Smoking Cessation Dr Victoria Scobie
Background <ul><li>Biggest single cause of preventable chronic illness, disability and premature death in Scotland </li></...
Role of Primary Care <ul><li>93% GPs thought helping a patient to stop smoking was the best thing they could do for their ...
Number Needed to Treat <ul><li>Best practice gives long term quit rate of 20% </li></ul><ul><li>50% long term smokers die ...
NNT-comparison 1140 Prevent 1 death over 10 yrs Screening for cervical cancer 700 Prevent 1 stroke, MI or death over 1 yr ...
30-second approach <ul><li>1.Do you smoke? </li></ul><ul><li>2.Are you aware of the risks? </li></ul><ul><li>3.Would you l...
Health Risks <ul><li>Stroke </li></ul><ul><li>Ca of mouth, throat, oesophagus </li></ul><ul><li>Ca of larynx </li></ul><ul...
Other effects of smoking <ul><li>Yellowing of teeth/fingers </li></ul><ul><li>Hair, skin, breath and clothes smell of toba...
Benefits of Quitting <ul><li>Time after last cigarette </li></ul><ul><ul><li>20mins -BP+HR return to normal, circulation  ...
Assess Motivation <ul><li>Number of previous attempts to quit </li></ul><ul><li>Previous NRT use </li></ul><ul><li>Willing...
NRT Options What Type of smoker? Regular Irregular Irregular + high behavioural dependence PATCHES GUM INHALATOR
Patches <ul><li>24hr patch if 1 st  cigarette within 20mins of waking up. Smokes >10/day. </li></ul><ul><li>6/52 21mg high...
Irregular smokers <ul><li>Gum <20cigs/day -  2mg gum, 15 pieces a day for 8 weeks, reduce by half for 2 weeks, then reduce...
NRT <ul><li>Aims to blunt nicotine withdrawal symptoms </li></ul><ul><li>NRT is not addictive </li></ul><ul><li>NRT may re...
Bupropion (Zyban) <ul><li>Antidepressant- selectively inhibits reuptake of dopamine + noradrenaline </li></ul><ul><ul><ul>...
Zyban contd <ul><li>C/I- pregnancy, breastfeeding, bipolar disorder, severe renal /hepatic impairment </li></ul><ul><li>Ri...
Varecicline (Champix) <ul><li>Binds to nicotinic acetylcholine receptors in brain </li></ul><ul><ul><li>Partial agonist-re...
Champix contd <ul><li>C/I pregnancy </li></ul><ul><li>Caution-renal impairment, breastfeeding, hx psychiatric illness </li...
Percentage of quit attempts achieving 6 months continuous abstinence <ul><li>No treatment 5% </li></ul><ul><li>NRT/bupropi...
<ul><li>Prescribe 1 month supply-dispense 2 weekly </li></ul><ul><li>Advise ongoing support  </li></ul><ul><li>Max 3 month...
Target groups  <ul><li>Pregnant smokers </li></ul><ul><li>Young smokers </li></ul><ul><li>Low income smokers </li></ul><ul...
Conclusion <ul><li>Opportunistic advice to smokers in GP surgery </li></ul><ul><li>Offer support to those who wish to quit...
References <ul><li>BMJ ABC of Smoking Cessation Molyneux,A 2004;328:454-456 </li></ul><ul><li>Smoking Cessation Guidelines...
