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17 March 2020
Smokers who use alcohol and other drugs are motivated to quit although there appears to be a wide variation in readiness to seek help to quit. in this webinar we discuss common misconceptions and attitudes that prevent patients who use alcohol and other drugs from quitting smoking. We also assist you in recognising health-related risks associated with smoking and the benefits of quitting with tobacco treatment options for this group of patients, and share pathways for patients to access smoking cessation support.
Dr Hester Wilson
Dr Tim Senior
Sammi: Good evening everybody and welcome to this evening’s Smoking Cessation for people who use Alcohol and other Drugs webinar. We are joined by our presenter this evening, Dr Hester Wilson and our facilitator, Dr Tim Senior. And my name is Samantha and I will be your host. Before we do make a start, I would like to make an Acknowledgment of Country. We recognise the traditional custodians of the land and sea on which we live and work, and we pay our respects to Elders past and present. Sammi: Good evening everybody and welcome to this evening’s Smoking Cessation for people who use Alcohol and other Drugs webinar. We are joined by our presenter this evening, Dr Hester Wilson and our facilitator, Dr Tim Senior. And my name is Samantha and I will be your host. Before we do make a start, I would like to make an Acknowledgment of Country. We recognise the traditional custodians of the land and sea on which we live and work, and we pay our respects to Elders past and present. Okay, so I would like to introduce formally our presenters for this evening. So we are joined by Hester Wilson. Hester is a GP and an Addiction Medicine Specialist, as well as the Chair of the RACGP Addiction Medicine Network. Hester has a Masters Degree in Mental Health and 25 years’ experience working in a primary health care setting. She is also a Staff Specialist in Addiction at Sydney’s Langton Centre Drug and Alcohol Clinic and has facilitated training for doctors and other healthcare workers since 2001. Welcome and thank you for joining us, Hester.
And we are also joined by our facilitator this evening, Dr Tim Senior. Tim is a GP at Tharawal Aboriginal Corporation in South Western Sydney. He was originally trained in the UK. Tim is an RACGP Medical Advisor for the National Faculty of Aboriginal and Torres Strait Islander Health, and a Senior Lecturer in General Practice and Indigenous Health an UWS. So, welcome Tim and Hester and thank you for joining us this evening.
Tim: Good evening, everyone.
Sammi: Perfect. So I might hand over to you now, Tim to take us through our learning outcomes for this evening and then we will jump over to Hester to get us started.
Tim: Lovely, thank you very much. Good evening everyone and welcome to the coronavirus friendly, social isolation CPD webinar. I hope you are all staying well and even though we are taken up by coronavirus, this will be a coronavirus-free zone because we still see patients with a lot of other problems. So what we are going to cover tonight we call learning outcomes, and this is just describing what we hope to get out of tonight. So by the end of this activity, we should be able to recognise the high smoking rates among people who use alcohol and other drugs, and the importance of addressing smoking in this group. We should be aware of the common barriers and debunk the myths around quitting and recognising the factors and opportunities for smokers to quit smoking. We should be able to discuss tobacco treatment options and provide advice on the usage of different forms of pharmacotherapy and understand the possibility of drug interactions with quitting smoking. And we should be able to provide practical support and tips related to smoking relapse prevention, including using specialist information to identify referral pathways and options for continued smoking cessation support. So we have got a lot to cover tonight, so let us move on to Hester.
Hester: Hi everybody. Look we have got a lot to get through. There are a lot of slides. I do want to just acknowledge first of all Diaz Ciweto, sorry Diaz, who actually put these slides together with her team at New South Wales Health, so thank you so much for assisting us with this. We have got a lot to get through. I am going to move through quite quickly. The slides will be available. There is lots of fabulous information on them so I encourage you to go back and have a look after we have finished up. But I wanted to start with Simon, aged 45. So he is someone, imagine this as someone you have seen in your surgery. You know him and his wife and children well. He says, I need to give up smoking. My son came home from school and has begged me to give up but I have tried a few times and I never succeed. And he has a few drinks with his mates on a Friday night, and in fact that is 12 to 15 schooners which is close to 20 standard drinks, and also often on Saturday nights as well. He shares a bottle of wine with his wife and he says, look I do drink most of the bottle. His wife is supportive of him stopping. He also smokes cannabis with his tobacco, probably monthly. And so, just thinking through, is this the sort of patient you guys might be seeing? And what are the issues that you might see with this? Have a think through that as we move on through the slides.
So bottom line. People who use alcohol and other drugs are more likely to smoke and smoke more heavily. They tend to start at an earlier age and they tend to smoke over a longer period of time, and they die of smoking related illness. In the clinic that I work in, 86% of our patients smoke, and that is in comparison to 15% of the Australian population. What we sometimes think is that people who use alcohol and other drugs do not actually want to give up smoking, but the truth is they do. They do want to stop. And it improves their recovery outcomes and we can help them do it. But they need more assistance, not less. So the range from 68% to 98%, certainly in my group it is 86%. And you know, it is uncommon if we are seeing somebody who has a substance use disorder, be that alcohol or opioids or benzodiazepines or cannabis or methamphetamines, cocaine, other drugs, it is uncommon to find someone who does not smoke. I am always a bit surprised when I ask that question and find that people do not smoke. And the thing that I would say to people is, that you know what, nicotine is one of the most addictive drugs and it is the hardest to give up. And certainly we know that there is a genetic predisposition that leads to the dependence and certainly the same pathways in the brain are kind of shared between nicotine and other drugs. I have to flag though, that that is not the full story. So looking at that biopsychosocial approach to people’s lives and their health and wellbeing, and their alcohol and other drug use, is much broader than that. But certainly dopamine, it is a happy hormone. It creates pleasure and enjoyment, and this is one of the things that nicotine does, when you have a cigarette it brings up that dopamine and makes you feel better. But as I have said before the relationship between tobacco and other drug use is quite complex and we will talk more about that. Next slide.
