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Introduction

Smoking is the number one risk factor associated with preventable disease and premature death.

  • the WHO estimates that 5.4 million people die prematurely each year as a result of tobacco related illness.
  • In smokers, stopping smoking is “the best” thing they can do to improve their health
  • Half of smokers will be killed by smoking
    • The average life expectancy of a smoker is 8-12 years less than for a smoker
    • There is also a large chronic disease burden – the quality of life in later years of life is also reduced – not just the duration of life
    • Those who stop by age 35 avoid almost all of the excess risk
  • Redcuing parental smoking is the most effective way of reducing youth uptake of smoking

The chemical in cigarette smoke

  • 4,000 chemicals
  • 60 of them are known to cause cancer

Rates of smoking have been falling in the developed world since the 1960s. Different countries have taken different approaches to reducing smoking. Australia is leading the way in the developed world. In many developing countries, the incidence of smoking is still on the rise.

In Australia in 2018, 13.8% of the general population were current smokers.

  • In indigenous populations the prevalence is about double

In the UK, figures are similar, with 14.7% of the population smoking in 2018.

The approaches to smoking cessation in the UK and Australia are similar but not identical. In particular, there is more of an emphasis on the use of vaping devices in UK policy, compared to Australia.

On average, it takes 7-9 quit attempts to become a successful long term non-smoker.

  • The average 40-year old will have made 20 quit attempts – most of them unsupported
  • Quit attempts are more successful if supported – by healthcare professional, medication and support groups – about 25-30% successful

There are three medical therapies available:

  • Nicotine replacement therapies (NRT)
  • Bupropion
  • Varenicline

NRT may be used in combination with either of the other two. A recent Cochrane review concluded that NRT (particularly patch combined with fast-acting oral form) and varenicline are more effective than bupropion, and equally effective as each other.

Diseases associated with smoking

Nicotine

  • Highly addictive
  • Absorbed into the blood through bout the lungs and the mouth
  • Reaches the brain in 7-10 seconds
  • Nicotine receptors when activated, promote the release of dopamine
  • Nicotine withdrawal symptoms
    • Sleep disturbance
    • Tiredness
    • Headache
    • difficulty concentrating
    • Increases appetite
    • Anxiety
    • Cravings!
    • Depressed mood
    • Irritability
    • All of these symptoms can be relieved by the administration of nicotine
  • Nicotine receptors are stimulated to proliferate by smoking – it is particularly the pulsatile nature of smoking – short, sharps “hits” that causes massive proliferation

Factors that encourage young people to smoke

  • Most people will try smoking in their teenage years (or younger) but <20% go on to become regular smokers
  • Factors that make someone more likely to smoke include:
    • Parental smoking
    • Best friend smoking
    • Beleif it relieves stress
    • Belief it prevents weight gain
    • Belief that the negative consequences wont affect them
    • Challenge to authority

Effects of smoking cessation

  • 20 minutes
    • BP and pulse return to normal
  • 8 hours
    • Nicotine and CO levels halved
    • O2 returns to normal
  • 24 hours
    • CO eliminated
    • Lungs start to clear excess mucus
  • 48 hours
    • Nicotine eliminated
    • Sense of smell and taste improve
  • 72 hours
    • Bronchiole dilatation, resulting in sensation of easier breathing
  • 2-12 weeks
    • Circulation improves
  • 3-9 months
    • Lung function increases by up to 10%
    • Cough and wheezing decreased
  • 5 years
    • Risk of MI halved
  • 10 years
    • Risk of lung cancer halved
    • Risk of MI equal to never smoked

Frameworks

The 5A’s

The 5A’s framework is used in several lifestyle related illnesses, including smoking and obesity.

  • Ask – Firstly – if they smoke! Then about their concerns their smoking. Ask if they have tried to stop previously
  • Assess – The stage of change (see stages of change below)
  • Advise – of the benefits of smoking – “It is the best thing you can do for your health”
  • Assist / Agree – attempt motivational interviewing – “What are the things you don’t like about smoking”. Explore doubts. Explore barriers to quitting. Offer written information, refer to Quitline. Discuss relapse prevention. Advise about medication options that may assist (see below).
  • Arrange – Follow-up. Encourage continuation of pharmacological methods. Discuss relapse prevention. Congratulate patient if smoking has ceased!

Stages of change

The stages of change model refers to the mental thought processes involved with smoking cessation. Traditionally it has been used as a framework to understand the process of quitting, although there is not much evidence behind it.

It involves 6 stages, and often patients cycle through the process several times

  • Not interested in quitting
    • “Precontemplation”
  • Thinking about change
    • “I know I should…”
    • “I don’t think I’ve got the willpower”
    • “I don’t know where to start”
  • Preparing
    • “This is my last packed / day / week”
    • Have prepared some coping strategies – e.g. nicotine replacement, signed up to a quit smoking group, agreed with a friend or partner to stop at a given date / time
  • Making a quit attempt
  • Maintaining the quit attempt
    • Patients can leave the cycle with a continued prolonged effective quit attempt!
  • Relapsing

Smoking Cessation Methods

A practical approach

  • Use nicotine and medication options (e.g. champix) in combination
    • Don’t under-dose the nicotine replacement!
    • Use patches, plus a short acting oral replacement – such as gum, tabs or oral spray
  • The use of a quitting service – such as QuitLine, in-person support groups, or apps, increases the chances of a successful quit attempt
  • About half of those attempting to quit do so with medical support – usually in the form of medication

