ASTHMA RESOURCE PACK SECTION 13. Stop Smoking

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1 ASTHMA RESOURCE PACK SECTION 13 Stop Smoking In this section: 1. How to calculate Pack Years 2. Why it is worth Stopping Smoking 3. Benefits of Stopping Smoking 4. How to explain to Smokers that it is Worth Stopping 5. Stop Smoking Support in Fife 6. Guidance on Nicotine Replacement Therapy Asthma Resource Pack: Section 13 Stop Smoking Version 2.2 Last Updated: August 2015

2 1. How to Calculate Pack Years Number of cigarettes per day X Number of years smoked = Pack years 20 OR 20 cigarettes per day for one year 10 cigarettes per day for two years = One pack year 5 cigarettes per day for four years 40 cigarettes per day for one year = Two pack years If a patient smokes cigars, rollups or a pipe the following are useful to calculate the equivalents values in cigarettes. Cigar = 5 cigarettes 1 rollup = 1 cigarette 1 pipe fill = 1 cigarette Page 2 of 13

3 2. Why it is worth stopping smoking Many patients believe that once damage has been done, smoking cessation isn't necessary anymore. The Fletcher-Peto graph clearly shows the importance of quitting smoking, even if serious damage is already present. Page 3 of 13

4 FEV 1 (% of value at age 25) 3. Benefits of stopping smoking 100 Benefits of Smoking Cessation Never smoked or not susceptible to smoke Disability Death Age (years) Page 4 of 13 Smoked regularly and susceptible to its effects Stopped at 45 Stopped at 65 Fletcher and Peto, 1977

5 4. How to explain to Smokers that it is worth Stopping Many smokers put off stopping smoking because they believe the damage is already done, or it is too late to prevent it. For most this is not true. The damage done by smoking accumulates over years. The risk of damage is greater for those who have smoked more, and smoked for longer. Conversely, the sooner smokers stop the greater the benefit. This is illustrated by the diagram. Based on research on chronic obstructive lung disease (bronchitis and emphysema), and on one particular measure FEV 1 - forced expiratory volume in one second, which is measured with a Spirometer. The diagram cannot necessarily be generalised to all smokers or all diseases caused by smoking, but it clearly illustrates the principle The sooner you stop, the sooner you avoid excess risk. The diagram shows that smokers with chronic airflow obstruction can avoid becoming disabled (first breathlessness, eventually emphysema) if they stop in middle age. The middle line, Stopped at 45, shows that the effect is to delay the onset of disability beyond a normal lifespan. The effect of delaying cessation will be to bring the Stopped at 45 line closed to the Smoker line. How you use the diagram will depend on individual smokers and their relationship with you, but they may find the following key points helpful. 1 The diagram shows the benefit to your lungs if you stop smoking. 2 Lung function gets worse as you get older, but normally only very slowly and very slightly (Nonsmoker line) 3 In smokers, lung function can get worse much more quickly. For example, the diagram shows a smoker who becomes disabled with emphysema at 65 (Smoker line) 4 If you stop smoking you delay the damage to your health and if you stop soon enough, there will be no damage (Stopped at 45 line) The diagram is based on Fletcher and Peto s 1977 paper, The natural history of chronic airflow obstruction. The text of this resource has been approved by Richard Peto, Professor of Medical Statistics and Epidemiology, University of Oxford. These are the relevant key conclusions of the study: Firstly, we found that FEV 1 declines continuously and smoothly over an individual s life The rate of loss seems to accelerate slightly with ageing. Secondly, non-smokers lose FEV 1 slowly and almost never developed clinically significant airflow obstruction. Thirdly, many smokers lose FEV 1 almost as slowly as non-smokers and never develop clinically significant airflow obstruction. They appear to be largely resistant to the effects of smoke on their airflow. Smokers who are more susceptible to these effects develop various degrees of airflow obstruction, which in some ultimately becomes disabling or fatal. Fourthly, stopping smoking will, of course, make little difference to FEV 1 of a non-susceptible smoker whose lungs are not being affected by his smoking. But it may make all the difference to a susceptible smoker. A susceptible smoker who stops smoking will not recover lost FEV 1 but the subsequent rate of loss of FEV 1 will revert to normal. This finding is strongly supported by the low death rate from bronchitis and emphysema among smokers, who have given up more than 10 years earlier. The important finding is that if those who would eventually die from airflow obstruction stop smoking in early middle age then their subsequent rates of loss of FEV 1 will on average be normal, so that most such individuals will keep well. Full reference: Fletcher C Peto R (1977). The natural history of chronic airflow obstruction. British Medical Journal. I Page 5 of 13

