Aids to cessation

In Europe, 29% of individuals identify as smokers. Some countries within Europe have alarmingly high rates of tobacco use; 40% of Greek adults smoke regularly.

Introduction

Smoking and chewing tobacco are directly related to 650,000 mortalities each year in Europe, which is roughly 14% of all deaths.

People have different needs when they attempt full cessation, with some requiring intensive interpersonal support with pharmacotherapy and others able to quit successfully by ‘going cold turkey.’

Physical withdrawal symptoms can be titrated through nicotine replacement therapy (NRT).

There are other medications which can be used alongside NRT to help maintain cessation in motivated individuals.

Examples of these include Buproprion, Varenicline, Clonidine and Nortryptiline which must be prescribed by specialist stop smoking services or medical professionals in the UK.

For people who need face to face support to assist with cessation, there are Stop Smoking Services which can offer counselling.

Unaided, studies show that the rate of smokers who succeed in quitting is typically 2-4%.

For those who utilise ‘Stop Smoking,’ services alongside pharmacotherapy, these rates can increase to 15-20%.

 

Stop Smoking Services

Effective communication during smoking cessation is one of the most important facets in encouraging reduction of potential harmful behaviours.

Various modalities of communication can be utilised in the cessation pathway; didactic presentations, video demonstration, practice exercises and case studies in both individual and group sessions. Telephone based interventions have also been shown to be beneficial compared to a self-quitting approach, with other technologies being shown to have benefit as well.

Individual therapy

involves face-to-face appointments with a trained cessation therapist. Intervention can vary in intensity, however there is no evidence that a more intense intervention increases cessation success. Motivational interviewing is an integral part of this approach and is a patient-centred, designed to be modified to the patient’s approach to cessation. The individual approach tends to include sessions over several weeks, with increased number and longer sessions shown to be more effective.

Group therapy
is shown to be helpful in cessation attempts compared to other less intensive interventions, however it has not been shown to be better or worse than individual counselling (Stead 2001). Group interventions can include skills training, mood management components and manipulation of group dynamics (Stead 2005). Group therapy allows interaction and peer support between users and is often combined with nicotine replacement therapy.
Telephone and Technological Support
Telephone support advice appears to be dose dependent, with increased telephone intervention increasing the chance of successful cessation. These phone lines may offer information, recorded messages or personal counselling. Telephone intervention is useful for smokers considering quitting and individuals who have just quit. It also provides intervention for individuals who may not have sufficient time or resources to attend group or individual sessions with stop smoking services. The use of mobile phone ‘apps’ have also been shown to have some merit.

Nicotine Replacement Therapy

All forms of nicotine replacement therapy have been shown to be beneficial in long term smoking cessation, almost doubling success rates. NRT can take the form of gum, skin patches, inhalers, lozenges alongside nasal and oral sprays. It is a frequent component of smoking cessation strategies as it reduces the physiological effects of cessation, providing nicotine to reduce the effects of withdrawal.

A Chart of Pros and Cons of different smoking cessation modalities
It should be noted that gum and patches do not provide 100% nicotine replacement, meaning combinations of different NRT may help heavy smokers, for example gum and patches together. We can use the following simple chart to assess nicotine dependence in patients, which is:
Heatherton’s adaptation of the Fagerstrom test of nicotine addiction.

Following is a chart to show suggested dosages of nicotine replacement therapies based on above dependence. The figure below should only be used as a suggestion, with practitioners identifying local guidelines if necessary.
Suggested NRT doseages, adapted from Government of Western Australia Department of Health Guidance

Pharmacotherapy (Varenicline, Buproprion, Clonidine & Nortriptyline)

Varenicline

Varenicline (Champix)

This drug blocks nicotinic receptors in the brain, removing the pleasurable sensations experienced upon having a cigarette. Any medicine which must be taken orally may result in side effects for the user.

Varenicline’s most common side effect is nausea, which is experienced by 33.5% of users.

There have been reports of more severe, neuropsychiatric adverse events such as depression and suicidal behaviour, however a literature search offers very limited evidence of such occurrences.

Buproprion

Buproprion (Wellbutrin)

Bupropion exerts its effect primarily through the inhibition of dopamine reuptake, which attenuates withdrawal symptoms by prolonging the presence of this neurotransmitter within neuronal synaptic vesicles.

The medication has been associated with manageable side effects such as nausea, dizziness and vomiting.

More serious side effects include hallucinations and seizures, although these are very rare, with the risk of seizures being reported by GlaxoSmithKline (2006) at 0.1%.

 

 

In relation to the two first line pharmacotherapy treatments, both have roughly the same amount of successful cessation after 2 years, although Varenicline seems slightly more effective in the short term.

 

Clondine and Nortriptyline

Second line pharmacotherapies; they iare given when the two first line therapies don’t work or are contraindicated.

These have both been shown to be roughly as effective as the first line medications, but have an increased number of side effects in most users.

In isolation, clonidine and nortryptiline have been shown to double quitting success.

Side effects are common in users and include:

  • Clonidine: hypotension and drowsiness
  • Nortriptyline: sedation, nausea, dry mouth, constipation, and urinary retention.

Did you Know

Each year, 3000 non-smokers die of lung cancer primarily caused by secondhand smoke. More than 33,000 non-smokers die of secondhand smoke-related heart disease.

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