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Clinical guidelines

SNAP Guide

Smoking

3.1.1 Ask and assess

Smoking status should be assessed for every patient aged 10 years and older.45 It is important to ask at every opportunity, especially if there is a related medical problem (eg. respiratory disease or CVD). Smoking status should be documented in the medical record.

The related health effects and the substantial cost are two key factors that trigger smokers to consider quitting. The Quit Now website’s online calculator, available at www.quitnow.gov.au/internet/quitnow/publishing.nsf/Content/online-calculator, can be used to estimate the cost of smoking and may be helpful to use with your patient.

Table 3. Smoking: when, how and who to assess

Question

Answer

Level of evidence and strength of recommendation46

When should I start screening?

All people aged 10 or older.

I–A

When should I stop screening?

No upper age limit for screening has been reported.

None available

How often should I screen?

Take every opportunity to ask about smoking cigarettes, pipes or cigars.

III–A

Which groups are at higher risk of developing smoking-related complications and would benefit most from quitting?

  • Pregnant women
  • Parents of babies and young children
  • Aboriginal and Torres Strait Islander peoples
  • People with mental illness
  • People with other chemical dependencies
  • People with smoking-related diseases
  • People with diabetes or other CVD risk factors
  • People from low socioeconomic groups47,48

I–A
III–A
III–A
III–A
III–A
III–A
III–A
III–A

What methods should I use when screening?

  • Include smoking status as part of routine history-taking.
  • Implementing recording systems that document tobacco use almost doubles the rate at which clinicians intervene with smokers and results in higher rates of smoking cessation.49

I–A

II–A

How should I assess readiness to quit?

This must be done in a non-judgmental and non-threatening way. For example, ‘How do you feel about your smoking?’, ‘Are you ready to quit?’.

I–A

What are the benefits and risks of preventive actions?

Quitting smoking has benefits in reducing the risk of cancers, coronary artery disease, chronic obstructive pulmonary disease and stroke. There are no risks from preventive actions.

III–B

Nicotine dependence can be assessed by asking questions related to:46

  • number of minutes between waking to first cigarette
  • number of cigarettes per day
  • the type of cravings or withdrawal symptoms experienced in previous quit attempts.

Smoking within 30 minutes of waking, smoking more than 10 cigarettes per day and history of withdrawal symptoms in previous quit attempts are all markers of nicotine dependence.

According to the RACGP’s Red book, available at www.racgp.org.au/your-practice/guidelines/redbook, pharmacotherapy for dependent smokers is proven to double the chances of successfully quitting.

3.1.2 Advise and assist

Patients who smoke, regardless of the amount, should be offered brief advice to stop smoking.49 Smoking cessation is well established as an effective intervention within the primary care setting. Simple, single-consultation advice from a physician results in 1–3% of smokers quitting and not relapsing for one year.50

This means the number needed to treat to prevent one excess death is 67 for minimal brief advice and 22 for optimal treatment (based on conservative assumptions that only 3% of people quit on their own, 6% quit with minimal treatment, 12% quit with optimal treatment and all quit after the age of 50).51

Table 4. Smoking: what advice should be provided (and to whom)?

Question

Answer

Level of evidence and strength of recommendation46

Is counselling from a doctor effective in getting people to quit?

Yes. Brief advice given by GPs and their practice team during a single routine consultation is more effective than no intervention at all. Interventions work best for people who are ready and motivated to quit and for whom follow-up support is provided.

I–A

 

I–A

Who should be offered patient education?

All patients, especially those presenting with smoking-related problems.52 This should be supplemented by written patient-education material.

I–A

Who should be offered pharmaco-therapy to assist with cessation?

Pharmacotherapy may be considered in all patients smoking more than 10 cigarettes per day. In the absence of contraindications, pharmacotherapy should be offered to all motivated smokers with evidence of nicotine dependence.

I–A

Should I counsel non-smokers about passive smoking?

Yes. Although there is no evidence regarding the effectiveness of counselling, the strong evidence on the harms of passive (second-hand) smoking justifies counselling non-smokers, especially parents of babies and young children and pregnant women, to limit exposure to tobacco smoke.53,54

III–B

 

I–A (for pregnant women)

Should patients be offered follow-up visits?

