Fiore et al, U.S. Dept of Health and Human Services, June 2000

1. “Difficult to identify any other condition that presents such a mix of lethality, prevalence, and neglect, despite effective and readily available interventions” Fiore et al, U.S. Dept of Health and Human Services, June 2000

2. “Smoking kills. If you're killed, you've lost a very important part of your life.” Brooke Shields

3. Tobacco-related deaths within Australia compared with other causes – 2003(AIHW)

4. Smoking rates 2007 • Young people aged 16-24 25-30% • Single parent (female) 45% • Aboriginal people 50% • People in prison 75% + • People with a mental illness 70-90% • Homeless adults 70-100% • Drug treatment groups 74-100%

5. Classification of nicotine dependence 305.1 Nicotine Dependence(substance use disorder) • Nicotine dependence and withdrawal can develop with all forms of tobacco • Cessation produces well-defined withdrawal syndrome • Use nicotine to relieve or avoid withdrawal symptoms on waking or after situation where use restricted • Continued use despite knowledge of medical problems related to smoking Diagnostic & Statistical Manual of Mental Disorders (DSM-IV). (American Psychiatric Association)

6. What Do They Say It’s different... It’s population health issue... Poor people got enough to deal with... Got a right to smoke… Have a choice to smoke… Anyway the staff smoke… Great way to form therapeutic relationship... BUT...

7. Barriers to Tobacco Dependence Treatment • Lack of staff training • “not my role” – go to primary care • Staff fear that patient’s will misuse NRT or smoke while taking NRT • Staff who smoke – normalize smoking, staff may help patient’s access cigarettes, program may sell cigarettes • Restrictive formulary • Limited income and cannot afford OTC medications

8. Consequences & Costs of Not Treating Nicotine Dependence • Increased Mortality • Increased Morbidity • Increased use of health care resources • Decreased Quality of Life • Increased Societal Costs, including costs to employers

9. The Vicious Cycle of Smoking and Disadvantage • Social Disadvantage and Deprivation: •  Adverse circumstances (Unemployment, lone parenthood, homelessness etc) •  Stress •  Isolation •  Smoking as “normal” •  Unsafe neighbourhoods • Limited recreation Makes Circumstances Worse:  Less money for essentials  Greater financial stress  Poorer health and wellbeing Creates Vulnerability to Smoking:  As a means of coping with difficult circumstances  As a response to stress and exclusion  As an ‘affordable’ recreation Smoking prevalence:  Increased smoking  Less quitting  Higher relapse (Cancer Council, 2008) 9

10. Motivating clients to stay smoke free • Health may not be primary motivator • Other factors might be: -stigma related to being a smoker -restricted access to places, activities -cost of smoking -being able to reduce medication -relief from stress related to neuroadaptation to nicotine, withdrawal, topping up, withdrawal etc (addiction cycle)

11. Nicotine Dependence and Major Depressive Disorder (MDD) (Breslau et al 1993) • A clear relationship has been identified between smoking and depression. • Presence of MDD increases the probability of persistent smoking, decreases the rate of smoking cessation and increases the rate of relapse.

12. Heart attack Stroke Cancer Emphysema Bronchitis Asthma Ulcers Premature ageing Impotence miscarriage Health EffectsSmoking causes:

13. Drivers of smoking - physical addiction • The brain is ‘switched on’ by nicotine, releasing ‘feel good’ chemicals (dopamine), as nicotine hijacks the role of acetylcholine to release dopamine at the receptor • Can occur after smoking one cigarette per day over few days • Inhaled and delivered to blood in seven seconds • Hits the brain in ten seconds • Short ‘half-life’ of only 20 to 40 minutes, meaning smokers need to be constantly ‘topped up’ • The cycle of ‘feel good’, withdrawal, and ‘top up’ reinforces addiction

14. Drivers of smoking - the behavioural aspect • Smoking-associated environmental stimuli (cues)play a role in reinforcing nicotine dependence8 • Stressors and triggers may lead to unexpected cigarette use after quitting. These may lead to a full relapse and failed cessation attempts • The most effective treatment includes both pharmacological and behavioural therapy • Caggiula AR et al. Importance of nonpharmacological factors in nicotine self-administration. Physiol Behavior 2002; 77:683–687