Addressing barriers to quitting

  • Weight gain
    • On average, smokers gain 4-5kgs within 12 months of smoking cessation
    • The health effects of quitting typically dramatically outweigh the health effects of the additional weight
    • 20% of quitters do not gain weight
    • Advise to focus on the quitting now, and address any weight gain later
  • Stress
    • Smoking generally increases stress, but temporarily relief is felt with each cigarette – this is actually the effect of the nicotine combatting nicotine withdrawal that has built up between cigarettes
    • With smoking cessation, typically stress levels fall
    • Warn about the short term symptoms of nicotine withdrawal
  • Managing withdrawal
    • Reassure that craving typically only last 2-3 minutes
    • Get less frequent and less severe with time – but may last years
    • Severe symptoms worst int he first week and typically last 2-4 weeks
    • Usually can be controlled with nicotine therapy and other medications
  • Fear of failure
    • Reassure that the average is about 7 attempts before a successful quit
    • Reframe failures as learning experiences that are likely to increase effectiveness of the next attempt
    • Advise that with professional support, quitting is more likely to succeed
  • Peer pressure
    • Discuss methods of avoiding peer pressure situations
    • Advise friends they are quitting
    • May be best to avoid certain friends and social situations temporarily in the first few weeks

Nicotine replacement therapy

  • A typical “20-a-day” smoker has an average nicotine level of 40ng/mL
    • Nicotine replacement therapies are commonly under-dosed
    • The strongest patches deliver nicotine levels of 10ng/mL, and gum 15ng/mL and thus x2 patches or combinations of agents are often required
  • Dosage needs to be sufficient to relieve withdrawal symptoms!
  • Often preferred by patients because they don’t require a prescription
  • Can be used in pregnancy
    • Safety not formally established, but widely believed to be safer than smoking in pregnancy
  • Patients typically should use at least 8 weeks of therapy
    • Analogy – a plaster cast for a fracture. The cast needs to be in place for 8 weeks to allow healing to occur

Options for nicotine replacement include:

  • Patches
    • Be wary of night-time patch use as it can affect sleep
    • Patient may prefer to remove the patch overnight
    • If using multiple patches, could try one patch on at night, and a second added in the morning
  • Inhalator
  • Nasal spray
  • Lozenges
  • Gum
    • Useful to manage cravings
    • Don’t be afraid to recommend using gum in addition to patches to manage the short-term cravings
    • Nicotine from the gum is absorbed by the oral mucosa
    • More effective if made into a disc shape and placed against the mucosa
    • Chewing it a lot just results in lots of nicotine being swallowed – and in the stomach it is not effective!
  • Micro-tabs

Lifestyle factors affecting the efficacy of quitting

  • Trying to change smoking patterns – help patients identify their triggers to smoke and minimise them
  • Avoiding usual areas or venues where they smoke
  • Involving their family and friendship group – avoiding friends trying to sabotage quit attempts!
  • Focus on positives – e.g. money saved and what they can do with this money

Medication

Bupropion (Zyban(R))

  • Bupropion hydrochloride is a dopamine and noradrenaline re-uptake inhibitor
  • Also used in obesity to treat food cravings
  • Advise patients to start taking in 1-2 weeks before smoking cessation
  • Continue for 7-12 weeks
  • Side effects:
    • Nausea
    • Vomiting
    • Headaches
    • Dizziness
    • Dry mouth
    • Seizure (1 in 1000)
  • Contraindications
    • History of seizures
    • Patient is on MOAI
    • Caution when used with other drugs that lower the seizure threshold

Varenicline – (Champix (R))

  • Nicotine receptor partial agonist
  • Gradually increasing dose for the first week, then 1mg twice daily for 12 weeks
    • A further course of 12 weeks can be given
  • Relieves cravings
  • Appears to make smoking less pleasurable
  • Patients typically find that they feel the need to smoke less after several days of the medication
  • 2 weeks after starting medication, 25% of patients are no longer smoking. Most of the rest will have reduced their smoking
    • In those still smoking – ensure adequate nicotine replacement
    • Complete non-responders probably have a genetic pre-disposition, and champix should be ceased
  • The most effective agent when used alone (compared to bupropion and NRT)
  • Side effects
    • Depression of mood – be wary in people with a history of mental health disorder (try alternatives)
    • Sleep disturbance – unusual or memorable dreams, not usually scary or nightmares
    • Nausea – 30% of patients. Tends to settle with ongoing use. Reduced if the medication is taken with food
  • Contraindications
    • Pregnancy
    • Age <18

Interventions that have been proven to be ineffective

  • Hyponotherapy
  • Acupuncture
  • Trying to “wean” down
  • Motivational interviewing
  • Explaining the stages of change model to patients

Smoking cessation and drug metabolism

Smoking has effects on several classes of drugs, and increases their metabolism. As such, when a patient stops smoking, if they are on any of the following, then doses may need to be reduced:

  • Antipsychotics
  • Antidepressants – including SSRIs and tricyclics
  • Benzodiazepines
  • Warfarin
  • Clopidogrel
  • Beta-blockers – particularly propranolol
  • Calcium channel blockers – particularly verapamil
  • Insulin
  • Metformin
  • Theophylline
  • Triptans

References

  • Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
  • Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
  • Beers, MH., Porter RS., Jones, TV., Kaplan JL., Berkwits, M. The Merck Manual of Diagnosis and Therapy
  • Supporting smoking cessation - RACGP
  • Helping Smokers Quit - RACGP

Read more about our sources

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