Yes. Patients should be offered follow-up visits at one week and one month. Further follow-up should be negotiated between doctor and patient.

I–A

Patients who are not interested in quitting should be offered brief advice on the risks of smoking and encouraged to consider quitting. Patients who are interested but unsure should be offered information on smoking cessation, including what is available to support smokers attempting to quit (Quitline, pharmacotherapy if they are nicotine-dependent) and a suggestion for a follow-up visit to discuss further.

Addressing beliefs about smoking and smoking cessation can help overcome barriers to quitting (refer to Table 5).

Table 5. Smoking: addressing patient barriers to quitting46

Belief

Evidence

I can quit at any time/I am not addicted.

Ask about previous quit attempts and success rates.

Use of cessation assistance is a sign of

weakness/help is not necessary.

Reframe ‘assistance’. Explain that nicotine dependence is a powerful addiction and highlight unassisted quit rate is 3–5%.

Too addicted/too hard to quit.

Ask about previous quit attempts.
Explore pharmacotherapy used and offer options (eg. combination therapy).

Too late to quit/I might not benefit so why bother?

Benefits accrue at all ages and are greater if earlier – at age 30 years, similar life expectancy to non-smoker. Provide evidence/feedback (eg. spirometry, lung age, absolute risk score).

My health has not been affected by smoking/you have to die of something/I know a heavy smoker who has lived for a long time.

Provide evidence/feedback (eg. spirometry, lung age, cardiovascular absolute risk score). Reframe (eg. chronic obstructive pulmonary disease (COPD) = smoker’s lung).

Not enough willpower/no point in trying unless you want to/to quit successfully you really have to want to, then you will just do it.

Explore motivation and confidence. Explore and encourage use of effective strategies (eg.Quitline, pharmacotherapy).

Smokers who are ready to quit should be assisted by:

  • agreeing on a quit date
  • identifying smoking triggers and discussing quitting strategies
  • providing self-help materials
  • prescribing pharmacotherapy based on clinical suitability and patient preference
  • arranging follow-up visits at 1–2 weeks to prevent relapse
  • considering referral to a quit program.

Pharmacotherapy

Tobacco use is most effectively treated with a comprehensive approach involving behavioural support and pharmacotherapy. Nicotine replacement therapy (NRT) increases quit rates by about 60% compared to placebo.46 All forms of NRT monotherapy have similar efficacy in increasing long-term cessation compared to placebo.

Combining the nicotine patch with an oral form of NRT is more effective than monotherapy and should be offered to smokers who are unable to quit or experience cravings or withdrawal symptoms despite monotherapy. Pre-cessation treatment with a nicotine patch, usually started two weeks prior to ‘quit day’, has also been shown to improve success rates compared to starting the patch on quit day.55 There are some contraindications, including recent onset of life-threatening arrhythmias, pregnancy or lactation. Caution should also be exercised in patients with recent acute myocardial infarction or severe or worsening angina pectoris, recent stroke and arrhythmia.

Varenicline is the most effective monotherapy, more than doubling sustained abstinence rates at six months’ follow-up compared to placebo.56 Nausea occurs in about 30% of users but can be minimised by gradually up-titrating the dose and having the tablets with food. Although there have been concerns about neuropsychiatric adverse effects with varenicline, evidence from a meta-analysis shows no increase in rates of suicidal events, depression, or aggression/agitation compared to placebo.57

Bupropion, when combined with behavioural support, has been shown to be effective in patients who are dependent.58 It is contraindicated in patients with allergy to bupropion, seizures, anorexia or bulimia, central nervous system (CNS) tumours or monoamine-oxidase inhibitor (MAOI) treatment within 14 days. It should be used with caution in patients who abuse alcohol, have experienced recent head trauma, have diabetes, renal impairment, patients who use stimulants or anorectic drugs, drugs that may lower seizure threshold and patients on NRT.