15. How addictive is Nicotine? • “If it weren’t for the nicotine in tobacco smokepeople would be little more inclined to smoke as they are to blow bubbles” MH Russell, tobacco researcher, 1974 • Criteria for addiction? • Smoke to obtain blood level of nicotine - cease smoking - withdrawal symptoms - relapse • Continue to smoke despite negative consequences (social, medical, financial). • User: Addict ratio Alcohol: 20:1 Heroin: 5:1 Nicotine: 2:1

16. Genetic predisposition? • In the majority of cases, smokers attending the clinic will report at least one parent was a smoker. • Recent research has implicated the Beta-II subunit of the nicotinic receptor in smokers. • It has also been argued that neonates exposed to tobacco smoke develop upregulated nicotine receptors, leading to susceptibility to nicotine dependence.

17. Brief Intervention + Pharmacotherapy • Ask about tobacco use • Advise to stop smoking • Assess willingness to quit • Assist with quit plan • Arrange follow up Clinical Practice Guidelines :Treating Tobacco Use and Dependence, U.S. Dept of Health and Human Services , Public Health Service 2000

18. ASK • Routine screening on forms - tick boxes for current smoker, non-smoker and ex-smoker (and when last smoked) • If a known smoker, ask “how do you feel about your smoking at present?” • ALWAYS RECORD!

19. ADVISE • Clear ,personalised, clinically-linked advice about quitting smoking from a health professional increases abstinence rates • “When you stop smoking, your diabetes/cardiac/respiratory symptoms will improve” • “The best thing for your health would be to quit smoking” • Clinical Practice Guidelines :Treating Tobacco Use and Dependence, U.S. Dept of Health and Human Services , Public Health Service 2000

20. ASSESS 1.Willingness to quit “are you interested in quitting?” “would you be interested in a ‘cut down then stop’ approach?” 2.Level of dependence -Fagestrom Test for Nicotine Dependence -Shortened Fagestrom

21. Assessment 2 simple questions to assess for extreme dependence are: • “How soon after waking up do you smoke your first cigarette?” • “How many cigarettes a day do you smoke?”

22. Assessment • Information about low nicotine products or reducing amounts of cigarettes are less relevant as people titrate to achieve their normal blood nicotine levels by: • smoking faster • taking deeper breaths • smoking more of the cigarette

23. ASSIST • Help includes: -Information on why smoking/nicotine is addictive -Regular sessions -Empathy and support - Advice on the use of a pharmacotherapy

24. ASSIST • Plan ahead • Triggers can happen quickly so have a plan on how to deal with them e.g. write the plan down and keep in wallet/purse to help in these situations • Make sure you have some oral NRT (if using) with you at all times to help with triggers and cravings • Ask what worked and what didn’t with previous quit attempts • Don’t quit before a party, wedding, or stressful event • Quit with a family or friend • Plan spending extra $$$ as a reward • Organise medication

25. The Fagerstrom test for nicotine dependence (full version) Source: NSW Health (2005) “Let’s take a moment” quit smoking brief intervention – a guide for all health professionals. Sydney: NSW Health.

26. The Fagerstrom test for nicotine dependence (short version) Source: NSW Health (2005) “Let’s take a moment” quit smoking brief intervention – a guide for all health professionals. Sydney: NSW Health.

27. Nicotine Withdrawal Usually at worst in the first 24 - 48 hours, then decline in intensity gradually over next 2 weeks. Symptoms may include craving for tobacco(can be strong, but typically come in bursts - only last a short time) plus 4 (or more) of the following within 24 hours of cessation, often causing significant distress : • Dizziness • Coughing • Tingling sensations in extremities • Appetite changes • Constipation • Decreased heart rate • Insomnia • Depressed mood • Increased appetite or weight gain • Irritability, frustration or anger • Anxiety • Difficulty in concentrating • Restlessness

28. ARRANGE FOLLOW-UP • Is client returning to you for follow-up? • Do they need a referral to GP/Community Health/cessation expert? • Have you made Quitline fax referral? • If they don’t want a referral, have they taken a “Quitline” brochure?

29. Treatment of nicotine dependence Commonly used methods for quitting smoking: • Cold turkey; although a high proportion of smokers attempt quitting this way, most will relapse and require multiple attempts to achieve permanent abstinence. • Hypnotherapy and acupuncture; There is no actual reported evidence that acupuncture has any effect on withdrawals or abstinence rates. Similar with hypnotherapy.

