Doncaster and Rotherham Smoke Free Services: Nicotine Replacement Therapy Voucher Scheme

1. Doncaster and Rotherham Smoke Free Services: Nicotine Replacement Therapy Voucher Scheme Simon Lister Service Manager Rotherham Stop Smoking Service

2. Aims • To provide an outline of the NRT voucher scheme (issuing the voucher and dispensing the product) • Provide an overview of the products available • Please note: there will be two NRT voucher schemes operating in Rotherham – SWYPFT and TRFT

3. Inclusion criteria Clients must be: • Registered with a Rotherham or Doncaster GP • Aged12 or over • Have set a quit date (must be attending support sessions with DRSFS or third party provider)

4. Exclusion criteria • Unstable angina, Myocardial Infarction (heart attack) or abnormal heart rhythm within the last 2 weeks • A stroke or transient ischemic attack (TIA or mini-stroke) within the last 2 weeks • Hyperthyroidism (over active thyroid) not controlled by medication • Phaeochromocytoma (rare tumour of the adrenal gland) • Does the client take clozapine (Clozaril, Denzapine, Zaponex) ropinirole (Requip), theophylline (Nuelin SA, Slo-Phyllin, Uniphyllin Continus) or aminophylline • If clients answer YES to any of the above they are not eligible for NRT via this scheme • Currently not possible to refer clients who meet the exclusion criteria to GP for NRT as before.

5. Completing the voucher • The Stop Smoking Advisor (Specialist Service or LES) will complete the first 3 sections of the voucher – client details, advisor details & request the product, strength, quantity and supply number. • The dispensing pharmacist must complete the date of supply, inclusion/exclusion criteria, client consent and sign the voucher at the bottom of the form. • DRSFS have produced an SOP for completing the voucher although not valid in your organisation it can be used as a template.

6. Completing the voucher • Explain that nominally one product will be issued via the voucher. • Combination therapy is only available in exceptional circumstances - defined as a score of 11 in the Doncaster and Rotherham Smoke Free Services Client Triage Algorithm (see handout) • Discuss and agree the choice of product(s), how to use them and possible side effects. • Advise the client to read the product information leaflet prior to commencement of treatment. • Complete the first 3 sections of the voucher (see handout), i.e. the client details, the advisor details and the product/dose and quantity

7. Completing the voucher • Advise clients to buy the ‘step down’ patch/s or a supply of a second product to support their quit attempt where appropriate. • Vouchers will be issued on a weekly basis for the first 4 weeks and thereafter on a fortnightly basis to a maximum total of 8 weeks (i.e. a maximum of 6 vouchers per client). • Issue the top 2 copies of the voucher (buff and yellow copies) to the client and retain the bottom pink copy for record keeping purposes, vouchers cannot be issued to a client representative. • Vouchers can be redeemed at participating pharmacies (to be confirmed) in Doncaster or Rotherham only and the products will be supplied under the supervision of a pharmacist.

9. Supply quantities- see handout

10. NRT products available • Nicorette invisi patch 25mg &15mg & 10mg. • NiQuitin patch 21mg & 14mg & 7mg • Nicotinelle patch 21mg & 14mg & 7mg • Nicorette gum 2mg & 4mg. • Nicorette Quickmist 1mg/spray • Nicorette Inhalator 15mg • NiQuitin Minis 1.5mg & 4mg

11. NRT – General information for clients • NRT works by providing a ‘clean’ replacement for the nicotine smokers would normally get from cigarettes/reduces the cravings and other withdrawal symptoms. • Step down programme - gradually wean off • NRT doubles your chance of quitting, however it is not a cure – need to manage unrealistic expectations • Combination therapy (patch + oral product) is more effective than a single product. • Nominally only one product is available on the voucher - remember to advise the client to buy the second product and the step down products. • There is no evidence for the effectiveness of combining NRT with Varenicline (Champix), therefore it is not to be recommended.

