Smoking/Nicotine

Tobacco smoking is the largest single, preventable cause of death and disease in Australia.

Methods for getting patients to quit Several studies have highlighted the value of opportunistic intervention by the family doctor. Not only is it important to encourage people to quit but also to organise a quitting program and follow-up.

Intervention: the 5A framework

• Ask about and document tobacco use at every opportunity.

• Assess motivation and confidence to quit: ‘Are you interested in quitting?’

• Advise all smokers to quit—diplomatically.

• Assist the smoker to quit with counselling and pharmacotherapy.

• Arrange follow-up to maintain quit advice or non-smoking (very important).

• If they say yes to quitting, make a contract (example below).

• Nicotine education: nicotine can be used to help withdrawal from cigarette nicotine dependence. It is a temporary measure and should not be used for longer than 6 mths.

Nicotine replacement therapy (NRT)

Formulations:

• nicotine gum

• nicotine inhaler

• nicotine oral spray and sublingual tablets

• nicotine polacrilex (lozenges)

• nicotine transdermal patches (probably best method)—use for 12 wks

  • – low to moderate dependence (10–20 cigs/d): 14 mg/24 h or 10 mg/16 h patch daily; change to 7 mg patch after 4–6 wks; aim to cease within 12 wks

  • – high dependence (>20 cigs/d): 21 mg/24 h patch daily → 14 mg after 4–6 wks → 7 mg after 4–6 wks; aim to cease within 12 wks

Note: Ongoing support and counselling (incl. anticipatory guidance) is essential. Patients must not smoke while on patches.

Other agents:

• bupropion (Zyban SR) 150 mg (o)/d for 3 d, then bd for 7 wks, is an option. Combining bupropion with NRT is not recommended

• varenicline tartrate (Champix) tablets 0.5 mg/d for 3 days titrating slowly to 1 mg bd by d 7 until the end of the 12-wk course. Effective but several side effects, esp. nausea and neuropsychiatric effects

• nortriptyline 75 mg (o) daily, start 14 d before quit date, continue for 12 wks

Note: Regular follow-up for all methods essential

• Support group recommended

• Going ‘cold turkey’: stopping completely is preferable but before making the final break it can be made easier by changing to a lighter brand, inhaling less, stubbing out earlier or reducing the number; changing to cigars or pipes is best avoided

Quitting tips (advice to patient)

• Make a definite date to stop (e.g. during a holiday).

• After quitting:

  • – Eat more fruit and vegetables (e.g. munch carrots, celery and dried fruit).

  • – Foods such as citrus fruit can reduce cravings.

  • – Chew low-calorie gum ...