30. Nicotine Fading; Many smokers attempt to reduce nicotine intake to assist quitting. As mentioned earlier, smokers are likely to titrate their nicotine dose. Another consequence is the increased rewarding effect of each cigarette smoked. • Pharmacotherapies; Currently the most effective tool for treatment of nicotine dependency. NRT has been well evaluated and has shown efficacy well above placebo effect. Zyban and Champix good option for some pts

31. Treating the addiction • Approved pharmacotherapies • Nicotine replacement therapy (NRT) • Bupropion hydrochloride (Zyban) • Varenicline (Champix)

32. GENERAL INFORMATION about Nicotine Replacement Therapy products NRT relieves cravings & withdrawal symptoms whilst the smoker deals with breaking their habits around smoking.

33. GENERAL INFORMATION about Nicotine Replacement Therapy products • A very low risk of nicotine toxicity from NRT. • A very low risk of addiction to NRT. • All the evidence states that nicotine obtained from NRT is safer than that obtained from smoking tobacco. • There is sufficient evidence that using NRT to abstain from smoking in situations where smoking is prohibited is well tolerated.

34. FOR HEAVY SMOKERS!!It is better to put patch on before going to bed so that the nicotine level in the blood is high on waking especially if you reach for cigarette on wakingMay need to put on another patch in the morning

35. NRT Side Effects - patch • Skin reaction / rash Treat area with cortisone cream • Vivid dreaming / insomnia Apply patch before retiring OR remove patch during sleeping hours • Pain in upper arm Use alternate NRT mechanisms for a few days

36. NRT Side Effects - Gum Jaw pain, hiccups Try alternate NRT products for a few days. Nausea Remind/educate on proper use…. (Remember –‘mouth patch’).

37. Start immediately on waking Liberal usage Use as often as “feel” like smoking Don’t chew - bite infrequently Half an hour per gum, then discard No drinks while gum in mouth If enough gum is used, smoking will not be necessary Heavy smokers need high gum usage CORRECT USE OF GUM

38. NRT Side Effects - lozenge Hiccups, heartburn, nausea Alternate between delivery devices for a few days. Check correct use – dissolve in mouth, DO NOT CHEW.

39. INHALER Lets you control the amount of nicotine you get when you get a craving to smoke Less concentrated & less addictive than if you smoke Leaves out the poisons found in cigarette smoke

40. Inhaler • -attach the cartridge to the tube, and inhale for the next 20-30 minutes. Throw cartridge out • You can put it down and pick it up during that time, but if you leave it for more than 1 hour , 1.5 hr max, the vapour (volatile substance) has gone and is not viable • People often use the one cartridge all day , but this is only a placebo effect. • Use 6-12 cartridges / day for best effect

41. Plasma nicotine levels –NRT vs. cigarettes9 25 Cigarette 20 15 Spray Plasma nicotine (mg/ml) Gum/Inhaler/Tablet 10 5 Patch 0 10 20 30 40 50 60 Time (minutes) 9. Royal College of Physicians of London. Nicotine addiction in Britain: A Report of the Tobacco Advisory Group of the Royal College of Physicians. London: Royal College of Physicians, 2000.

42. Changes to NRT indications20 • More than one form of NRT can be used concurrently • NRT can be used by pregnant and lactating smokers • All forms of NRT can be used by patients with cardiovascular disease • All forms of NRT can be used by smokers aged 12 to 17 years 20. ASH Australia. Nicotine replacement therapy – Guidelines for Healthcare Professionals on using NRT for smokers not yet ready to stop smoking. February 2007.

43. Cut down then stop21 • the evidence supports the following conclusions: • Nicotine replacement helps smokers unwilling or unable to stop achieve sustained reduction in cigarette consumption • This reduction is accompanied by a reduction in smoke intake (biochemically validated) • There is minimal risk of significant adverse reactions to smoking concurrently with nicotine replacement • Smoking reduction using NRT increases motivation to stop smoking • Smoking reduction using NRT increases subsequent cessation Adapted from reference 21. ASH Australia. Nicotine replacement therapy – Guidelines for Healthcare Professionals on using NRT for smokers not yet ready to stop smoking. February 2007.