6 5. Stop Smoking Support in Fife Page 6 of 13

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9 6. Guidance on Nicotine Replacement Therapy This NHS Fife Stop Smoking Prescribing Guidance provides recommended support pathways for staff on medicines and services, when undertaking stop smoking interventions. It is aimed at all practitioners involved in stop smoking support in NHS Fife. See also Nicotine Dependence section of Fife Joint Formulary 1 st line choice: Nicotine replacement therapy (NRT) + specialist support* 1 st line: Patches 2 nd line: Gum, Inhalator, Lozenges, Oral spray 2 nd line choice: Varenicline + specialist support** * For NRT, specialist support = NHS Fife stop smoking services, community pharmacists, specialist GP clinics. ** For varenicline, specialist support = NHS Fife stop smoking services, community pharmacists (via varenicline PGD), specialist GP clinics Ask - Are you (still) smoking? Yes Record in notes if smoking and try to establish if aware of risks? Yes Patient identified as requiring help to stop smoking No No Congratulations, Record in Notes Briefly outline health risks. Give written material e.g. How to stop smoking booklet & Fife Stop Smoking Service information INITIAL REVIEW - Is patient motivated to stop smoking? Ask: Have you ever thought about smoking and your health? Yes/No Are you interested in trying to stop? Yes/No Would you be prepared to stop smoking in the next 2 weeks? Yes/No (If response is Yes to all 3, patient is likely to be sufficiently motivated) Yes Able to deal with now? - if not set separate appointment No Suggest information on improving motivation and confidence (reassess at next visit) Patient wishes drug therapy? Medically suitable for NRT or Varenicline (Champix ) Prescribing interval since last quit attempt assessed as appropriate prescribing at discretion of health professional (guided by answers to questions re motivation) No Refer to CHP stop smoking services for ongoing support. Yes Drug therapy options - see page 2 IN ADDITION If client consents, they should always be referred to specialist services for behavioural support. Each Community Services Area (East & West) has a specialist stop smoking service offering intensive support, either on a one to one or group basis (telephone ) All community pharmacies offer a stop smoking service which consists of a programme of individual support and advice and NRT or varenicline. Quit 4 Life is for pregnant women and their partners. The service offers ongoing support before and during pregnancy and after the baby is born (telephone or ). Support from GP practices - many GP practices offer support for people who want to stop smoking. Prepared by: Subgroup of the Smoking Cessation Prescribing and Supply Group Date: May 2015 Version 3 Review Date: May 2018 Document approved on behalf of NHS Fife by the Fife Area Drugs and Therapeutics Committee, June 2015 Page 9 of 13

