Brighton and Hove NHS Stop Smoking Service Course

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Brighton and Hove NHS Stop Smoking Service

• Course Facilitator
• Anna Fairhurst

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Brighton and Hove NHSStop Smoking Service

• Nicotine Addiction
• - a chronic relapsing condition
• - Quit at 4 week follow up
• - benchmark for DOH monitoring data collection
• - Quitting is not easy and it can take some
  smokers several attempts to get off cigarettes
  for good
• Evidence Base
• - smokers who quit with NHS support are up to
  four times more likely to succeed

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• - 9.8 million smokers in England
• - 24 smoking prevalence recorded by latest
  general household survey 2005 (Office for
  National Statistics)
• Brighton and Hove NHS Stop Smoking Service
• - specialist team commissioned within SDH
• - 80 intermediate team within GP surgeries
• - 50 intermediate team within pharmacies

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Monitoring/Evaluation for DOH and PCT Requirements

• 2003 - 2004 - 1399 set a quit date
• 903 quit at 4 week follow up
• 2004 2005 - 2634 set a quit date
• 1577 quit at 4 week follow up
• 2005 2006 - 2788 set a quit date
• 1729 quit at 4 week follow up
• 2006 2007 - 2875 set a quit date
• 2014 quit at 4 week follow up
• 2007 2008 - 3531 set a quit date
• 2087 quit at 4 week follow up
• 2008 2009 - 3340 set a quit date
• 2017 quit at 4 week follow up

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The Components of a cigarette

• The components of cigarette smoke
• Nicotine
• Carbon Monoxide
• Tar
• Other chemicals and additives

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Nicotine Addiction

• Addiction
• An addiction is a behaviour over which an
  individual has lost control
• Addiction is the product of the
• person
• drug
• situation
• Reproduced with permission from Professor Robert
  West, St Georges Hospital Medical School

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Nicotine Addiction

• The Key Signs of Addiction
• continued use despite knowledge of harmful
  effects
• craving during abstinence
• failure of attempts to stop
• withdrawal symptoms during abstinence
• compulsive use

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Nicotine Addiction

• How to Assess Nicotine Addiction
• time of first cigarette
• smoking even when ill
• smoking more in the morning
• difficulty not smoking in non-smoking areas
• which cigarette would be hardest to give up
• number of cigarettes smoked

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Nicotine Addiction

• Stimulant Effects of Nicotine
• increases the activity in the sympathetic nervous
  system
• - increasing heart rate
• - stimulating adrenaline release
• - decreasing circulation in the
  extremities
• - increasing tremor
• - altering glucose regulation
  
• Reproduced with permission from Professor Robert
  West, St Georges Hospital Medical School

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Withdrawal Symptoms and the Withdrawal Oriented
Approach

• Withdrawal oriented therapy sees withdrawal
  discomfort as the major remediable obstacle to
  quitting in dependent smokers.
• evidence based model
• extensive data on efficacy
• extensive experience to draw on
• Reproduced with the permission of Professor Peter
  Hajek, St Barhtolomews and the Royal London
  School of Medicine

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Withdrawal Symptoms and the Withdrawal Oriented
Approach

• The focus is on helping clients remain abstinent
  over the initial acute withdrawal period.
• It uses a combination of group or individual
  support (to boost motivation) and medication (to
  alleviate withdrawal discomfort).
• The course consists of seven weekly sessions.
  Total abstinence is required from week two.
• Reproduced with the permission of Professor Peter
  Hajek, St Bartholomews and the Royal London
  School of Medicine

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Withdrawal Symptoms and the Withdrawal Oriented
Approach

• Symptom Duration Prevalence
• Irritability lt4 weeks 50
• Depression lt4 weeks 60
• Poor concentration lt2 weeks 60
• Restlessness lt4 weeks 60
• Increased appetite gt10 weeks 70
• Night time awakenings lt1 week 25
• Urges to smoke gt2 weeks 70
• Light-headedness lt48 hours 10

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Withdrawal Symptoms and the Withdrawal
Orientated ApproachFactors associated with
level of withdrawal discomfort - possibly
worse in smokers with higher nicotine intake


when smoking- possibly worse in smokers who
have had previous bad experience of withdrawal -
probably reduced by exercise- probably made
worse by stress and boredom - probably reduced
if smoker taken out of normal environment-
probably reduced by eating sugary
foodsReproduced with the permission of
Professor Robert West, St Georges Hospital
Medical School
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The Shropshire Model