44. Cut down then stop • Good for people who may not be ready to quit but who want to move towards it, or who smoke high volume • Smoker chooses one cigarette to miss, same time every day for a week or , using oral NRT instead • Next week, choose another cig to drop • Over 6 months aim to reduce by half • Stops smokers titrating dose and creating positive reinforcement

45. Combination therapy • Combined forms of NRT • Combine rapid onset form (e.g. gum, lozenge, inhaler) with slower delivery • form (e.g. patch) • More effective than single form of NRT in dependent smokers2 • Offer if smoker experiences withdrawal symptoms, or quitting unsuccessful on single form of NRT • Combined NRT patch and bupropion • More effective than NRT patch alone • Consider if quitting unsuccessful with monotherapy Adapted from reference 2. Australian Government Department of Health and Aging. Smoking Cessation Guidelines For Australian General Practice. Practice Handbook 2004. Available from www.quitnow.info.au.

46. Buproprion - Zyban • The most frequently reported adverse effects were insomnia, headache, dry mouth, nausea, dizziness and anxiety • Bupropion is contraindicated in the following patients • Past or current seizures • Known CNS tumours • Undergoing abrupt withdrawal from alcohol or benzodiazepines • Current or previous history of bulimia or anorexia nervosa • Those taking monoamine oxidase inhibitors or who have taken them within the last 14 days • The safety of bupropion in pregnancy has not been established 23. ZYBAN SR® (bupropion hydrochloride). Approved Product Information. eMIMS. Last updated Sept 2007.

47. Varenicline (Champix®)designed for smoking cessation • Varenicline was designed specifically for targeting the nicotinic • receptor responsible for nicotine dependence: the 42 nicotinic • acetylcholine receptor24 • First in class with novel mode-of-action • Champix® is PBS reimbursed in Australia Adapted from 24. Coe JW et al. Varenicline: an alpha4beta2 nicotinic receptor partial agonist for smoking cessation. J Med Chem 2005; 48:3474-3477.

48. Varenicline: A selective 42 acetylcholine receptor partial agonist25,26 Antagonist • Prevents stimulation of the receptor • by nicotine • This reduces the pleasurable effects • of smoking and potentially the risk of • full relapse after a temporary lapse Partial agonist • Binds with high affinity to the 42 • receptor, only partially stimulating • dopamine release • Provides relief from craving and • withdrawal symptoms 25. Jorenby DE. et al.Efficacy of varenicline, an α4β2 nicotinic acetylcholine receptor partial agonist, vs placebo or sustained-release bupropion for smoking cessation. JAMA 2006; 296:56-63. 26. Gonzales D et al.Varenicline, an α4β2 nicotinic acetylcholine receptor partial agonist, vs sustained-release bupropion and placebo for smoking cessation. JAMA 2006;296:47-55.

49. Safety and tolerability of varenicline • Varenicline has a favourable safety and tolerability profile. It can even be safely administered for up to one year28 • The most frequently reported adverse events with varenicline were nausea, headache, insomnia and abnormal dreams29 • Nausea was reported by approximately 30% of patients treated with varenicline 1mg bid25,26,29 • discontinuation rate due to nausea was low (<3%) and generally described as mild or moderate and decreased over time • Varenicline has not been studied in pregnancy, childhood or in patients with history of, or intercurrent psychiatric illness • Serious neuropsychiatric symptoms have occurred in patients being treated with varenicline. • Although a causal association has not been established, in some reports the association cannot be excluded • All patients being treated with varenicline should be observed for neuropsychiatric symptoms 25. Jorenby DE et al. Efficacy of varenicline, an α4β2 nicotinic acetylcholine receptor partial agonist, vs placebo or sustained-release bupropion for smoking cessation. JAMA 2006; 296:56-63. 26. Gonzales D et al. Varenicline, an α4β2 nicotinic acetylcholine receptor partial agonist, vs sustained-release bupropion and placebo for smoking cessation. JAMA 2006;296:47-55 29. Champix® (varenicline tartrate) Approved Product information. Pfizer Australia Pty Ltd

50. Varenicline – dosing29 • Varenicline is indicated as an aid for smoking cessation in adults over 18 years • The patient should set a date to stop smoking: varenicline dosing should start 1-2 weeks before this date • Varenicline tablets should be swallowed whole with water • Varenicline tablets can be taken with or without food • Varenicline tablets for oral use with titration as shown • Varenicline is supported with a patient support programme 29. Champix® (varenicline tartrate) Approved Product information. Pfizer Australia Pty Ltd