Desktop Helper No. 4 - Helping patients quit tobacco - 3rd edition - online version

Ask ALL patients about tobacco use (smoking or smokeless tobacco) at every clinical contact. Document tobacco/smoking* status because this makes it easier for colleagues in your health system to ask the question next time, especially if you have a shared record with patients and colleagues.
IT DOES NOT NEED ANY ASSESSMENT OF READINESS TO QUIT

“Have you used tobacco at all in the last year?” OR
“I can see from your records that you have used tobacco recently. Is that still the case?”

You will now need to ACT. The best way to stop tobacco is with the combination of behavioural support from a trained clinician and the use of a first line quit tobacco medication. At the optimal end of the scale, IPCRG member countries have many modalities of nicotine replacement therapy and a number of anti-nicotine receptor medicines that are available free for patients as part of a national health system. These countries will also have a trained stop tobacco workforce that can provide 20-30 minute appointments for the behavioural support element of the intervention. We have also worked with countries where stop tobacco medicines are not available at all or only available to purchase privately and where there is no programme of stop tobacco specialists. We illustrate these scenarios below. Refer to the most appropriate.

Would you like to talk about the options available to help with your tobacco use today?

• Consider exhaled carbon monoxide (CO) testing prior to referral and advise that this is one measure for you both to monitor success.
• Ensure that the service you refer to offers both behavioural and pharmacotherapy interventions and that staff are trained and updated.
• Assure the patient that you will prescribe appropriate medicines if requested by the service for as long as is required. Reassure about the value and safety of these medicines.
• Hand out written material/contact numbers to show your support.
• Make sure your referral happens: have a system to check: Ask for feedback from the service.
• Consider offering initial prescription of NRT patches.

The evidence-based VBA, Ask-Advise-Act, is intended to be used by all healthcare practitioners and works best when there is a nationally-funded stop tobacco service that includes free pharmacotherapy. Identified people who wish to quit or reduce harm are best managed in evidence-based services where practitioners are formatively trained and regularly updated. However, globally such an offer is not always available and individuals and organisations will need to agree a treatment plan for people who receive VBA and declare a desire to quit in the absence of a comprehensive national service. We explain why we advocate 3As not 5As in our position paper.1 However, this does not preclude the family practitioner with a long-term relationship with the tobacco user and family from supporting the individual with other behaviour change techniques to help treat their dependency. VBA is intended to serve as the minimal treatment that should be delivered to all patients. More involved quit tobacco interventions which support behaviour change techniques are intended to be delivered by the specialist tobacco cessation service or, when not available, by GPs who have been trained in evidence-based tobacco treatment and can work with the person long-term as part of their long-term condition management. Tobacco dependency is a long-term relapsing remitting condition and therefore needs an intervention from a clinician. Motivational Interviewing (MI) is effective in treating people with tobacco dependence. You may have had training in the principles of MI as part of primary care training. These principles can be effectively and easily applied by a range of clinicians in the treatment of tobacco dependence. A Cochrane systematic review with moderate quality evidence3 supports - particularly the GP - in delivering this intervention. It can be done, and is preferable to be done, in less than 20 minutes. This is therefore likely to be a significant treatment option in those countries where pharmacotherapy and stop tobacco specialists are not available.

Dialogues: Select from these and adapt to your own style and rapport with the patient. More listening than talking!

Green dialogue

“That’s great to hear. Why is it a 9 for confidence not a 7?”

LISTEN to reply as way to hear patient beliefs; which often include stopping without help. “It sounds like you really want to try stopping tobacco (again). May I talk you through the options that are available for us to help you (building on what worked for you last time)?”.

Amber dialogue

“Can you tell me why is it a 6 and not a 4?”

LISTEN to reply; and celebrate previous quitting success, which is what is often the reason given, although perceived by the patient as failure because they have then relapsed.

Reflect back “It sounds like this has been really hard for you in the past but even so you succeeded for xx time. What would need to happen to move this up to an 7?”

Listen to reply then ask permission “May I talk you through some of the options we now have available that we know work for patients like you, where tobacco is a big part of their lives, so that you can see whether you think any of them might be of interest to you?”

Red dialogue

“It sounds like tobacco is a really important part of your life. That makes me want to know why you’ve scored it as a 3 and not a 1?”

LISTEN to reply and name and affirm all positives.

Reflect back “It sounds like this has been really hard for you in the past and you still feel it’s not the right time for you to stop tobacco. We know that nicotine is more addictive than heroin….; even so you succeeded before for xx time.” “What would need to happen to move this up to a 4 or 5?”

