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Smoking cessation

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Most smokers want to stop ... Smokers go through a series of distinct phases ... If a smoker's attempt to quit is unsuccessful with treatment using either NRT, ... – PowerPoint PPT presentation

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Title: Smoking cessation


1
Smoking cessation
2
How do we stop people from smoking?
  • Population measures

3
The 5 basic ways to help smokers quitSchroeder
AS. JAMA 2005294482-7
  • Increase the price of cigarettes
  • Prohibit smoking in public places
  • Create and disseminate effective counter
    marketing messages about smoking (media, pack
    displays)
  • Ban tobacco advertising and promotion
  • Provide cessation aids
  • Counselling / Behavioural therapy
  • Pharmacotherapy
  • NRT
  • Bupropion
  • Varenicline
  • Nortriptyline, Clonidine

Population measures (Government initiatives)
Individual measures (NHS Stop Smoking
Services)
4
How do you stop people smoking?
  • Changing behaviour

5
Changing behaviour"Giving up smoking is easy
I've done it a hundred timesMark Twain
  • Most smokers want to stop
  • 90 of the practice populations will visit the
    surgery during a three-year period (and more will
    see other health professionals)
  • This provides a good opportunity to change
    behaviour
  • Theories of
    behaviour change
  • - Health Belief
    Model (Becker, 1974)
  • - Theory
    of Reasoned Action
  • (Ajzen
    Fishbein 1980)
  • - Stages of
    Change

  • (Prochaska DiClemente 1984)
  • -
    Catastrophe pathway
  • (West
    Sohal, 2006)

6
Communicate effectively when giving advice to
stop smokingRCN Clearing the Air 2
  • Listen to the reasons the patient gives you for
    their smoking and paraphrase them e.g. I can
    hear that it would be very hard for you to give
    up smoking at the moment because.. or right
    now continuing smoking is important to you even
    though you know you risk having another heart
    attack
  • When a patient hears the things they have said
    summarised back in this way it helps them reflect
    on the consequences of their current choice. The
    yes but may become I know I should stop
    smoking or but I do really want to give up
  • Try to ask questions that will help them work out
    for themselves, why they smoke and why they
    should stop. This person focused approach will
    help smokers much more than advice

7
Summary Changing behaviour
  • Most smokers want to quit, but changing behaviour
    is difficult
  • People need to recognise that their health is
    threatened, and that the benefits of giving up
    outweigh the benefits they obtain from smoking
    (Health Belief Model)
  • Intention to change behaviour is influenced by
    personal attitudes and by the behaviour and
    attitudes of people around them (Theory of
    Reasoned Action and Planned Behaviour)
  • Smokers go through a series of distinct phases in
    their attitudes towards smoking cessation
    (Stages of Change model)
  • Many people get to the stage of wanting to quit
    without formal planning of their quit date
    responding to immediate needs (e.g. by providing
    NRT and/or behavioural support) may be
    appropriate (Catastrophe Model)

8
Public Health Intervention Guidance 1NICE March
2006. Brief Interventions and referral for
smoking cessation in primary care and other
settings
  • Everyone who smokes should be advised to quit
  • Advice to stop smoking should be sensitive to the
    individuals preferences, needs and circumstances
  • Those who want to stop should be offered a
    referral to an intensive support service
  • The smoking status of those who are not ready to
    stop should be recorded and reviewed with the
    individual once a year

9
Hard to reach and high smoking prevalence
groups NICE Public Health Guidance 10. Smoking
Cessation Services February 2008
  • Managers and providers of NHS Stop Smoking
    Services should ensure services are responsive to
    the needs of people who smoke from minority
    ethnic and disadvantaged communities
  • Consider developing links with local community
    groups
  • Wherever possible provide people with advice,
    counselling and support in their first language

10
Smoking cessation servicesNICE Public Health
Guidance 10. Smoking Cessation Services February
2008
  • Interventions proven to be effective for smoking
    cessation
  • Brief interventions
  • Individual behavioural counselling
  • Group behaviour therapy
  • Pharmacotherapies
  • Self-help materials
  • Telephone counselling and quitlines
  • Mass media campaigns

