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CDHB

Nicotine Dependent Patients

ABC(+D) Strategy for Smoking Cessation - all health professionals to implement

A: Ask all patients for their smoking status.
B: provide Brief advice to quit and offer support.
C: consider nicotine replacement therapy (NRT) and refer to Cessation support.
D: Document smoking status and intervention.

Current Smokers

Inpatients identified as current smokers should be offered appropriate Nicotine Replacement Therapy (NRT), whether or not they wish to quit long term. This should enable them to be more comfortably smokefree during the in-patient stay or at least reduce their smoking. This may be crucial, especially for those admitted with cardio-respiratory illness and/or needing oxygen treatment.

• Inform all patients of the CDHB Smokefree Policy and offer NRT.
• Provide advice to quit - be supportive and non-judgmental.
• 24% of people who smoke will attempt to quit after receiving brief advice from a health professional - this increases to 35% when an offer of support (referral) is made.
• 1/40 people who smoke will successfully quit on brief advice from a doctor.
• 80% of smokers want to quit and nearly 50% of smokers try to quit each year.
• NRT doubles the chances of success (NNT = 23). Other cessation medications are equally effective.

Nicotine Replacement Therapy Products and Dosage

NRT will reduce nicotine withdrawal symptoms but the pharmacokinetic properties of the respective preparations must be considered; peak blood levels are achieved within seconds when smoking cigarettes, but not for several hours when a nicotine patch is administered. NRT gum and lozenges have faster onset of action and achieve high levels of nicotine concentration at around 15-30 minutes. The nicotine inhalator and the QuickMist mouth spray deliver nicotine to the oral mucosa - not the lung!

• Patches (21 mg, 14 mg and 7 mg), lozenges (2 mg and 1 mg), and gum (4 mg and 2 mg) are available for hospital inpatients and subsidized in the community.
• Inhalator (15 mg) is available for mental health service users but is not subsidized in the community.
• Many people who smoke will require a combination of products (e.g., patch and gum, or patch and lozenges). Combination treatments are safe and more effective than single products.
• Strength of addiction is assessed by number of cigarettes smoked per day and time from waking to first cigarette.
• NRT should be used for at least 8-12 weeks, although many smokers may require longer treatment courses. Underdosing is often the cause of NRT failure. Dosage depends on individual level of addiction.

NRT Dosage Guidelines

Other pharmacological management options

• Varenicline/Champix® (NNT=10) - fully subsidized under Special Authority
• Bupropion/Zyban® (NNT=18) - fully subsidized
• Nortriptyline (NNT=18) - fully subsidized

Practitioners should refer to the product information for contraindications, precautions, and potential drug interactions. Further advice on these can be obtained from the clinical ward pharmacists or Drug Information 80900.

Monitoring

• Each patient should be assessed once per duty for their urge to smoke.
• If patients on NRT develop nicotine withdrawal symptoms, their dose is likely to be insufficient.
• Nicotine withdrawal symptoms include depressed mood, irritability or anger, insomnia, increased appetite, anxiety, decreased heart rate, difficulty concentrating, and restlessness.

Notes regarding NRT dosage

• Cigarette consumption on its own is not a good measure of dependence as people who have recently cut down are likely to compensate by smoking the fewer cigarettes more intensively.
• Patients 12 years of age and older who smoke ≥10 cigarettes or more per day can use NRT as per table above. Young patients smoking <10 cigarettes per day should be offered gum (2 mg) or lozenges (1 mg) in the first instance with monitoring of their urge to smoke on a daily basis. If their craving is not controlled by these products, they can be offered higher dose products or patches.
• NRT does not contain the toxic substances found in cigarette smoke, such as carbon monoxide, cyanide, ammonia, vinyl chloride, and tar. It does not produce dramatic surges in blood nicotine levels, and does not produce strong dependence.
• Contraindications: same as for smoking, i.e., acute myocardial infarction, unstable angina pectoris, severe arrhythmias, recent CVA, Buerger's disease. However, these are relative contraindications; if the options are NRT or smoking, NRT is preferable.
• Symptoms of NRT overdose include abdominal pain, nausea and vomiting, diarrhoea, dizziness, tachycardia, headache, hypotension, and confusion. Symptoms of NRT underdose are the same as for nicotine withdrawal.

  Note: Aromatic hydrocarbons in cigarette smoke induce hepatic drug metabolizing enzymes, notably CYP1A2. Smoking cessation may result in elevated concentrations of drugs that are metabolized by this pathway such as theophylline, caffeine, and clozapine.

• Pregnant or breastfeeding: Whether the mother smokes or uses NRT, nicotine passes through the placenta to the fetus, and via breast milk to the baby. However NRT is preferable for the reasons explained above. Provide PRN products (lozenges or gum) to pregnant women.

Discharge - Electronic Discharge Summary (EDS)

Complete all smokefree fields in the EDS. If no evidence of provision of an intervention is found, deliver an intervention by providing a Quitpack/ Quitcard.

Refer to a cessation programme:

• PEGS smoking cessation programme - available through most GPs (minimal costs).
• Aukati Kaipaipa 'by Maori, for Maori and their whanau' (free programme) - phone 0800 425 700.
• Smokechange for pregnant women and their partners - phone 03 379 9947.
• QUITLINE - provides a range of telephone and online cessation services - phone 0800 778 778.
• Pacific Trust Canterbury - for Pacific patients and families - phone 03 366 3900.

Quitcards enable access to subsidized NRT at a community pharmacy for $5 per product (two months' supply). Parkside Pharmacy in the hospital provides NRT free to the patient. NRT products can also be provided to patients using a standard prescription.

Topic Code: 3371