One thing that is really important to think about is that in some people, they have a different rate of nicotine metabolism. So those fast metabolisers will tend to be more addicted. They have increased risk of harm, they crave their first cigarette on waking, and they will be the ones when you ask them, how long after waking till you have your first cigarette, they will say I have got it rolled up by the bed ready to go as soon as I wake up. Or even I wake during the night to have a cigarette. And they find it harder to give up. That does not mean that they do not want to and that does not mean that they cannot do it. They need more support. Moving on to the next slide.
So, polycyclic aromatic hydrocarbons (PAHs), really are the big issue here, and there are 4,500 different types in tobacco. And they are the carcinogenic substances and toxic substances and smoking leads to health effects in just about any organ in any part of the body that you care to mention. The other thing just to be aware of is that people who smoke tend to drink more coffee and people who drink alcohol tend to drink more than the non-smokers. So if you are a cigarette smoker you will tend to drink more caffeine and you will drink more coffee. We will talk about medications because this is a really important thing to be aware of, and look here they have mentioned antipsychotics, anticoagulants, pain relievers and insulin. But be aware that smoking tobacco affects the metabolism of a lot mediations and when people stop, you have got to keep an eye on those medications and quite often you can cut the dose down because they do not need as big a dose. And that can be a really nice thing when you are working with people, to be able to work with them. Well, they are on methadone, we can cut the dose. They are on anti-psychotics, we can cut the dose once they stop their tobacco. Next slide.
So, cigarettes and alcohol together add to the happy hormone dopamine and certainly once again, drinking alcohol, there is the whole kind of dynamic there of having a drink and a smoke, and the genetic predispositions and the neurological effects there. Smoking counters those cognitive effects of alcohol and reduces the severity of alcohol withdrawal. It is not a great treatment for alcohol withdrawal, and we also know that the risk of cancer is increased. Smoking tobacco causes cancer as does alcohol. Cannabis users. Very few cannabis users do not use tobacco as well. There are some, but quite often they will use tobacco with the cannabis either in their joint or in their bong. It gives a smoother smoke because the tobacco inhibits your cough reflex you do not cough as much when you use your cannabis. So the issue is that you have a double whammy there of dependency with cannabis and tobacco and quite often people focus on, I have got to stop the cannabis, it is the cannabis that is the issue. But if you do not pay attention to the tobacco, it is the nicotine dependency that can make it difficult for them to change that. So it is always when you have got someone who is using both cannabis and tobacco, help them to quit both.
Once again, with the stimulants, we are talking methamphetamine, amphetamine or speed and cocaine. People using cocaine tend to smoke more and more nicotine means you use more cocaine. Opioid users have the highest smoking rates as I say in the people I work with, it is 86%. Methadone is affected by cigarettes and cigarettes are affected by methadone and they tend to smoke more heavily. Certainly because with nicotine tobacco, you increase the metabolism of methadone so they might need a bigger dose, but it also reduces sedation. The other thing of course to think of with many people who are using opioids, that they have higher levels of psychiatric distress or comorbidity and smoking to some extent is an antidepressant. We will talk more about that, because it is not a particularly useful antidepressant, but given that it raises those dopamine levels it is an important thing to consider with your patients. Moving onto the next page.
So why should smoking be addressed? I mean, it is a bit of a no-brainer. You know, we know that smoking will kill two out of the three people who continue for some time. It affects every part of your body in an adverse way. And in the group of people who use alcohol and other drugs, quite often they started smoking earlier, they smoke more heavily, they are at higher risk. Their health issues are profound and as a result they have high morbidity and they die much earlier than other people in our community. It reduces the effectiveness of some medications as we have seen. Stopping smoking can actually improve treatment outcomes. It can be a gateway to illicit drugs? Oh, I do not know, I do not know if I entirely agree with that. I mean, I kind of say that in a way, use of illicit drugs leads to continued smoking. But certainly that relationship between smoking and using other drugs very clearly, if you have got a smoker you need to ask about other drug use. If you have got someone that is drinking a lot or using other drugs, then always ask about the smoking, because you are likely to find that tobacco and nicotine dependency is part of the picture. Moving on.
Can alcohol and drug users, so people who are using alcohol or other drugs whether it be harmful, hazardous or dependent use, can they quit smoking? Absolutely. Absolutely. The issue that we have is that they find it harder and they need more support, not less. And it certainly it is something that I have seen, is this kind of nihilism that we as health workers quite often have with somebody that is using alcohol and other drugs, oh they do not really want to give up. They actually do. And we need to put more effort in, not less. They have better outcomes if they stop. Their mortality and morbidity will be very positively affected. So it is a really worthwhile thing to do. But the long term quit rates are low and in a group of people like this it might be that they give up smoking 20 times in their life. But I always say to people, every cigarette that you do not have is doing you good. Every day that you do not smoke is doing you good. And there may be people who say, look I am not ready to quit right now. But it is important for us to continue to have those conversations, to continue to flag I am concerned about your smoking. When you are ready I want to talk to you about this. I will continue asking you because this is really important. And it is one of the things for me that I see quite a lot, we work really hard, people work really hard to get their lives back together. To stop their injecting use, to get themselves on a program to get themselves housed, to get them to work and five years down the track they are doing really well, but they are still smoking. And it really, really concerns me that at that point they are still smoking and we really need to be working with them to actually change that, because that is what is going to kill them. Moving on.