Listen to reply then ask permission “I am hearing this does not feel the right time for you to stop tobacco and I completely respect this. However, we also saw that your CO level was very high, x, and we know this is making your condition [eg breathlessness/COPD/asthma] worse. If it would be helpful, I am happy to talk with you about what we could offer in the future, that we know works for patients like you, where tobacco has been and continues to be a major part of their lives, so you at least you know that we do have treatments that work.”

The themes used in MI conversations are more listening than talking, using open-ended questions, specifically naming and affirming previous success, communicating hope especially for a long-term condition so strongly associated with shame, reflecting back and summarising. A few other things that work include:

• Name and clarify that the team is not judgemental about tobacco “We know how hard this is and that this is an addiction and that nicotine is more addictive than heroin…”
• Open-ended questions eg “Tell me about when you tried to stop tobacco before?”
• Exhaled CO testing is a very powerful motivator because the numerical reading improves quickly after cessation and is an objective measure4
• Encourage the person to imagine and communicate what they think might be the benefits of quitting; reflect back and summarise and tailor your offer to their reply.
• You will know the patient’s comorbidities so consider how treating their tobacco use can improve the other disease outcomes that they want eg “Did you know you …will get fewer asthma attacks? ... your wounds will heal better after surgery?” Keep it positive.
• However, most patients who use tobacco know this – listen for the people who matter to them eg being around for grandchildren growing up.
• Explore and then reflect on ambivalent feelings: “What are the things you like and don’t like about your tobacco use?” “On the one hand you say that …and on the other….”
• You may use these scales more than once in the consultation, or in subsequent conversations and if the scores increase, this will improve motivation.

If you are in the situation of options 2 or 3, where you will provide the counselling and medication advice then are some key actions you will want to take:

• Provide assistance in developing a quit plan – how often will you see them; how long will the session be, and what is the duration of the treatment. A 12 week intensive treatment is recommended if varenicline is prescribed, but ongoing support may be needed for much longer.
• Agree with the patient how you will review them to prevent relapse and provide support over subsequent months and years.
• Could you use email, text or phone for some of these sessions?
• Help them to set a quit date – make it realistic: a date chosen by the patient that you can then support.
• Know what pharmacotherapy is available OTC, free and private. Your best options are varenicline and combination NRT. Ensure doses are adequate.
• People quitting tobacco are often under-dosed on nicotine. Treat dosing, use and technique as seriously as you would for blood pressure or diabetes mellitus control.

Include the following as needed:

• Discuss abstinence and suggest coping strategies
• Encourage social support
• Assist in dealing with barriers such as fear of failure, stress coping, weight gain, social pressure
• Give nutritional advice: sleep well, avoid caffeine and alcohol
• Physical activity may help
• Withdrawal symptoms occur mostly during the first 2 weeks and are less troublesome after 4-7 weeks

We give the best available evidence; we appreciate this is not the situation everywhere but we urge reconsideration of national formulary for these life-saving interventions.

Medication is recommended for all patients who use the tobacco equivalent of 10 or more cigarettes. There may be cases where short-acting NRT is used for patients who use less. They are likely to suffer from withdrawal symptoms and should be offered pharmacological support once they set a quit date.

Nicotine Replacement Therapy (NRT)

Its main effect is to reduce withdrawal symptoms and help the patient through the first 10-12 weeks of quitting. The most effective way to use NRT is to use a combination of two products at once, a long-acting patch and a fast-acting form such as gum, nasal spray or lozenge. (7)

Most patients use too low a dose for too short a time. They should use a dose that takes away withdrawal symptoms and helps manage craving. Most people need a full dose for 2-3 months, and then they can gradually reduce the use over some months. Sometimes longer courses are needed to prevent relapse.

Skin patch

Dosage: The WHO Model List of Essential Medicines (EML) (last updated 2017) includes 5 mg to 30 mg/16 hrs; 7 mg to 21 mg/24 hrs. A 2019 Cochrane systematic review (7) suggests higher dose
patches (containing 25mg/16 hours or 21mg/24 hrs) make it more likely that a person will quit tobacco than lower dose nicotine patches (15mg/16 hours or 14mg/24 hours).

Possible side effects: skin rash, allergy, insomnia, vivid dreams.

Oral forms such as gum, inhalators, nasal and mouth spray, lozenges, sublingual tablets:

To be administered according to the specific product instructions for relief of symptoms while awake. (8)

Gum 

The EML includes 2 mg and 4 mg.