10 NRT 1 st line Drug therapy options Varenicline 2 nd line NRT Prescribing (see also page 3) Select formulary choice, form and strength Can be used in patients aged over 12 years Prescribe sufficient for 1 month of therapy Add instruction Dispense either weekly or fortnightly to avoid potential waste NRT dose is determined by previous level of smoking related nicotine See SPC* for contraindications, cautions, interactions, adverse effects Varenicline Prescribing Week 1: Prescribe Treatment Initiation Pack (contains 2 weeks supply) - Set target stop date within the first two weeks of treatment, preferably in the second week. Week 3: Prescribe Varenicline 1mg twice daily 28 Tabs (2 weeks supply) Thereafter varenicline should be prescribed as 4 week prescriptions with annotation Dispense Fortnightly. Normal Dose - 0.5mg daily on days 1-3, 0.5mg twice daily on days 4-7, 1mg twice daily for 11 weeks (Review SPC* for exceptions) Patients should be advised to discontinue treatment and seek prompt medical advice if they develop agitation, depressed mood, paranoid or suicidal thoughts. Monitor closely those with a history of psychiatric illness. Varenicline is a black triangle drug therefore all adverse drug reactions should be reported to the MHRA, not just serious events. Varenicline should not be used in patients under 18 years old or in those that are pregnant or breastfeeding. See SPC* for full list of contraindications, cautions, interactions and adverse drug reactions. Pharmacists should also refer to the CPSSS varenicline PGD No Ongoing assessment/review of quit Has patient stopped smoking? Yes Re-assess motivation to quit. NRT - Lapse (puff or less than 5 cigarettes) continue with treatment and reinforce need to remain smoke free when using NRT - Re-lapse - return to regular smoking - discontinue immediately. Varenicline if smoking after week 4 discontinue therapy NRT 1 st line Normal course length is weeks If longer course anticipated refer to specialist service Review progress and side effects Prescribe next supply Varenicline 2 nd line Normal course length is 12 weeks Scottish Medicines Consortium do not recommend a further 12 week course Not managed to quit - reassess at subsequent visits. NB Often clients will take numerous quit attempts before being successful. Perseverance is needed NHS Fife does not support cutting down to quit. Advise the patient that if they relapsed, and are thinking about a further quit attempt, make another appointment or self refer to stop smoking services Patients who have had numerous quit attempts over the previous 12 months; reassess & refer to specialist service No Action Where possible support should continue until the end of the course Remember the use of CO monitor at each meeting Review & record Managed to stay stopped? Yes At subsequent opportunities ask about smoking status At subsequent opportunities ask about smoking status * Summary of Product Characteristics General Prescribing Notes Physiological changes resulting from stopping smoking, with or without treatment, may alter the metabolism of some medicines, for which dosage adjustment may be necessary the most important examples are theophylline, olanzapine, clozapine and warfarin. In such cases GPs to be informed that patient is undergoing a quit attempt. When NRT and varenicline have been tried and failed or are unsuitable, bupropion can be considered. Bupropion can also be considered in patients that have previously undergone a successful quit attempt with bupropion. See SPC* for full prescribing details for bupropion. Page 10 of 13