12. NicoretteInvisi Patch (16 hours) • Available in: 25mg, 15mg, 10mg • If smoking 10 or more cigs/day start on 25mg, • If less than 10cigs/day start on 15mg • Usual regime: 25mg for 8 weeks, followed by 15mg for 2 weeks, followed by 10mg for 2 weeks • Apply one patch per day (on waking), to any hair free, dry patch of skin. Take off at bedtime. • Advantage: provides sustained levels of background nicotine, is discrete & easy to use. • Disadvantage: can cause local irritation, not possible to titrate dose. Slow acting

13. NiQuitin 24 Hour Patch • Available in 3 dose’s – 21mg, 14mg, 7mg • If smoking 10 or more cigs/day start on 21mg, • If less than 10cigs/day start on 14mg • Usual regime: 21mg for 6 weeks, followed by 14mg for 2 weeks, followed by 7mg for 2 weeks • Apply one patch per day (on waking), to any hair free, dry patch of skin. • Advantage: provides sustained levels of background nicotine, is discrete & easy to use. • Disadvantage: can cause local irritation, not possible to titrate dose. Slow acting

14. Nicotinell 24 Hour Patch • Available in 3 dose’s – 21mg, 14mg, 7mg • If smoking 20 or more cigs/day start on 21mg, • If less than 20cigs/day start on 14mg • Usual regime: 21mg for 4 weeks, followed by 14mg for 4 weeks, followed by 7mg for 4 weeks • Apply one patch per day (on waking), to any hair free, dry patch of skin. • Advantage: provides sustained levels of background nicotine, is discrete & easy to use. • Disadvantage: can cause local irritation, not possible to titrate dose. Slow acting

15. Nicorette Gum • Available in: 2mg & 4mg • If smoking 20 or more cigs/day take 4mg • If less than 20cigs/day start take 2mg • Maximum 15 pieces/day • Take up to 15 pieces/day for first 4-6 weeks then gradually cut down to zero. • Chew until taste the flavour then ‘park’ between cheek and gum until flavour recedes than repeat. • Advantage: easy to titrate dose, available in several flavours • Disadvantage: some clients do not like the taste, difficult with dentures, may cause local irritation

16. NicoretteQuickmist • Available in single 13.2 ml dispenser and duo pack ( 2 x 13.2ml). Each spray contains 1mg of nicotine • Use 1-2 sprays every 30 minutes to 1 hour (maximum 64 sprays in 24 hours). • Use as above for first 4-6 weeks then gradually cut down to zero • After priming, point the spray nozzle as close to the open mouth as possible. Press the top of the dispenser and release one spray into your mouth, avoiding the lips. Do not inhale while spraying to avoid getting spray down your throat. For best results, do not swallow for a few seconds after spraying. • Advantage: fact acting, easy to titrate • Disadvantage: some clients do not like the taste, may cause local irritation

17. Nicorette Inhalator • Available in 15 mg cartridges (20 and 36 pack size – each pack contains one inhalator mouthpiece) • Use up to 6 cartridges/day • Nicorette Inhalator should be used whenever the urge to smoke is felt or to prevent cravings in situations where these are likely to occur. • Each cartridge lasts for approximately eight 5-minute sessions, but change when can no longer taste the nicotine • Advantages: fact acting, easy to titrate • Disadvantages: some clients do not like the taste, may cause local irritation

18. NiQuitin Minis • Available in: 1.5mg & 4mg • If smoking 20 or more cigs/day take 4mg • If less than 20cigs/day start take 1.5mg • Use up to 15 lozenges/day • One lozenge should be placed in the mouth and allowed to dissolve. Periodically, the lozenge should be moved from one side of the mouth to the other, not be chewed or swallowed whole • Advantages: fact acting, easy to titrate • Disadvantages: some clients do not like the taste, may cause local irritation.

19. Any questions? Thank you for listening