Patients with other drug and alcohol problems, or who are living with mental health issues may need particular support to reduce smoking. SANE Australia has materials for GPs and people who smoke and are living with mental issues. SANE Australia can be contacted on 1800 18 SANE (7263) or online at www.sane.org

3.1.3 Arrange

Motivated patients who are physically or psychologically addicted to nicotine should be referred to a quit program 46 such as Quitline, a tobacco treatment specialist or local Quit programs. Patients with a chronic medical condition and complex needs may benefit from a GP Management Plan and Team Care Arrangement under Medicare’s CDM GP services (formerly Enhanced Primary Care). Refer to Chapter 4 and Chapter 5 for more information about what is available under Medicare, including links to MBS templates.

Quitline (13 78 48) is a telephone service that offers information and advice or counselling for people who want to quit smoking. Quitline can send patients a Quit Book or provide information on:

  • the best way to quit
  • coping with withdrawal symptoms
  • proactive telephone counselling
  • Quit courses and details of local organisations that provide individual help and counselling.

Visit www.quitnow.gov.au for more information.

quit now Reproduced with permission from the Department of Health

Refer to Chapter 5 for information on referral services and tools, such as a lung age calculator and where to locate a tobacco specialist.

Section 4.5.4 includes information on how to set up a practice directory.

Follow-up

Patients should be reviewed within one week, and again at one month, of stopping smoking in order to help increase the long-term chance of quitting. The practice information system should generate reminders or lists of patients who are overdue for follow-up (refer to Section 4.5.1). Most relapses occur within the first few weeks of quitting and patients should be counselled that they should not give up even if they have relapsed. It often takes a number of attempts to quit successfully. Relapse is associated with the severity of withdrawal symptoms and a number of other factors, such as stress and weight gain, so addressing these regularly will help the patient to remain tobacco-free. Strategies to deal with the habit of negative emotions also help patients to become long-term non-smokers.

References

  1. United States Department of Health and Human Services. Physical activity guidelines advisory committee report. Washington DC: US DHHS; 2008.
  2. Supporting smoking cessation: a guide for health professionals. Melbourne: The Royal Australian College of General Practitioners; 2014.
  3. Higgins K, Cooper-Stanbury M, Williams P. Statistics on drug use in Australia 1998. Drug statistics series. Cat. no. PHE 16. Canberra: AIHW; 2000.
  4. Hill DJ, White VM, Scollo MM. Smoking behaviours of Australian adults in 1995: trends and concerns. Med J Aust 1998;168(5):209–13.
  5. The Tobacco Use and Dependence Clinical Practice Guideline Panel and Consortium Representatives. A clinical practice guideline for treating tobacco use and dependence: A US Public Health Service report. JAMA 2000;283(24):3244–54.
  6. Stead LF, Buitrago D, Preciado N, Sanchez G, Hartmann-Boyce J, Lancaster T. Physician advice for smoking cessation. Cochrane Database Syst Rev 2013;5:CD000165.
  7. Hughes JR. A quantitative estimate of the clinical significance of treating tobacco dependence. Am J Prev Med 2010;39(3):285–6.
  8. Wynn A, Coleman T, Barrett S, Wilson A. Factors associated with the provision of anti-smoking advice in general practice consultations. Br J Gen Pract 2002;52(485):997–9.
  9. He J, Vupputuri S, Allen K, Prerost MR, Hughes J, Whelton PK. Passive smoking and the risk of coronary heart disease--a meta-analysis of epidemiologic studies. N Engl J Med 1999;340(12):920–6.
  10. World Health Organization. Report on passive smoking and children. Geneva: WHO; 2000.
  11. Stead LF, Perera R, Bullen C, et al. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2012;11:CD000146.
  12. Cahill K, Stevens S, Perera R, Lancaster T. Pharmacological interventions for smoking cessation: an overview and network meta-analysis. Cochrane Database Syst Rev 2013;5:CD009329.
  13. Gibbons RD, Mann JJ. Varenicline, smoking cessation, and neuropsychiatric adverse events. Am J Psychiatry 2013;170(12):1460–7.
  14. Hughes JR, Stead LF, Hartmann-Boyce J, Cahill K, Lancaster T. Antidepressants for smoking cessation. Cochrane Database Syst Rev 2014;1:CD000031.

 

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