So, there are some issues with tobacco, you know the idea that tobacco is not a real drug – well it is. Nicotine, yes it has receptors, we have the same issues as you know, it is a drug of dependence. And smoking actually does not reduce stress. And that is one of the things that is an issue quite often, that smoking helps my mental health. Actually, no. It does not help your mental health. It will make your mental health worse and when you give up and when you stop, your mental health will improve. As we have said before, health professionals, and there is a lot written in the literature around this, well patients are not interested, well they are. The other thing is oh my goodness, it is too hard to address all substances at once. And this is a tricky thing that I am always talking to my patients about. And very commonly people will say, oh no I can only cope with changing one thing at a time, and you need to work with where your patients are at. The reality is, it can be really effective for people to stop all their substances at once to make an attempt to change that entirely with good treatment, not cold turkey, but with good treatment to help them change what they are doing. People do worry, you know like, oh God I will not be able to stand the withdrawals. That is why we have good treatments and they can make a difference to that. You know, and it is going to make me more unwell. There have been a lot of concerns particularly with people who have major mental health issues, that it will undermine their recovery and make their mental health issues worse. In fact, it makes it better. But just flagging if you have got someone who has got a major mental health issue, you do need to follow them up and see them quite frequently and we will talk more about that as we go to the medicines and treatments that are available. Next slide.
Okay, so the barriers. So for patients, so if you are very dependent you are going to need lots of support to actually change that dependence on nicotine. Conflicting drivers. So for people, look you know, I enjoy a cigarette. And getting them to think about what that actually means. Is it that they enjoy it or is it that it actually relieves their withdrawals. If they are in a community where everybody smokes, where the way that things happen includes smoking and it is part of the social scene, it really, really can be difficult and that is particularly an issue for people in indigenous communities where smoking is seen as part of a kind of a community activity. You know, people have tried before and have failed. And that sense of failure, I cannot do this, this is too hard. Really, working with them around what quitting actually means and what it looks like, and we will come back to that in a moment. If people are actually really unwell with chaotic or problematic use and other things in their life are falling apart, you probably need to help them get back on track. And you know, so it may not be the right time while they are withdrawing from their alcohol or getting themselves housed. And the reality is that this is a group of people who actually access less support when in fact they need more. Moving on.
So, as I have been saying, it is part of our role to advise smokers to quit. We know that concurrent or combined treatments, so that is combined NRT or even using Varenicline and NRT, actually make a difference. They help people quit and they help people to quit long term. Tobacco and difficulty of quit smoking – yes it may be more difficult for someone that is highly dependent but there are good treatments that can help them do it. And once again, just flagging, do ask people about their caffeine and their alcohol use. Encourage them, use positive affirmations. For some people can be useful to talk about the financial benefits from quitting smoking, while others, they just get really depressed. They think oh my God, I have wasted all this money and then that makes them want to have another cigarette. Looking at the other things they can do, quite often can be really useful for people to think about, okay, I am going to do the detox, I am going to get to the gym, I am going to make these other changes. I am going to change my diet. I am going to do that with my partner, with my family. You know, certainly for a fellow whose child was saying, Dad I want you to stop smoking, that that can be a really great driver in terms of family support and helping him to change what they do. And people can have this really black and white view, I have got to quit. I have got to stop and never do it again. And that can feel impossible. So we are really working with patients individually to look at, well how can you manage this change? What can this look like for you? What can success? And success can build over time. Next page.
So, we are going to talk a little bit about the five A’s, the pharmacotherapies, hospital based smoking cessation, quit smoking groups, referral to Quitline and ICanQuit, educational interventions and tobacco control legislation which is interesting. I would also add to that, looking at the Apps, SmokeFree App and other supports that are a little bit more I guess novel. Moving on.
The most effective treatments are pharmacotherapy and support and counselling behavioural treatments. And that does not need to be full on stuff, it can be the conversation that we have in general practice. But just flagging four people who have very strong dependence and find it difficult to make that change, that additional counselling can be really useful. As I say, they need more support, not less. So that means for us as GPs, following them up really regularly. Looking at the other supports that they can put in place to assist them to make the change. So the counselling, helping them to look at what are their triggers, what happens, when are their at risk times for smoking, what are the things that are really important to them around changing their smoking, and where can they go for support. Pharmacotherapy is great for managing cravings and withdrawal symptoms and we will talk more about those in a minute. And of course we have got the smoking cessation services. Older people like those, younger people like the more novel online options including the Apps. And really remember that you are going to need to tailor the treatment to the patient that you are seeing at that time and their situation. Moving on.
