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Therapeutic strategies to assist with smoking cessation

Well Close Square protocol - smoking
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 If sleep disturbance use 16 hour patch If craving cigarette on waking use 24 hour patch
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

2mg and 4mg Takes 30 mins to reach effectiveness Recommend 10 -15 pieces per day
Recommend it is used for 3 months
Chew slowly - takes time to get used to
Each piece lasts for 30 minutes but can be chewed for longer
Unpleasant taste initially

Microtab

Takes 30 mins to reach full effectiveness
Pills are placed under the tongue and dissolve in 20 minutes
Recommend 15-30 tablets per day
Recommend use for up to three months
Unpleasent taste initially

Inhalator

Reaches it's full effectiveness in 30 minutes
Required to puff vigorously for some 10-20 minutes every hour
10 puffs equals one puff from a cigarette
One cartridge lasts for at least 3 puffing sessions

Nicotine nasal spray

Is effective in only minutes
Recommend one shot to each nostril hourly
Recommend to be used for up to 3 months
Warn of initial adverse effects and supervise the first trial

Transdermal patch

16 and 24 hr patches - varying doses
Smaller patches for weaning off period not necessary
Takes hours to each full effectiveness
Recommended use for 2 -3 months
Change product if skin reaction presents

Advantages of patch over other products

Easy to use, not aversive
Social acceptability
Better compliance
No long term use

Advantages of other products over the patch

Faster nicotine absorption
Control over nicotine dose
Some behavioural replacement
Can be used opportnistically for Relapse prevention

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 Zyban 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

Logo Brad Cheek: 06 March 2010