• Delivered on a one to one basis
• First appointment is for 30 minutes and includes
  an assessment of the patients motivation to
  quit, previous experience of quitting,
  suitability for NRT, Zyban or Champix
• A quit date is set and a plan of quitting agreed
  that is appropriate to the individuals
  circumstances

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Follow up appointment within one week of their
quit date and at regular intervals during their
first three months as a non-smoker. Follow up
appointments normally last for 10 minutes and are
typically held at 1,2,3,4,6,8 and 12 weeks, then
6 and 12 months post cessation. If a patient
attends all appointments a total of two hours
nurse time will have been spent over one year.
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Nicotine Replacement Therapy

• How NRT Works
• based on nicotine weaning
• increases chance of stopping by 1.6-2.3 fold
• smokers try different formulations
• different formulations have similar efficacy
• 1. Silagy et al, The Cochrane Library 1999

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Nicotine Replacement Therapy

• How does NRT work?
• Reduces severity of withdrawal symptoms
• Reduces desire to smoke (craving)
• Delays weight gain
• Reduces relapse back to smoking
• Provides a coping behaviour
• Gives ex-smoker a breathing space - two stage
  approach behaviour then drug
• Reproduced with permission from Professor
  Peter Hajek

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Nicotine Replacement Therapy

• NRT Products
• Chewing gum
• Patches
• Nasal spray
• Inhalator
• Sublingual tablet
• Lozenge

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Chewing Gum

• 2mg and 4mg
• Takes 30 minutes to reach plateau
• Enters bloodstream via buccal mucosa
• Chew each piece slowly for 30 minutes
• Recommend 10-15 pieces per day, hourly

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Transdermal Patch

• 16 and 24 hour patches
• 3 different strength patches
• Nicorette 5, 10, 15mg
• Nicotinell 7, 14 21mg
• Niquitin CQ 7, 14, 21mg
• Takes 3 hours to reach plateau
• 8 weeks of patch has been shown to be as
  effective as longer courses of treatment (1) (2)
• 1. Silagy et al. The Cochrane library 1999. 2.
  Tonneson et al, Eur Resp Journal 1999

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Nasal Spray

• Take 10 minutes to reach plateau
• Recommend one spray in each nostril hourly up to
  16 times per day
• Absorbed through nasal mucosa
• Can initially be unpleasant and
• necessitates close initial supervision

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Inhalator

• Takes 20 minutes to reach plateau
• Buccal membrane absorption
• 10 puffs 1 puff of a cigarette (approx)
• Recommend frequent and intensive use

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Microtab - Sublingual Tablet

• Takes 20-30 minutes to reach plateau
• Tablets held under tongue until they dissolve
• Recommend 15-30 tablets per day
• May be more user friendly than other products

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Lozenge

• Takes 20-30 minutes to reach plateau
• Lozenges are sucked and parked in cheek
• Recommend 8-12 lozenges a day

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Nicotine Replacement Therapy

• How does NRT vary?
• Speed of nicotine absorption
• Ease of use
• Frequency of use
• Type of side effects
• Amount of behavioural replacement
• Potential to titrate dose as required

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Nicotine Replacement Therapy

• NRT Summary
• NRT is safe in therapeutic doses, twice as
  effective as placebo
• Most smokers have little difficulty stopping,
  under-use is more of a problem
• Smokers should be encouraged to use it unless
  medically contraindicated (protocol)

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Nicotine Replacement Therapy

• How can we improve success with NRT?
• Motivation is essential
• Provide clear rationale and instructions on how
  to use
• Be aware of
• Unrealistic expectations
• Under dosing
• Irregular use
• Stopping too early

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• Bupropion HCI SR
• Zyban

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History of Bupropion HC1 in smoking cessation

• Bupropion HCI available in US since 1989
• Anecdotal reports of spontaneous smoking
  cessation in depressed patients taking Bupropion
  HCI
• First licensed pharmacological treatment for
  smoking cessation not to contain nicotine

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Bupropion HCI SR

• Treatment Regimen
• Licensed for use in the UK in 2000
• Selective inhibitor of neuronal re-uptake of
  noradrenaline and dopamine (not serotonin)
• Adjunct to smoking cessation in combination with
  motivational support
• Start treatment 1-2 weeks before target stop date
• - 150mg (one tablet) daily for 6 days, then 150mg
  twice daily for period of treatment 7-8 weeks
• Minimum 8 hours between doses - Quit date day 10
• Discontinue if abstinence not achieved at 7 weeks
• Not a magic cure