11 NICOTINE REPLACEMENT THERAPY FORMULARY CHOICES o The nicotine patch should be considered the 1 st line choice in clients with a stable smoking pattern. o Patch formulation is suitable for clients who prefer a continuous dose of nicotine throughout the day. Other formulations may be suitable for individuals who prefer to self dose when urge to smoke occurs or when the patch is unavailable. o Clients/patients with a high level of nicotine dependence or those who have failed with NRT previously may benefit from using a combination of a patch & an immediate release NRT formulation. o Combination therapy should be reviewed at least every 4 weeks post-quit date to see if both products are still required. Combination therapy should not be continued long-term. If a second product is required the maximum recommended dose should be reduced. o The use of immediate release NRT, as monotherapy, in patients with high nicotine dependence (>20 cigs. /day) can be relatively expensive. o For pregnant women who wish to stop smoking; - Referral to Quit 4 Life is recommended. - Ideally, pregnant women should stop smoking without using NRT but if this is not possible, NRT may be recommended to assist a quit attempt as it is considered that the risk to the fetus of continued smoking by the mother outweighs any potential adverse effects of NRT. - The decision to use NRT should be made following a risk-benefit assessment in consultation with the pregnant woman as early in pregnancy as possible. The aim should be to discontinue NRT use after 2-3 months. - Intermittent forms of NRT are preferable during pregnancy although a patch may be appropriate if nausea and/or vomiting are a problem. o o - If patches are used would recommend a 16 hour patch only and should be removed at night. NRT can be used by women who are breastfeeding. - Referral to Quit 4 Life is recommended. - The amount of nicotine the infant is exposed to from breast milk is relatively small and less hazardous than the secondhand smoke they would otherwise be exposed to if the mother continued to smoke. - NRT products taken intermittently are preferred as their use can be adjusted to allow the maximum time between their administration and feeding of the baby, to minimize the amount of nicotine in the milk. If possible, patches should be avoided. For details on doses, adverse effects, cautions and contra-indications of individual products refer to the Summary of Product Characteristics.( 1 st Line Nicotine patch Discreet and easy to use. Available in different strengths, lasting 16 or 24 hours. 16 hour patch useful for those who suffered sleep disturbance during a previous quit attempt with 24 hour patches Supplies nicotine continuously throughout the day (helps relieve withdrawal symptoms and physical cravings). Rotate the patch site to avoid itching, redness or skin dryness under the patch. 2 nd Line Nicotine gum Available in different strengths and flavours. Nicotine is absorbed through the lining of the mouth therefore discourage constant chewing by chew/park/chew technique for around 30 minutes. Can taste slightly peppery at first. Can irritate the mouth and throat, increase salivation and aggravate stomach ulcers. Gum is not recommended in denture wearers. Nicotine lozenge (including minis) Discreet, flexible and offers good dose control. An effective alternative to gum and available in several strengths and flavours; mint flavour may be more palatable. One lozenge is used every 1-2 hours for the first few weeks reducing the number gradually each day and over the next few weeks until they are not required. Do not chew/swallow. Use suck/park/suck technique. Nicotine inhalator The inhalator is helpful if the smoker misses the ritual of smoking. Nicotine is taken into the mouth and the back of the throat by a short suck on the inhalator when craving a cigarette. Patients with obstructive lung disease may find use of the inhalator difficult. Nicotine oral spray It is discreet, works quickly, & offers good dose control The spray dispenser may require priming before use. Avoid spraying on the lips. Do not inhale while spraying. Do not swallow for a few seconds after spraying. May experience a strong taste sensation after spraying. Page 11 of 13

12 NRT Products Patient Information Pros & Cons NRT GUM Pros It s easy to control the amount that suits you. Chewing can keep your mind off the cigarettes. It can stop you overeating. Cons You may find the taste unpleasant. Early side effects can include hiccups and indigestion. A proper chewing technique is needed. It is tricky to use with dentures. You need to chew enough or it won t work. NRT PATCHES Pros They deliver the correct amount of nicotine automatically. They are very easy to use. The 24 hour version may help with early morning cravings. Cons Some people may experience a skin reaction. 24 hour patches can cause vivid dreams and disturbed sleep. They won t help imitate the mouth action associated with smoking. NRT NASAL SPRAY Pros Very effective relief from cravings. Fast acting. Easy to alter doseage. Cons May cause nasal irritation at first. May cause embarrassment in public. More likely to cause dependency. Ref: Smoking Cessation Treatment Guide NHS Fife 2008 Page 12 of 13

13 NRT INHALATOR Pros Cons Helps to occupy the hands. Copies the hand to mouth action associated with smoking. May help to prevent overeating. Convenient to carry. Allows the user to regulate their own dose. Not as effective for heavy smokers. May be embarrassing to use in public. Imitating the smoking action may increase cravings. NRT MICROTABS Pros Convenient and discreet to use. Easy to control. Something to occupy your mouth. Cons Side effects may be heartburn, mouth irritation, hiccups, nausea, dizziness, headache and a sensation of a lump in the throat. These may be off-putting. Need to take enough of the product for it to work. Needs to be taken regularly. NRT LOZENGES Pros Cons Can be used discreetly. Easy to use. Sugar free May cause throat irritation or indigestion. Ref: Smoking Cessation The Treatment Guide NHS Fife 2008 Page 13 of 13

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