The Five A’s approach. Now I am assuming that the vast majority of you have heard of this. There is certainly the SNAP guide, the Smoking, Nutrition, Alcohol and Physical Activity guide, which goes through it, and really when you think about it, the Ask, Assess, Advise, Assist and Arrange really are what we do in a consultation. So we are screening. We are making an assessment. We are giving support and information. We are assisting with medications and other treatments and we are arranging to follow up. I just want to flag with smoking, I do not actually do the Five A’s. I do a much shorter one, I give very brief information and this is I think really something that I want you guys to take away. Because one of the things for us in general practice is that we are always busy, we have always got lots of things to do. So if you have not got a lot of time and you think, oh geez I do not have time to do the Five A’s and start the whole smoking thing, you can in this situation in 15 seconds to 30 seconds, you can do a really quick approach which is checking in first of all, do you know if they are a smoker? So asking them if they are smoking. Or are they still smoking? Or if they have stopped, are you still stopped? And saying to them, I just want to let you know that of course there are really effective treatments for smoking. Are you interested in having another go? Can we make another appointment? I do not think you even need to talk to people about the risk. They all know that smoking is bad for them. They are all really likely to want to make a change. It may not be now, it may be in the future. But with that very brief advice, you are just saying, just reminding you that there are really brilliant, effective treatments. Can we make another time or can I refer you on to a smoking cessation service to start making this change? And there is your intervention done in 15 seconds, 30 seconds, and then you can make another time to follow up with them to go into it in more detail. Moving on. We are going to move on from that.
Once again, so they are interested in quitting. Beautiful. Advising the harms and the benefits. Once again, I would suggest that they probably already know that. Sometimes with younger people you might think, geez, maybe we are not going to go for the lung and cardiovascular harms, it might the stuff around fertility or bad breath or teeth or whatever. But looking at the medications, looking at the treatments, we have got medications and pharmacotherapy. We will talk about those in more detail. Healthy lifestyle as I mentioned before, getting out there and having some exercise. Healthy eating, changing your caffeine and alcohol. And looking at the New South Wales Quitline, Aboriginal Quitline which is fantastic and they can give counselling, telephone support, the ICanQuit website, the Apps and other supports that are out there online as well. And as I mentioned, following up. You know, arrange for follow up and with people that are highly dependent, arrange it soon. You might arrange for it later that week. Or you might arrange for it in one week’s time. But be aware that you want to be there to support them through that, and so if they have the lapses, if they slip up, if it does not work the first time, then you are in place there to support them to continue making that shift to not smoking. Moving on.
Okay. So, just withdrawal symptoms. Just so that we really are aware, DSM-5 links are the ones on the left there. So the anxiety, irritability, difficulty concentrating, appetite, restlessness, depressed mood and insomnia. The other ones we see really commonly are cravings and urges to smoke. The tiredness. Craving sweet food is a really common one. Mouth ulcers, constipation, cough, nausea, sore throat. A number of those are things that you may see that people may not actually realise is part of their withdrawal. Moving on.
Most relapses occur within the first three months after smoking. And smoking in the first two weeks, likely to fail. Well, let us have a think about that. It depends on how you set up the quit attempt and for some people, total abstinence, the not even a puff rule, can be really, really useful. However, I you have someone that has tried that in the past and not succeeded, you might chose to do it a slightly different way. Once again, alcohol and smoking do go together, so really looking at can you stop your alcohol for a couple of weeks just to give you a break? If people can do the not a puff rule, their physical dependence on nicotine will pass in the first two weeks, if they do not smoke at all. And we know that is really effective. So they want to avoid those places and the times that they are triggered. So alcohol, or smoky places, or hanging out with other people that smoke. Caffeine, in any form of caffeine. Once again, encourages you to smoke. And thinking about the things that are particularly triggers for them. So when they get on the phone and talk to their mates, it might be that that is the time when they have a cigarette. When they are having a break at work. They have been super busy and they go out and have a smoko, that is the time when they will be triggered to smoke. So if they can give up with the not even a puff rule, that first two weeks is brilliant. They get through the nicotine, the physical nicotine withdrawals in those first two weeks. After that, they need to be continue to be aware of the psychological triggers to actually smoke. Moving on.
If they have a lapse, once again, they will tend to say, geez, I failed. I failed 100%. And what I am always doing with people is going okay, so how many days did you manage to not smoke? And what did you do in that time that you were not smoking that you can use to build on this? You had success for a number of days or the week that you managed to not smoke. That is totally brilliant, how can we build on that? You know, and that it can take up to 20 quit attempts before people stop and maintain that long term. As I say, it is you know, every cigarette that you do not have is doing you good. Every day that you do not smoke is doing you good. The other thing is that smoking can be really different, sorry, quit smoking attempts can be quite different each time people try. So just because they have had an experience of it being really difficult in the past, it may not be the case this time around. At the same time, you want to learn from the issues that they had last time they tried to support them through this time. Moving on.
Quitline. Really, really brilliant. Great place to go to get some support. And there are the referral things there. We will move on from that, you can go back to that for your patients when you need it.
So, a successful quit attempt. The prescribed cessation medications. Once again, you need to be clear on the contraindications but pharmacotherapy is the basis of smoking cessation, of changing nicotine dependence. It works so much better than cold turkey. Cold turkey is setting people up to fail and certainly, you know that first line pharmacotherapy nicotine replacement combination rather than just single, and understanding that with the combination, both of those are not both subsidised, you need to buy the oral options. Varenicline alone or combined with NRT or bupropion alone or combined with NRT are your first line options. Behavioural support is important there and that can be Quitline, that can be seeing you, that can be seeing your nurse. Following up to ensure that people are on track and there are no issues that are coming up again, and supporting them and being a cheerleader to help them make that change. Moving on.
