT-up to 20% abstinence at 1 yr.
Nicotine Replacement (NRT) - can help with withdrawal symptoms and reduce the urge to smoke.
Silagy & others reviewed >80 studies (Cochrane 2001)- doubles the success rate of stopping smoking c.f. to control groups (about 5% a year). Absolute success rate of 7-10% at 1 year.
Different preparations-all equally effective-so patient preference.
Should be only offered on prescription if >10 cigs per day (insufficient evidence re benefit if <10 cigs/day). NRT probably safer than smoking in pregnancy-refer to specialist clinic if wants to use, patches not ideal).
4mg gum may be more effective than 2mg in pts who smoke >20/day (Silagy Cochrane 2000).
21mg 24 hr patch may be more effective than lower dose patches if >10 cigs/day (Daughton Prev Med 1999)
NRT used for 2-3/12, then gradually reduce over weeks to avoid withdrawal symptoms.
Avoid NRT in recovery period post MI or stroke and in arrhythmias.
S/E of NRT- nausea, dizziness, headaches & palpitations.
Support from health care professional is impt, but may not be essential for NRT to be effective. Shiffman et al (Tobacco Control 1997) found was as effective as OTC. A more recent systematic review of trials of OTC shows that long term abstinence rates are similar to prescribed NRT plus behavioural programme (Tobacco Control 2003;12:21-7). The reviews conclusion is that Governments that provide NRT only through doctors or reuire complementary psychosocial Rx may be putting barriers in way of people who want to stop smoking.
Combining a patch with other forms of NRT- may be more effective than patch alone & seems safe (Stapleton BMJ 1999).
Non-NRT treatments- main one is Bupropion. It is the only non-nicotine drug licensed for use in smoking cessation in UK & Europe. Available since 2000.
Originally atypical antidepressant in USA. Similar to appetite suppressant. Mechanism of antidepressant effect not fully understood. The antismoking effect not related to the antidepressant effect since equally effective in smokers with and without depression. Does inhibit reuptake of dopamine, noradrenaline & serotonin and non-competitive nicotine receptor antagonist. The first 2 effects likely to be impt since see reduction of dopamine and noradrenaline with nicotine withdrawal.
Bupropion plus behavioural support as effective as NRT, doubling of cessation rate. Long term abstinence in 19%. Effectiveness .if less intensive behavioural support-not tested in trials.
Attenuates wt gain.
If used for >8/52-seems to confer further protection vs. relapse.
Dose 150mg tablet. Days 1-6 1 tablet daily. Day 7 onwards for 8/52 1 tablet bd. uit smoking between Day 7-14 of treatment. Elderly and if liver/renal impairment-keep at 1 tablet daily.
Unwanted effects, seizure 1/1000 users. More commonly – dry mouth, insomnia, skin rash and pruritis and hypersensitivity.
C/I if epilepsy, eating disorders, bipolar disorder, severe hepatic necrosis. Should not be used within 14 days of MAOI.
A no. of drug interactions-antidepressants, antipsychotics, type 1 antiarrythmics, b-blockers = if on Bupropion start at low dose, or decrease dose if start Bupropion (p450). Carbamazepine, PHB, PHT = keep at 1 tablet daily. L-dopa = only with caution. Ritonavir = avoid concomitant use.
Shown to be effective and well tolerated in COPD.
IHD fine, but caution in diabetic pts treated with hypoglycaemic agents or insulin or antiarrhythmics flecinide/propafenone when need to reduce antiarrhythmics dose.
No trials in pregnancy.
Other non-nicotine treatments – nortriptyline, considered 2nd line as less evidence of efficacy. Also clonidine (but quite serious S/E)
Hypnosis, acupuncture, other antidepressants/anxiolytics- none shown to have efficacy for smoking cessation.