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The Use of Bupropion HCI SR

• Predisposing risk factors where the lower dose of
  150mg daily should be considered for patients
  throughout the treatment period if the benefit of
  smoking cessation outweighs the potential risk of
  seizures.
• Concomitant administration of any drug known to
  lower the seizure threshold (e.g. antipsychotic,
  antidepressants, antimalarials, theophylline,
  systemic steroids, tramadol, quinolones and
  sedating antihistamines)
• Alcohol abuse
• History of head trauma
• Diabetes treated with hypoglycaemics or insulin
• Use of stimulants or anorectic products

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The Use of Bupropion HCI SR Contraindications

• Hypersensitivity to Bupropion or any of the
  excipients
• Current seizure disorder or any history of
  seizures
• Current or previous diagnosis of bulimia or
  anorexia nervosa
• Known central nervous system tumour
• Experiencing abrupt withdrawal from alcohol or
  benzodiazapines
• Severe hepatic cirrhosis
• Use of MAOIs
• History of bipolar disorder
• Not recommended in pregnancy

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The Use of Bupropion HCI SR

• Contraindications
• Zyban must not be prescribed in patients with
  other risk factors for seizures unless there is
  compelling clinical justification for which the
  potential benefit of smoking cessation outweighs
  the increased risk of seizure. In such patients a
  lower dose of 150mg daily through the entire
  treatment period should be considered.
• Committee on Safety of Medicines. 30 May 2001

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The Use of Bupropion HCI SR

• Summary
• Zyban is effective - but not a magic cure without
  motivational/behavioural support
• There are contraindications and side effects
  which need to be communicated to the patient
• Its effect without motivational/behavioural
  support is not known

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Tolerability Common(gt1/100)
Includes insomnia, dry mouth, headache, rashes,
tremor, dizziness, agitation and anxiety.Some
of these effects may also be associated with
nicotine withdrawalUncommon(gt1/1000,
lt1/100)Includes chest pain, feeling of
weakness, tachycardia, confusion, increased blood
pressure and flushingRare (gt1/100000, lt1/1000)
Includes vasodilation, postural hypotension,
severe hypersensitivity reactions and seizures
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Varenicline - Champix

• Selective nicotine acetylcholine receptor
  partial agonist
• Relieves cravings and withdrawal from nicotine,
  simultaneously blocking the reinforcing effects
  of nicotine

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Varenicline - Champix

• How does Varenicline work
• Nicotine from a cigarette stimulates the release
  of dopamine - a substance produced by the body
  which triggers feelings of pleasure
• When a smoker quits, the lack of nicotine leads
  to reduced levels of dopamine, causing feelings
  of craving and withdrawal
• Varenicline both blocks the nicotine receptors
  (reducing the addictive power of the drug) and
  triggers moderate dopamine release to alleviate
  withdrawal symptoms

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Explaining Champix to Patients

• It is not a magic cure
• Can make quitting easier
• May cause nausea which most users tolerate well
• Start with - one 0.5mg tablet daily for 3 days
• two daily for the rest of the week
• then two 1mg tablet daily from day 8
• Quit date day 10
• If nauseous it may help to take tablets with food
• Not recommended in the following groups
• - smokers with severe renal malfunction
• - smokers under the age of 18
• - pregnant or breastfeeding women

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Smoking Cessation is one of the most cost
effective healthcare interventions
Inflated to represent a common base year (1996)
1. Parrott et al, Thorax 2. Briggs et al, Health
Technol Assess 1999 3. Fenn et al, Br J Clin
Pract 1991. 4. van Ineveld et al, Eur J Cancer
1993. 5. Pharoah et al, Br Med J 1996
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Timetable and payment scheme for LES
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Intermediate Smoking Cessation Services
Monitoring GOLD MONITORING FORM VERSION 9 -
2008
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Monitoring Form (Continued - 2)
NB Additional motivational support is assumed
for all pharmacological categories
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Monitoring Form (Continued- 3)
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Brighton Hove NHS Stop Smoking Service

• Anna Fairhurst Stop Smoking Service Royal
  Sussex County Hospital
• Eastern Road
• Brighton
• BN2 5BE
• Telephone 696955 Ext. 7445
• Fax [phone]
• Mobile [phone]