Dosage: According to the new Cochrane review people were also more likely to successfully quit if they used higher dose nicotine gum containing 4mg of nicotine in comparison to lower dose nicotine gum containing 2mg of nicotine. (7) Since nicotine is absorbed through the mucosa in the mouth it is important to instruct the patient in the use of gum carefully. Chew a few times on the gum then “park” it in the mouth.

Possible side effects: sore dry mouth, dyspepsia, nausea, headache, jaw ache.Often dose dependent.

Contraindication: Use in children and teenagers under 18 years is unlicensed in many countries.

Inhalator

Advise patient to swirl around the oral mucosa.

NRT and Pregnancy

NRT is safer than tobacco; clinicians should offer this option to all pregnant women who cannot quit unaided. The shorter-acting forms are preferred. NICE and other groups recommend 16 hour patch + oral NRT for pregnant tobacco users. Remove patch at night. (9)

NRT and breastfeeding: Advise use of nicotine gum, lozenges, or nasal spray immediately after a breastfeed so that blood levels of nicotine have time to fall before the next feed. (1)

Varenicline

Varenicline is a nicotinic receptor partial agonist. In addition to blocking the receptor it also stimulates it, thus reducing withdrawal symptoms. In clinical trials varenicline has increased quit rates two to three fold over placebo.

Dosage: Start one week before quit date: 0.5 mg for 3 days, 0.5 mg b.i.d for 4 days, then 1mg b.i.d from quit date for 12 weeks.

Possible side effects: nausea (mild in 30%; severe in 3%) and headache (10-15%), insomnia (10-13%); abnormal/vivid dreams. Compared to other tobacco cessation medications, no increased risk of neuropsychiatric events (10) and no significant increase in CVD risk. Drink with full glass of water and meal to reduce nausea. (4) Advise caution when driving and operating machinery.

Contraindication: Pregnancy. (8)

Bupropion
Bupropion was originally developed as an antidepressant. It reduces the urge to use tobacco as well as symptoms from nicotine withdrawal.

Dosage: 150mg (1 tablet) a day for the first 6 days, then on day 7 – 150mg (1 tablet) b.i.d (at least 8 hours apart). Then regularly 150 mg b.i.d for 7-12 weeks. Possible side effects: Seizure (1%), insomnia, headache, dry mouth, dizziness, anxiety, taste disturbance.

Contraindications: NRT, history of seizures, pregnancy, eating disorders, under 18, hypersensitivity reaction to the active ingredient. In hepatic impairment lower/adapt the dosage. Be aware of
interactions with common drugs like theophylline, clopidogrel, carbamazepine, several antidepressants and antipsychotics, especially those taking monoamine oxidase inhibitors. There is no increased risk of neuropsychiatric events compared to placebo or other tobacco cessation medication.  (10) Advise caution when driving and operating machinery.
 

1. van Schayck CP et al. Treating tobacco dependence: guidance for primary care on life-saving interventions. Position statement of the IPCRG NPJ Prim Care Respir Med 2017;9;27(1):38 http://rdcu.be/tlgE
2. Stead LF, et al. Combined pharmacotherapy and behavioural interventions for smoking cessation. Cochrane Database of Systematic Reviews 2016, Issue 3. Art. No.: CD008286.
3. Lindson-Hawley N, Thompson TP, Begh R. Motivational interviewing for smoking cessation. Cochrane Database of Systematic Reviews 2015, Issue 3. Art. No.: CD006936.
4. Helping Smokers Quit 2014. http://www.londonsenate.nhs.uk/helping-smokers-quit/ (no longer live)
5. https://smokefree.gov/
6. Taylor G et al. Change in mental health after smoking cessation: systematic review and meta-analysis. BMJ 2014;348:g1151.
7. Lindson N et al. Different doses, durations and modes of delivery of nicotine replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews 2019; Issue 4; Art. No.: CD013308
8. https://cks.nice.org.uk/smoking-cessation#!prescribingInfoSub
9. https://www.nhs.uk/conditions/pregnancy-and-baby/smoking-pregnant/
10.  Anthenelli RM et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled clinical trial. Lancet 2016;387(10037):2507–2520
11. West R et al. Placebo-controlled trial of cytisine for smoking cessation. N Engl J Med 2011;365:1193-200.
12. Hughes JR et al. Nortriptyline for smoking cessation: a review. Nicotine Tob Res 2005;7:491-9.
13. Hajek P et al. A Randomized Trial of E-Cigarettes versus Nicotine-Replacement Therapy. N Engl J Med 2019;380:629-637
14. O’Connor RJ. Non-cigarette tobacco products: what have we learnt and where are we headed? Tob Control 2012;21(2):181–190.