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Smoking Cessation Dr Victoria Scobie

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Smoking Cessation Dr Victoria Scobie

  1. 1. Smoking Cessation Dr Victoria Scobie
  2. 2. Background <ul><li>Biggest single cause of preventable chronic illness, disability and premature death in Scotland </li></ul><ul><li>30% adults smoke </li></ul><ul><li>Average smoker will lose 10 years of life because of smoking </li></ul><ul><li>250 people in Scotland die every week from their smoking </li></ul>
  3. 3. Role of Primary Care <ul><li>93% GPs thought helping a patient to stop smoking was the best thing they could do for their health </li></ul><ul><li>BUT - 63% didn’t have time </li></ul><ul><ul><ul><ul><ul><li>61% thought input was ineffective </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>40% felt they lacked skills </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>23% thought it wasn’t their job </li></ul></ul></ul></ul></ul>
  4. 4. Number Needed to Treat <ul><li>Best practice gives long term quit rate of 20% </li></ul><ul><li>50% long term smokers die of smoking related illness </li></ul><ul><li>So if 10 smokers attempt to quit </li></ul><ul><ul><li>2 stop long term </li></ul></ul><ul><ul><li>1 would have died of smoking related disease </li></ul></ul><ul><ul><li>Therefore NNT for smoking cessation = 10 </li></ul></ul>
  5. 5. NNT-comparison 1140 Prevent 1 death over 10 yrs Screening for cervical cancer 700 Prevent 1 stroke, MI or death over 1 yr Antihypertensive therapy in mild hypertension 107 Prevent 1 death over 5yrs (from MI, stroke or other cause) Statin as primary prevention NNT Outcome Intervention
  6. 6. 30-second approach <ul><li>1.Do you smoke? </li></ul><ul><li>2.Are you aware of the risks? </li></ul><ul><li>3.Would you like to stop? </li></ul><ul><li>4.Would you like my/our help to stop smoking? </li></ul>
  7. 7. Health Risks <ul><li>Stroke </li></ul><ul><li>Ca of mouth, throat, oesophagus </li></ul><ul><li>Ca of larynx </li></ul><ul><li>Coronary heart disease </li></ul><ul><li>COPD </li></ul><ul><li>Asthma exacerbations </li></ul><ul><li>Lung Ca </li></ul><ul><li>Pancreatic Ca </li></ul><ul><li>Peptic ulcer </li></ul><ul><li>Bladder Ca </li></ul><ul><li>Osteoporosis </li></ul><ul><li>Cervical Ca </li></ul><ul><li>Peripheral artery disease </li></ul>
  8. 8. Other effects of smoking <ul><li>Yellowing of teeth/fingers </li></ul><ul><li>Hair, skin, breath and clothes smell of tobacco </li></ul><ul><li>Skin around eyes and mouth wrinkled </li></ul><ul><li>Reduced fertility </li></ul><ul><li>Increase risk LBW baby </li></ul><ul><li>Increased risk spontaneous abortion </li></ul><ul><li>Increased risk premature labour </li></ul><ul><li>Cost (20 cigs/day costs £1000 per year) </li></ul><ul><li>Increased premiums for life insurance </li></ul>
  9. 9. Benefits of Quitting <ul><li>Time after last cigarette </li></ul><ul><ul><li>20mins -BP+HR return to normal, circulation improves in hands + feet </li></ul></ul><ul><ul><li>8hrs -O2 levels in blood return to normal </li></ul></ul><ul><ul><li>24hrs -CO is eliminated from body </li></ul></ul><ul><ul><li>48hrs -nicotine no longer detected in body, ability to taste + smell improved </li></ul></ul><ul><ul><li>2-12wks -circulation improves- walking easier </li></ul></ul><ul><ul><li>3-9months -lung function improved by 5-10% </li></ul></ul><ul><ul><li>1year -50% reduction coronary heart disease </li></ul></ul><ul><ul><li>10years -risk of MI similar to non-smoker </li></ul></ul>
  10. 10. Assess Motivation <ul><li>Number of previous attempts to quit </li></ul><ul><li>Previous NRT use </li></ul><ul><li>Willingness to attend individual counselling or group sessions </li></ul><ul><li>>10 cigs/day </li></ul><ul><li>Prepared to stop in next 2 weeks? </li></ul><ul><li>Encouraged to stop through use of will power and smoking cessation clinics. </li></ul>
  11. 11. NRT Options What Type of smoker? Regular Irregular Irregular + high behavioural dependence PATCHES GUM INHALATOR
  12. 12. Patches <ul><li>24hr patch if 1 st cigarette within 20mins of waking up. Smokes >10/day. </li></ul><ul><li>6/52 21mg high strength, 2/52 14mg med strength, 2/52 7mg low strength </li></ul><ul><li>16hr patch-doesn’t need cigarette within 20mins waking or vivid dreams with 24hr patch </li></ul><ul><li>6/52 15mg high strength, 2/52 10mg med strength, 2/52 5mg low strength </li></ul>
