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Ovid: Oxford Handbook of Respiratory Medicine

Authors: Chapman, Stephen; Robinson, Grace; Stradling, John; West, Sophie Title: Oxford Handbook of Respiratory Medicine, 1st Edition Copyright ©2005 Oxford University Press > Table of Contents > Part 3 – Supportive care > Chapter 58 – Smoking cessation Chapter 58 Smoking cessation P.644
Aims and nicotine replacement therapy Smoking is the main cause of chronic obstructive pulmonary disease and lung cancer. The NHS spends £1.7 billion per year caring for people with smoking-related conditions. Government targets have been set to reduce the number of smokers in the UK and health authorities have been allocated funding for smoking cessation services.

  • 31% of men and 29% of women in the UK smoke
  • 82% of smokers start as teenagers
  • The incidence of smoking is increasing in developing countries
  • Smoking is also associated with bladder, oesophageal, cervical, and renal cancers, as well as cardiovascular and cerebrovascular disease
  • Nicotine exerts its effects on the CNS and is very addictive
  • Peak nicotine withdrawal time is 2–3 days
  • 2% of smokers manage to stop each year
  • Stopping smoking is associated with an average weight gain of 2 kg.

Aims of smoking cessation interventions In order to achieve the goal of sustained abstinence, the aim is to reduce short-term cravings for nicotine (nicotine and non-nicotine replacement therapy) and in the long term to modify behaviour (counselling, telephone or group support, buddy systems). It is vital that the smoker is motivated to stop, or attempts will fail. It is important as a health professional to address smoking cessation at all opportunities. Health professionals can trigger quit attempts by giving brief advice to all smokers. This can lead to 1–3 out of 100 people stopping smoking for 6 months. Doctor advice often has the strongest impact. People can be more receptive to smoking cessation messages during times of concern for their own or their families health. A guide to approaching the topic is:

  • Ask how much a person smokes and document pack years
  • Advise on risks of continued smoking and suggest possible treatments and the help available
  • Assist by referring to a counsellor or providing nicotine replacement therapy
  • Arrange follow-up.

Some hospitals or primary care trusts have smoking cessation counsellors. The best results in terms of quit rates are achieved by combining counselling with nicotine replacement therapy or bupropion, with regular support and follow-up. These can improve quit rates to around 25%. The National Institute of Clinical Excellence has issued guidance on the use of nicotine replacement therapy and bupropion for smoking cessation. Nicotine replacement therapy (NRT) allows short- and medium-term nicotine withdrawal symptoms to be minimized, by replacing the nicotine. Should not be used whilst still smoking, as it is possible to overdose on nicotine (symptoms: agitation, confusion, restlessness, palpitations, hypertension, dilated pupils, SOB, abdominal cramps, vomiting). Can be bought over the counter or be prescribed by general practitioner. Cheaper than cigarettes! Most NRT products are contraindicated in P.645
pregnancy, breast-feeding mothers, and in children under 18, but are used under supervision.

  • Patches Give small amounts of nicotine via transdermal patch to decrease cravings before they occur. Different strength patches according to how much is smoked. Use higher dose patch if 10+ cigarettes per day smoked. Convenient. Worn continuously throughout day, but often removed at night due to vivid nature of dreams. Can get localized irritation at patch site. Patches should be used for 6–8 weeks at the higher dose and then weaned to a lower dose for 2–4 weeks. Available to buy over the counter
  • Chewing gum Different strengths of gum that release nicotine as they are chewed. Relieves cravings as they occur. When mouth tingles and has peppery taste, should stop chewing and ‘park’ the gum inside the cheek. Nicotine is then absorbed through the lining of the mouth. Should not chew continuously, or may become nauseated. Nicotine needs to be absorbed through mouth and not swallowed in saliva. Therefore don’t drink with gum. Physical act of chewing can relieve craving. Can taste unpleasant and may need to use several packs of gum a day. Use high-dose gum if 20+ cigarettes per day are smoked. Use for 3 months and then reduce the strength and the amount of gum used. Available to buy over the counter
  • Sublingual tablets used on demand to help with cravings. Useful for smokers wanting a discreet form of treatment. 1–2 tablets should be placed under the tongue every hour when needed. Dissolve over 30 minutes. Licensed for use in pregnancy (one tablet only). Use for 3 months and then gradually reduce the number of tablets used a day. Available on prescription
  • Lozenges Available to buy over the counter
  • Inhaler Cigarette style appliance giving small amounts of nicotine when used. Useful for people who are habitual or ritualistic in when they have a cigarette and want the ‘hand to mouth’ routine. Nicotine is absorbed through the lining of the mouth, not via the lungs. Use for 2 months, and then gradually reduce. Available on prescription
  • Nasal spray provides rapid relief of craving. Faster absorption than other forms of NRT. May cause local irritation. Use for 2 months; then reduce. Available on prescription.

Non-nicotine replacement therapy Drugs Bupropion (Zyban) is promoted as an aid to smoking cessation in combination with motivational support. It is an antidepressant that was found to reduce the desire to smoke, regardless of whether people were depressed or not. It weakly inhibits dopamine, serotonin, and noradrenaline reuptake in the CNS. It counteracts nicotine withdrawal symptoms by increasing these levels in the brain. It is suitable if people smoke 10 or more cigarettes a day. Liver metabolized. 20 hour half-life. Smokers start taking bupropion 1–2 weeks before their intended ‘quit day’. Continue taking it for 7–9 weeks after. Improved abstinence rates compared to placebo or nicotine patch if associated with counselling (30% 12 month abstinence rate with bupropion, 16% with nicotine patch, 15% with placebo, 35% with patch and bupropion). Also thought to lessen weight gain associated with stopping smoking. Contraindicated in patients with epilepsy or at risk of fits, pregnancy, and those on monoamine oxidase inhibitors. Reduce dose if elderly or hepatic or renal impairment. Recognized adverse effects include dry mouth, hypersensitivity, insomnia, and seizures (1 in 1000 users) and death. Prescription only. Hypnosis aims to improve will power in the subconscious state with therapeutic suggestion. Anecdotal success, but Cochrane review of trials showed no greater abstinence rate with hypnosis than any other treatment, or placebo treatment. Acupuncture/acupressure No evidence in favour of it over placebo acupuncture. Future developments

  • Increasing and improving hospital-based smoking cessation services with links to community-based services
  • Nicotine immunotherapy. Laboratory-based models to create a ‘nicotine vaccine’ to try and prevent abstinent smokers from re-starting are in progress. Induce specific nicotine antibodies to prevent inhaled nicotine from binding to nicotine receptors and causing neurological stimulation.

Further information ABC of smoking cessation series. BMJ Feb-April 2004 Systematic review of the effectiveness of stage based interventions to promote smoking cessation. Riemsma RP et al. BMJ 2003; 326: 1175 Smoking cessation guidelines for health professionals. West R et al. Thorax 2000; 55: 987–99 A controlled trial of sustained-release bupropion, a nicotine patch or both for smoking cessation. Jorenby DE et al. NEJM 1999; 340: 685–91 http://www.doh.gov.uk/tobacco http://www.nosmokingday.org.uk Quitline 0800 002200

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