11
Smoking cessation PharmacotherapyNICE Public
Health Guidance 10. Smoking Cessation Services
February 2008
  • Nicotine replacement therapy (NRT), bupropion and
    varenicline can be used to help people quit
    smoking
  • All pharmacotherapy options can be offered to
    smokers with cardiovascular or respiratory
    disease, according to clinical judgement
  • Neither varenicline or bupropion should be
    offered to people under 18 years nor to pregnant
    or breastfeeding women
  • Normally treatment should only be prescribed as
    part of an abstinent-contingent treatment (ACT),
    in which the smoker makes a commitment to stop
    smoking on or before a particular date (target
    stop date)

12
Smoking cessation PharmacotherapyNICE Public
Health Guidance 10. Smoking Cessation Services
February 2008
  • Initial prescription should be sufficient to last
    only until 2 weeks after the target stop date
    (normally 2 weeks of NRT, and 3-4 weeks of
    varenicline or bupropion therapy)
  • Second prescriptions only given if demonstrated
    that quit attempt is continuing on re-assessment
  • If a smokers attempt to quit is unsuccessful
    with treatment using either NRT, varenicline or
    bupropion, the NHS should normally fund no
    further attempts within 6 months, unless special
    circumstances hampered the initial attempt

13
Smoking cessation PharmacotherapyNICE Public
Health Guidance 10. Smoking Cessation Services
February 2008
  • Do not offer NRT, varenicline or bupropion in any
    combination
  • There is insufficient evidence to conclude that
    one form of NRT is more effective than another
  • Combinations of NRT patches and other fast
    release formulations such as gum can be
    considered for people with high level of
    dependence, or have found single forms inadequate
  • People receiving pharmacotherapy should also be
    offered advice encouragement and support,
    including referral to NHS Stop Smoking Service

14
What about combinations of NRT?NRT MHRA QA
document December 2005
  • And agreement from NICE
  • NICE Public Health Guidance 10. Smoking Cessation
    Services February 2008

15
Nicotine Assisted Reduction to Stop (NARS)NICE
Public Health Guidance 10. Smoking Cessation
Services February 2008
  • Smokers who want to stop smoking but not
    immediately can consider NRT to help them to cut
    down with a view to stopping at a later date
  • NICE state this strategy should only be used if
    part of a properly designed and conducted
    research study for people who have failed
    repeatedly to quit smoking abruptly
  • Suggested reduction programme from CKS Smoking
    Cessation 2006

16
CSM advice for bupropionCSM 2002
  • CSM advice (bupropion). The CSM has issued a
    reminder that bupropion is contra-indicated in
    patients with a history of seizures or of eating
    disorders, a CNS tumour, or who are experiencing
    acute symptoms of alcohol or benzodiazepine
    withdrawal. Bupropion should not be prescribed to
    patients with other risk factors for seizures
    unless the potential benefit of smoking cessation
    clearly outweighs the risk. Factors that increase
    the risk of seizures include concomitant
    administration of drugs that can lower the
    seizure threshold (e.g. antidepressants,
    antimalarials such as mefloquine and
    chloroquine, antipsychotics, quinolones,
    sedating antihistamines, systemic
    corticosteroids, theophylline, tramadol), alcohol
    abuse, history of head trauma, diabetes, and use
    of stimulants and anorectics.

17
Europe-wide review recommends updates to product
information for varenicline?MHRA December 2007
  • Doctors are already aware of the risk of using
    Champix in patients who have an underlying mental
    illness. They also need to be aware of the
    possibility that patients who are trying to stop
    smoking can develop symptoms of depression, and
    they should advise their patients accordingly
  • Patients who are taking Champix and develop
    suicidal thoughts should stop their treatment and
    contact their doctor immediately

18
KEY POINTS
  • Smoking cessation

19
Pharmacotherapy Key points
  • Pharmacotherapy e.g. NRT/ bupropion/ varenicline,
    can be prescribed, if appropriate, by trained
    professionals but are most effective when used
    with other forms of support
  • Abrupt smoking cessation is desirable, however a
    NARS strategy with NRT can be considered for
    those who are unwilling or unable to stop
    completely, if part of a research study
  • Safety and efficacy data for bupropion and
    varenicline are limited
  • NRT is a less harmful alternative to smoking and,
    where non-drug approaches alone are not
    sufficient, can now be considered for
    adolescents, women who are pregnant or
    breastfeeding

20
Smoking cessation Key points
  • Advising and effectively assisting a person to
    stop smoking is the single most important thing
    that can be done for their health
  • All health professionals should take the
    opportunity to advise smokers to stop smoking,
    and consider referral to the NHS Stop Smoking
    Service
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