  13. 13. Irregular smokers <ul><li>Gum <20cigs/day - 2mg gum, 15 pieces a day for 8 weeks, reduce by half for 2 weeks, then reduce to zero over 2 weeks . </li></ul><ul><li>Gum >20cigs/day – 4mg gum, 15 pieces a day </li></ul><ul><li>Nicotine inhalator – inhale when urge to smoke – inhale 12 cartridges/day 8 weeks, 6 cartridges/day for 2 weeks, 3 cartridges/day for 2 weeks </li></ul>
  14. 14. NRT <ul><li>Aims to blunt nicotine withdrawal symptoms </li></ul><ul><li>NRT is not addictive </li></ul><ul><li>NRT may reduce weight gain on quitting smoking </li></ul><ul><li>Contra-indications – under 18yrs, severe hepatic/renal impairment. </li></ul><ul><li>Caution - pregnancy, breast-feeding, cardiovascular disease, active PU disease, hyperthyroidism, DM. </li></ul><ul><li>Problems-GI upset, dry mouth, skin irritation, nose/throat irritation </li></ul>
  15. 15. Bupropion (Zyban) <ul><li>Antidepressant- selectively inhibits reuptake of dopamine + noradrenaline </li></ul><ul><ul><ul><li>150mg daily for 6 days </li></ul></ul></ul><ul><ul><ul><li>150mb BD for 6-8 weeks (150mg OD elderly) </li></ul></ul></ul><ul><ul><ul><li>Stop date 1-2 weeks after start treatment </li></ul></ul></ul>
  16. 16. Zyban contd <ul><li>C/I- pregnancy, breastfeeding, bipolar disorder, severe renal /hepatic impairment </li></ul><ul><li>Risks- seizure in 1/1000 pts </li></ul><ul><ul><ul><li>Assess risk factors- history of seizure, alcohol abuse, head trauma, concomitant use of drugs which lower seizure threshold </li></ul></ul></ul><ul><li>Anaphylactic reaction 1/1000 pts </li></ul><ul><li>Other-mild allergic reaction, insomnia, dry mouth </li></ul>
  17. 17. Varecicline (Champix) <ul><li>Binds to nicotinic acetylcholine receptors in brain </li></ul><ul><ul><li>Partial agonist-reduces cravings + withdrawal symptoms </li></ul></ul><ul><ul><li>Antagonist- reduces satisfaction asso smoking </li></ul></ul><ul><li>500mcg OD 3 days, 500mcg BD 4 days, 1mg BD for 11 weeks </li></ul><ul><li>Stop smoking after 1-2 weeks treatment </li></ul>
  18. 18. Champix contd <ul><li>C/I pregnancy </li></ul><ul><li>Caution-renal impairment, breastfeeding, hx psychiatric illness </li></ul><ul><li>Avoid abrupt withdrawal-relapse, irritability, depression, insomnia </li></ul><ul><li>Problems-GI upset, dry mouth, sleep disturbance, abnormal dreams </li></ul>
  19. 19. Percentage of quit attempts achieving 6 months continuous abstinence <ul><li>No treatment 5% </li></ul><ul><li>NRT/bupropion plus limited support 13% </li></ul><ul><li>Behavioural support only 13% </li></ul><ul><li>Behavioural support with NRT/buproprion 21% </li></ul>
  20. 20. <ul><li>Prescribe 1 month supply-dispense 2 weekly </li></ul><ul><li>Advise ongoing support </li></ul><ul><li>Max 3 months treatment offered </li></ul><ul><li>If patient has not stopped or significantly reduced by one month- discontinue Zyban/Champix </li></ul><ul><li>Relapse-no further prescribing of smoking cessation products in a 6 month period </li></ul>
  21. 21. Target groups <ul><li>Pregnant smokers </li></ul><ul><li>Young smokers </li></ul><ul><li>Low income smokers </li></ul><ul><li>Hospital patients who smoke </li></ul><ul><li>Psychiatric patients who smoke </li></ul><ul><li>Smokers with cardiovascular disease </li></ul><ul><li>Smokers with chest conditions </li></ul>
  22. 22. Conclusion <ul><li>Opportunistic advice to smokers in GP surgery </li></ul><ul><li>Offer support to those who wish to quit </li></ul><ul><li>Best results with behavioural support plus NRT/zyban/champix </li></ul>
  23. 23. References <ul><li>BMJ ABC of Smoking Cessation Molyneux,A 2004;328:454-456 </li></ul><ul><li>Smoking Cessation Guidelines for Scotland 2004 Update.Health Scotland and ASH Scotland. </li></ul><ul><li>Encouraging Smokers to Stop-A Guide for Health Professionals-www.healthscotland.com </li></ul><ul><li>A Simple and Time Effective Intervention in Smoking Cessation-The 30 Second Approach. GlaxoSmithKline </li></ul><ul><li>Guidance for Smoking Cessation in Tayside 2001. Tayside Drug and Therapeutics Committee </li></ul><ul><li>Simply Stop Smoking-A Practical Pocket Guide.British Thoracic Society 1999. </li></ul><ul><li>Smoking Cessation with NHS Tayside Community Pharmacy 2005 </li></ul><ul><li>www.bnf.org </li></ul><ul><li>www.nice.org.uk </li></ul>

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