So is combined use of pharmacotherapies more effective than single? So combined NRT. And that is what we mean with the patches and the other forms, whether it is the inhalator, the lozenges, the gum. They are really much better used in combination with NRT. And varenicline or Champix, is actually the most effective form. It is slightly more effective than combination NRT. Bupropion is second line really. I do not use it very often and you do need to just be aware that it can decrease seizure threshold, so be careful in your heavy drinkers and anybody that has a seizure history. Moving on.
So, pharmacotherapy is supported through the PBS, but unfortunately you cannot get both NRT and varenicline. You cannot get both patches in oral form. Aboriginal people do have access to free NRT through Closing The Gap. Now, when you look on here you will see that we have got 25, we have got 15, we have got 5. We have got 21, the 14 and the 7. I have to say that there is no point from my point of view using those lower doses. Generally I go for the 21, 24 hour and I get people to put it on and leave it on for 24 hours a day. The 25s can be useful sometimes. People will talk about when they are trying to give up smoking, that issue with getting really vivid dreams. I have to say that I think for the most part, that is actually a withdrawal symptom, but some people cannot tolerate it and for some people the 25, 16 hour patch may be better. But do not bother with the smaller doses, they really are not useful for people who are highly dependent. The oral forms, the gums, the lozenges, the inhalers are also available and I suggest that people always use a combination. So get the patch on the PBS and then buy the gums, lozenges, whatever suits you. You keep the patch on and every time you have a craving you use the oral forms of NRT instead of having a smoke. Okay, look there is lots more information on the PBS schedule if you wish.
Tim: I have just had a few questions come through and now might be a good time. So, if a patient wants to go cold turkey, should that be encouraged or discouraged?
Hester: Look, it just does not work. It really does not work. Their chances of giving up are about 3%. And so if people are saying, fair dinkum I have done it before, I want to do it again, I would say okay, look you have a go. Generally that is hard for people and in this group of people it is really tricky. If they want to have a go, absolutely and there will be people who do manage in that 3%. There are three people out of 100 who will manage it. But I would be really flagging, it is really tricky and there are really good treatments, or if it does not work for you, I want to see you again so we can offer treatment.
Tim: Yes, excellent. And if someone is trying to quit both smoking and alcohol, can we use pharmacotherapy for both of those?
Tim: Yes, excellent.
Tim: And another question about weaning onto weaker patches. Is it worth weaning onto weaker patches?
Hester: No point. No point at all. There is no evidence that you need to cut down. The evidence is that you have the bigger patches and you continue them. You have got three months of patches on the PBS and sometimes people need to continue them for a longer period but there is no evidence that cutting down the patches to cease makes any difference to relapse.
Tim: Excellent. And there is a question that regularly comes up and I wonder if this is different for people with other alcohol and drug use as well, about pregnant women who are trying to quit smoking and using pharmacotherapy for that.
Hester: Yes, fantastic. We will come to that, because it is super important.
Tim: Lovely. Thank you very much.
Hester: Moving on. Okay, so nicotine replacement works by relieving cravings and withdrawals. So it replaces some of the nicotine. But it is not like having a smoke. It is not like having a smoke. The longer people use it, so you encourage them even if they have had the patches and they say, two weeks and I have stopped, keep using the patch. Keep using it for the full three months, because they may well relapse with the patch. It helps them to stay quit. Approved by the TGA, you can use the patches in pregnancy. You know, look the issue with oral NRT. It can be useful particularly in people that have a low dependency on its own. And when they crave, then they have some gum or a lozenge. The reality is, oral NRT is not as effective as a patch. And combination patch and NRT are even more effective. Some people will notice that they have some side effects from the patches and the gum tastes disgusting and can make them feel a bit nauseous. The inhalator can work well for some people, but sometimes it causes an irritation. But really, side effects are minimal, not an issue. Sometimes people will go, oh my God, what happens if I have the patch on and I smoke? It is such a tiny dose that they are not going to have a problem.
Now this is a really great graph, because what you are seeing here is what happens with a cigarette, okay? Now this is only 1 mg to 2 mg and I want to flag here that people will talk about going down to a lower milligram cigarette. Complete waste of time. The way people smoke will affect how much nicotine they get delivered. So if they are someone that draws it in and sucks up really, really effectively, they will have a much higher level of nicotine than someone that just has a little puff and then the rest of the cigarette smoke goes out into the atmosphere. But what you can see here is, there is no way that any of the NRTs actually replace the cigarette entirely. So, it is really important to be saying to people that you know, the sprays are slightly better, but they will not give as much relief. So you can see with the pink one we have got the Nicabate 21 which is one of the nicotine patches. Very slow onset. It is not like having a cigarette. It does not give you that lovely lift and that lovely hit. It does not give you the back of the throat and give you that lovely feeling. And it is important to talk to people about this and to say it can help with cravings. And I always say to people, you know, the patch is your background that helps you to not want to smoke as much, and then the oral forms do about 30% of the craving and you have got to do the other 70%. So it will not feel the same. But we do know that this works and it helps people to give up much more effectively than on their own. Moving on.
