Therapeutic
strategies to assist with smoking cessation- Smoking protocol
- Nicotine Replacement Therapy
- Nicotine Replacement Therapy (Northumberland guidelines)
- Bupropion
- Nicotine addiction
- Oral cancer
Nicotine Replacement Therapy
Cautions and contraindications
- Nicotine Replacement Therapy is not licensed for use in:
- Pregnant women (Nicorette microtabs are licensed for use as a final option to aid smoking cessation in pregnancy).
- Breast feeding women (Children under 18 (for some preparations children under 16).
- NRT should be avoided in:
- Patients with severe cardiovascular disease including severe arrhythmias
- In the immediate post myocardial infarction period
- After recent cerebrovascular incidents
- NRT should be used in caution with patients who have any of the
following conditions:
- Cardiovascular disease
- Peripheral vascular disease
- Phaeochromocytoma
- Diabetes mellitus
- Hyperthyroidism
- Renal/hepatic impairment
- History of gastritis or peptic ulcers
Before recommending use of NRT in these patients medical advice should be sought from the patients GP. In general it is considered safer to use NRT products than to let patients continue to smoke.
Advice to patients
- Patients should not smoke whilst using NRT products.
- Only one product should be used at any one time.
Choice of treatment
| Low dependency (less than 10 cigarettes per day), high motivation | Encouragement and advice only |
| Low dependency | 2mg gum |
| Moderate dependency (10 - 20 cigarettes per day), low behavioural component and normal to heavy build | Patch starting with highest strength
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| Moderate dependency, low behavioural component, slight to medium build | Patch starting on middle strength |
| Moderate dependency, high behavioural component | Inhalator, Microtab or 2mg gum - switch to 4mg if require more than 15 pieces daily |
| High dependant (more than 20 cigarettes daily) | 4mg gum Patches seem to be of little use in this group |
The Role of NRT in Pregnancy - brief points
- Smoking during pregnancy causes intrauterine growth retardation and is associated with an increased risk of spontaneous abortion, prematurity, perinatal mortality and poor postnatal development.
- Smokers are exposed not only to nicotine, but a vast array of chemicals that are known to be harmful e.g carbon monoxide and tar.
- If smoking can be stopped or significantly reduced prior to 20 weeks of gestation then birth weights are likely to be within the normal range, and both mother and child benefit from the long term health advantages associated with stopping.
- Pregnant women who smoke are often highly motivated to quit and may be able to do so without the use of nicotine replacement therapy. Counselling/behavioural therapies should be offered in the first instance. If these measures fail, nicotine replacement therapies should be considered if it will lower fetal nicotine exposure.
- Nicotine replacement therapies are not licensed for use during pregnancy. Due to lack of safety data their routine use cannot be recommended, and it is difficult to select the regime of choice.
- Nicotine gum, inhalators and nasal spray treatments prevent continual exposure to nicotine and allow easy dose adjustment to fit cravings. However, the nasal spray appears to have a high frequency of side effects. Patches should be avoided unless other treatments are unacceptable. If used, 16-hour patches are preferable to 24-hour patches.
- Replacement therapies are not without risk to the fetus, as exposure to nicotine still occurs. The lowest effective dose should be used for as short a time as possible in order to aid withdrawal.
- Any use of NRT in pregnancy requires approval of the patients GP or Consultant.
What are the benefits of NRT?
- Reduces the severely of withdrawal symptoms
- Reduces urges to smoke
- Delays weight gain
- Reduces relapse
- Do not cause new dependence as the user is already dependant on nicotine
- There is evidence to suggest that NRT is as effective as zyban if combined with regular support and advice
NRT products
Nicotine chewing gum
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Microtab
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Inhalator
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Nicotine nasal spray
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Transdermal patch
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NRT side effects
- Gum - throat irritation, indigestion patch - skin irritation
- Nasal spray - nose and throat irritation
- Inhalator - throat irritation
- Microtab - mouth and throat irritation
Relapse
- 60% of 4wk abstainers go back to smoking in 1 yr
- Relapse may be predicted by dependence, depression, strong urges to smoke during initial withdrawal
- Associated with stimuli
Relapse prevention
- Avoid risky situations
- Maintain morale- offer support
- Develop active coping strategies
- Relaxation technique
- Encourage compliance with medication
Bupropion
- 419,000 patients have used Zyban
- 5,000 adverse reactions reported
- 126 reports of seizures (50% had predisposing factors)
- Dosage: One 150mg tablet daily for 6 days bd for remaining 8 weeks
Contraindications
- Current or previous history of seizures
- Previous diagnosis of bulimia or anorexia nervosa
- Known CNS tumour
- Abrupt withdrawl from alcohol or tranquillisers
Risk factors
- Alcohol abuse
- History of head injury
- Diabetic on hypoglycaemics or insulin
- Use of stimulants or anorectic products
- Drugs known to lower seizure threshold
- Scuba diving
Nicotine addiction
- 70% of smokers would like to give up
- Each inhalation delivers a bolus of nicotine to the brain within 10-19sec - faster than if given i.v.
- 10 puffs per cigarette - 20 a day smoker gets approx 200 drug highs each day
- Short half life of 2-3hrs
- Low blood levels of nicotine trigger withdrawal symptoms
Glucose
- An association between hunger and the craving for nicotine
- Smokers are more prone to low blood sugars
- A recent study suggests that the use of glucose not only relieves the low blood sugar but also eases the nicotine withdrawal
- A relationship between serotonin levels and blood sugar levels
- Diabetics must seek advice
- Only 10 calories per tablet
Withdrawal symptoms
- Symptoms affect 60-70% of heavy smokers
- Mood changes - lasts on average 4 weeks.
- Can be severe Difficulty concentrating - lasts under 2 weeks
- Urges to smoke - usually over 2 weeks, frequency declines
- Increased hunger - usually until the new body weight stabilises
- Weight gain 5kg over the first year
Less frequent symptoms include:
- Night time waking - 25% in the first few days. More severe if aggravated by bupoprion induced insomnia
- Mouth ulcers - 30% in first 2 weeks
- Lightheadedness - 10% in first few days
- Productive cough - 15% over the first 2 weeks
- Anxiety and headaches not normally withdrawal symptoms
CO monitoring
CO levels can be affected by:
- Number of cigarettes smoked so far that day
- Time of last cigarette
- Time of the day (co levels higher during the smoking day declining over night)
- Duration of breath holding -15 secs
Oral cancer
- Smokers 4 x greater risk
- Smokers & alcohol 16 x greater risk
- 3rd commonest cancer in men
- 6th commonest cancer in females
- Young males (under 45) 80% increase in Floor of mouth and tongue cancer
- Young females (under 45) 70% increase In tongue cancer
Presentation
- Oral ulceration (non-healing) / erosions
- Red or white patches
- Abnormal swelling
- Loss of tongue mobility
- Cauliflower growths
- Tooth mobility (abnormal)
- Non-healing tooth sockets
- Changes in mucosa (blue/brown)
- Reduced or altered sensation
Reference: Regional Drug and Therapeutics Centre (National Teratology Information Service) February 2000