Smoking cessation

Three questions to ask

• Do you smoke?

• Do you want to stop?

• Would you like me to help?

Smoking cessation options

• NHS services including text messages: https://www.nhs.uk/smokefree

• Nicotine replacement

• Alan Carr book

• Pharmaceutical options

  • Bupropion (Zyban): avoid if bipolar, epilepsy, anorexia, alcohol abuse: 11 weeks

  • Varenciline (Champix): 8 weeks

Question

A 43-year-old woman, who has smoked for 20 years, has decided that she would like to stop smoking. She has come to ask for advice about both conventional and complementary therapies.

Medical history:

• Asthma

• Depression – stopped fluoxetine six months ago

• Mechanical low back pain

Current medication:

• Salbutamol inhaler two puffs whenever necessary

• Beclometasone inhaler two puffs twice daily

Which ONE of the following smoking cessation treatments is a CAUTION for this patient? 

A. Nicotine replacement therapy (NRT)

B. Bupropion

C. Hypnotherapy

D. Acupuncture

E. Varenicline

Depression has been reported in people using varenicline who are trying to stop smoking, and symptoms of depression may include suicidal thoughts and behaviour. The Medicines and Healthcare Products Regulatory Agency (MHRA) advises that:

• Individuals taking varenicline should be told to stop treatment and contact their doctor immediately if they develop suicidal thoughts or behaviour

• Varenicline should be stopped immediately if agitation, depressed mood, or changes in behaviour are observed that are of concern to the patient, family, or caregivers

• The safety and efficacy of varenicline in people with serious psychiatric illness have not been established. People who have a history of psychiatric illness should be monitored closely while taking varenicline

Resource:

• NICE. Tobacco: preventing uptake, promoting quitting and treating dependence. NG209. 2021 (updated 2023).

Ask, Advise, Act

The Ask, Advise, Act model is an example of very brief advice and can be used to initiate behavioural change. The benefit of using this technique is that it can be given within 30 seconds and is realistic for use in routine consultations. Motivational interviewing takes longer and needs repeated consultations to work. The AUDIT–C is a brief alcohol screening tool which identifies patients who drink hazardously. Cognitive behavioural therapy and exposure therapy are not appropriate or as practicable within a primary-care consultation.

Resource:

Marchant R. Cancer prevention and improving cancer outcomes. InnovAiT 2020; 13(3): 146–151

Pack years

Pack years are calculated by dividing the number of cigarettes smoked per day by 20, then multiply by the number of years smoked.

Nicotine replacement therapy

For which ONE of the following smokers, is nicotine replacement therapy (NRT) LEAST appropriate? 

1. A 11-year-old boy with behavioural problems

2. A 15-year-old girl who is 28 weeks pregnant

3. A 35-year-old woman who is breast-feeding

4. A 54-year-old woman who had a myocardial infarction a month ago

5. A 75-year-old man taking anti-epileptic therapy

NRT is only licensed for children over 12 years.

Resources:

• BNF. Nicotine.

• BNF for Children. Nicotine: indications and dose.

• RCGP. Curriculum Topic Guides: Population and planetary health. 2019.

Resources

• Smokefree (NHS)

• Smoking cessation (CKS)

• Smoking cessation treatment options (MIMS)

• Allen Carrs Easy Way to Stop Smoking (Amazon)

• British National Formulary (BNF)