Okay, avoid under-dosing. From my point of view, you really cannot overdose, and there are some more slides that will look at using multiple patches. Combination NRT, the patch and the gum, really safe, better outcomes and really reassure your patients when they say, oh my gosh, I am scared that I will overdose on nicotine if I smoke and use the patches and the gums. No, you will not. It is okay. The only way you can overdose on your patch is if you squeeze out all the nicotine, stick in a syringe and inject it into your veins. Then you might have an overdose of nicotine. Other than that, you cannot overdose on these substances the way they are taken.
Night patching. Sometimes this can help if people really have that very strong urge to smoke on waking, to put the patch on at night before they go to sleep so that they have the peak just when they get up. Really from my point of view it is around putting a patch on at a time that you remember is more important. Do not stop too early. Once again, continue with the patch for as long as you need. Of course it goes off PBS after three months, but if people are having success and want to continue it, it is okay to continue it for some months. Next page.
So, Renee Bittoun. I do not know how many people know her, an amazing respiratory physiologist who has done a lot of work in this space. And this is a really great way to look at it, particularly with people who are highly dependent. In terms of people who are highly dependent, once again I mentioned, you know the thing that we have always been taught to ask is how many cigarettes do you have a day? That can give you an indication that they are a smoker and can give you some incitation of their level of dependence, but the single most important question you can ask is how long after waking up do you have your first cigarette? And if they are a person who has a cigarette there ready on the night table, light as soon as they wake up, within five minutes of waking, within 15 minutes of waking, they are more highly dependent. The other thing that I love and not many GP practices have this, but to get a CO monitor or a Smokerlyzer or one of those monitors that actually looks at the carbon monoxide in people’s blood. Great biofeedback. People use it, you know people can have carbon monoxide of 50, 70, 100. A non-smoker is kind of two to three or up to five if you live in a polluted environment. It is a great thing that you can use with people so that they know when they start that their CO was you know, 30 and when they start changing their smoking it comes down. It is a great feedback tool.
But coming back to this algorithm. Basically you start somebody on one and on a large patch, the 21, 24 hours. You know just before sleep, change each night. And within four days, have they stopped smoking? Fantastic, continue on the patch. If they have reduced but they are still smoking, add in the gums, add in the oral forms. If they are still smoking and it is more than 10 a day, if it really has not shifted, add a second patch and put it on daytime only and then if they are still smoking then go back to the lozenges. Once again, there have been times where I have used more than two patches. You know, for someone who is highly dependent you may go to three patches. And certainly Renee would say you just keep going until people become nauseous. The issue here is that you cannot get additional ones on the PBS so you are looking at people having to pay for it, but once again using more than one patch is very, very safe, particularly in this highly dependent group. Tim, you are going to ask me a question.
Tim: I am, which links in very nicely with that. People were asking what the cost of patches are over the counter and on PBS?
Hester: Yes, so on PBS they are the cost of a script, and if you are on a healthcare card, I believe that is $6.60. In terms of buying them over the counter, they are a bit cheaper than buying cigarettes. Do not quote me on the price, it has been a while since I looked at what the over the counter cost is. But they are totally available over the counter. One of the interesting things though, is if people get these over the counter and do not get them through their doctors, they do not do as well. There is something about that therapeutic alliance, that engagement, the support that happens with seeing a doctor or seeing a healthcare worker, to actually change your smoking that actually improves outcomes. So, yes you cannot get it on PBS but it is worthwhile looking at, well am I going to use more than two patches if this is really not helping?
Tim: And it is three months’ supply, isn’t it?
Hester: Three months’ supply through the PBS in a 12 month period. Yes, that you get on the PBS. The other thing is just working with people around if they really have very low confidence. Okay, do not even try to stop smoking. Do not even try to change it. Put a patch on. Put a patch on and see what happens. And very commonly they will come back and they will go, I just put the patch on, I did not bother, but you know what I did not have a cigarette until two hours after I woke up. They have dropped their nicotine use. They have dropped their tobacco intake. They have dropped the harmful amount of chemicals that are going into their body just by doing that. And so that is a success. And so you can say, that is brilliant. That means that the level of your smoking has gone down. Now the nicotine dependence has stayed the same. You have replaced it with the patch, but they have made a really important change to how they smoke. And if you have got a CO monitor, that is a great time to say, look it was 30 now it is 15. You really have made a huge difference. And that can actually build their confidence. Okay, so can you now put off your smoking for three hours? Can you add in some oral alternatives, the lozenge or the gum or the inhalator? Shall we add a second patch and see what happens? People do have a whole kind of story around it is will power, I have just got to commit, I have got have the motivation. And the fact is, this is highly addictive stuff and it is really hard to change and if we can build people’s efficacy with the support, they actually do better. Moving on to the next page.
Varenicline. Varenicline on its own has the best odds ratio of all treatment. It is a really good treatment. There are no known drug interactions. It does not work for everyone and if you have got someone who does not smoke every day, it perhaps does not work so well. And once again, the same with NRT. The longer you use it, the better the outcomes. So it stops the cravings. It is really, really great. Moving on.
And combining NRT and varenicline, there is not a great deal of evidence but it may improve quit rates. And it is certainly something to think about. The issue that you have is that you cannot get both of them on PBS. There has been a lot of concern about varenicline and the fact that it destabilises people’s mental health and it causes more mental health issues, particularly in people with enduring significant mental health issues. It actually does not. There is no good evidence that it does actually destabilise, however I always talk to people about the fact that, because the thing with varenicline is it stops the craving but it does not stop the nicotine withdrawal, so as you are changing your smoking, you can find that you are a bit more irritable and that is because you are changing your smoking. So let us keep a close eye on you. Let us make sure that you are doing okay. So I might see them, if I am concerned, I might see them more often. And I would certainly consider adding an NRT to help with the withdrawal. Look, and the other thing is varenicline may well have a role in changing alcohol and alcohol consumption in heavy drinkers. At the moment it is not recommended for pregnant and breastfeeding women and for adolescents. Hopefully over time that will change but it is one of those things where we just do not have enough evidence yet for it to be used in that group.
Nausea is the big thing. And sometimes it means that you start off with the low dose, so with the starter pack and you build up the dose. And for some people you can never get up to the full dose or they need to have anti-emetics, things like Maxolon, but it is an issue. Sleep disturbance and vivid dreams really are not a side effect of the medication, they are more a side effect of the withdrawal. You know, and so that is a really important thing to let people know. This is really likely to be your withdrawal. Taking some food may help with the nausea. Taking the tablets eight hours apart might make a difference to the sleep disturbances, I have not really actually seen that. But adding in the NRT can actually help with the withdrawal. Moving on.
So, this is really important because it is an issue that I know came up in my practice when we first started using varenicline, this sense that it made people really irritable and depressed and aggressive, and there was more suicide. There is no evidence that it is actually the varenicline. And kind of issues that happen are actually due to the nicotine withdrawal. And for people who have a history of psychiatric disorders and for those that do not, there is no difference. But once again, do if you have someone that has serious psychiatric illness issues, do keep a close eye on them and let them know. And we will talk more about how you actually use varenicline I hope at some point in this because there are some really interesting ways you can use it, particularly in this group. You know, and say to your patient, is anything happening? Any kind of unusual mood or behavioural stuff? I really want to know because I want to support you through this. Once again, avoiding alcohol is a really good idea during this time. Moving on.
So here we go. So here is a flow chart. Once again, you get your first script. Do not pick a quit day. And certainly the literature from the company that makes this may well say, quit on day eight. And that can work for some people. But I would usually do is say just start it and see how you go. And so you can do a quit on day eight. You can do a cut down to quit. Or you can do a quit day any time during the time that they are using the varenicline, generally within the four weeks. Sometimes it can take a little longer. You know, it is really individualising it for your patient and for their particular situation. So you may find, and this is really common, I say, just start taking it and see what happens. But you will see that within four weeks that they are still smoking but they have really reduced. They are not smoking as much, they have got a longer time after waking before their first cigarette. They are really not enjoying their smoking and when you check the CO monitor, it has gone down. And that is such great feedback for people, that they have actually made a change. What they are suggesting here is that if people are still smoking by about six to eight weeks, that you add in the NRT patch, or the oral NRT. Some people I might even use it sooner. And really it depends on how things are going. You know, so if it has no effect and the patient is still smoking the same amount, perhaps varenicline is not going to be useful for that person and you would probably stop that one and move on to combined NRT. And once again, you have with this medication under the PBS, you have up to six months that they can continue on in a calendar year. So once again, the longer people stay on it, the better their outcomes are in terms of stopping smoking.
Bupropion. We use this for a period of time, sorry overseas it was Wellbutrin which was an anti-depressant but licensed here for smoking cessation, Zyban. Zyban came out before the others, used a little. It is not as effective as the others, but it is something that you could try if they did not respond to the others. But please be aware of the history of seizures, eating disorders. You do not want to put them off it, particularly if they are on an MAO or even if they are on another antidepressant. You cannot use it in women who are breastfeeding or pregnant. Moving on.
I have to say, in terms of bupropion, I have not used it in a very, very long time. Some more warnings around use with other medications, alcohol use and the drug interactions. I will leave you to read that after the show. Moving on.
So, Jodie aged 28, 12 weeks pregnant. So she is stable on treatment for opioid dependence with a stable dose of buprenorphine sublingual. So, 14 mg which is a fairly middling dose. She is on buprenorphine mono because she is pregnant and she has been smoking since age 13. So, first of all it tells us something really important about Jodie. Any child that starts smoking at aged 13, you have to wonder about what is happening for that young person that they are smoking at 13. What is the cultural background? What are the mental health issues in the family or in the individual? First cigarette within five minutes of waking and she is smoking 25 a day. So I know from this that this is a person who is going to be highly dependent, who is going to find it tricky to give up, but she is pregnant and she is likely to really, really want to change this. You know, pregnant women absolutely want to change this. They can be as dependent as anything, but this is something that they really want to change and it is really important to support them and support them really strongly, because it is going to make a difference to them and to their baby and to the wellbeing of the newborn if they can stop smoking now and continue to not smoke once the baby is born as well.
So just thinking about how we might help Jodie. Moving onto the next slide and this answers the question before. Yes, really, really important. I really, really strongly support quitting smoking in the women that I see who are pregnant. And they do want to stop. It might be really tricky, but they do want to stop. And one of the things that can be tricky for pregnant women is that they feel so shameful about the smoking, and if you have any kind of judgement around, oh you should not be smoking, it is bad for the baby kind of approach, they feel so shamed that they will actually not want to engage. So, it is really turning that around and having a really positive spin. You know, there are evidence based treatments that can help you with this. Let us get it happening. Counselling and behavioural treatments are really important in NRT. Now, in the women that I see, I do not actually wait to see if the behavioural strategies are unsuccessful if somebody is 12 weeks pregnant. I want to get onto the NRT straight off. You know, certainly there is financial incentive, you have got a baby coming, this is going to make a huge difference to the costs for your family. And the other thing is, just thinking about a smoke-free home and cars. Is their partner smoking? Can they give up together? If anybody smokes, they need to smoke outside the household. If she cannot totally give up, you want it to be as low as it possibly can, and if she continues to smoke after the baby is born, only smoke outside with a change of clothes so that you are not exposing the baby to passive smoke. But ideally, helping them to give up and this high-risk and high-motivation time. Moving on.
NRT is not the first line of treatment. Well, you know, certainly in this group absolutely behavioural measures, if they work, fantastic. But the bottom line is, is that NRT in a high dependent woman, yes you are replacing nicotine with nicotine, but you actually want them to stop and you can get them to stop using that. So really, you know yes it is not first line, but in a highly dependent woman I would be moving to it very quickly. Generally we would start with the shorter acting ones, trying to avoid the amount of nicotine that the baby is subjected to, but the reality is if they are smoking, they are subjected to the nicotine anyway and the other 4,500 other poly hydrocarbons that are an issue. So I would, with some women what I am looking at, is I am talking about oral and I am talking about patches, I am working with them on what they want, but they may need combination. And while you can say, look nicotine use during pregnancy can affect the baby, but you are already using nicotine. What we are looking at is a short, sharp treatment that can actually assist you to change this and nicotine on its own is safer than smoking, you know. So it is a tricky one because they do not want to do their baby’s any harm but you do need to support them so they can change this really, really sticky, addictive habit. So, you know, start off with behavioural stuff. Start off with the short acting but do not hesitate to go to the patches and the short acting together if they cannot stop, because it is really important that they do. Moving on.
And when people stop, yay, congratulations! Even if people stop for a few weeks, fantastic, it is great that you did that. And what are you noticing, what has changed? What are the benefits that you are noticing? Looking at how they might manage the triggers if they are going out with their mates for a drink, that is the time they always smoke. How are they going to manage that? And if they do have a lapse, how are they going to manage that? People very commonly will say, oh I had one cigarette, I am useless, I am hopeless, I have failed. And then I started smoking a whole packet. I would always say to them, okay you had a lapse, but what do you want to be? Do you want to be a non-smoker? Look upon this as a learning opportunity. How did it happen, how can you support yourself to not do this? And let us get back on the horse and let us start riding again to become a non-smoker. Next one.
Sammi: We have got six minutes left, Hester. Did you want to instead of jumping into the resources, did you want to look at the case study of John?
Hester: Yes. Yes, totally, totally.
Hester: Because the resources are all there. You can take a look at them. Beautiful things there both for providers and for patients.
Okay, so Johan. History of alcohol dependence. Recent withdrawal in hospital. Now on acamprosate 666 mg tds. Not drinking. He is 20 mg bd of his oxycodone for his back pain. There is a whole issue there around what needs to happen with him there. Long standing depression, high blood pressure, high cholesterol and previous AMI. He has been smoking since age 15 and wakes during the night to smoke. His carbon monoxide is 50 parts per million. So how do you approach this? Tim, how would you approach this?
Tim: What a great question. The first part of the case actually feels quite familiar in its complexity where the sort of thing I would do would be talking to him and seeing what he wants to do first of all. Where does he feel he is at? What does he want to work on? What is contributing to each other? So that back pain I think is significant and he is on oxycodone for that. He has had withdrawal in hospital I see and he is not drinking, so I congratulate him for that. He has made a really good start. I would want to know a bit about past history including the depression, because that is going to play a great deal into his ability to sort of think through what he wants to do and make decisions around that and feelings of guilt around perhaps not being able to achieve it or not being confident that he can achieve it. He wakes during the night to smoke, so he is significantly addicted to cigarettes and so we are going to have to really work on that, he is going to need help to get off the cigarettes and he has already started with alcohol which is fantastic. We have to consider the role of the oxycodone as well, whether he may have an opioid addiction going on too.
Hester: Yes, absolutely, absolutely. And certainly with that CO of 50 parts per million, he has got a significant nicotine dependence. So it is a surrogate marker. The amount of carbon monoxide in your blood is a surrogate marker for your nicotine dependence. So for someone like this, you can use the combined NRT, you can use varenicline. I would put the bupropion on a very distant second. You could look at using both of those. But once again, working with him around what does he want? What does he want to achieve now? What are his worries? And I would certainly be looking with him, has he tried to give up smoking before? It is very likely that he has. He may have had times in his life where he has had years at a time where he has not smoked and he has really good success. Or he may be someone that has never successfully in his mind, stopped. So you want to support him. He will need a lot of support to actually change this. And the other thing is, with the oxycodone that he is using, you may find that once he stops smoking, that he does not need as much. That his need for the oxycodone will actually go down. But you are absolutely right to flag the issues with dependence. I think we are finished.
Tim: Marvellous. We have got about three minutes left. I will just fly through some of the questions for you as well. There are a couple of questions around using cannabis as well, say if a pregnant woman was using cannabis, what you might do and if medicinal cannabis has any effect on quitting smoking?
Hester: Ah, the medicinal cannabis issue. Look this is really unclear. There is really not a great deal of evidence around the role of medicinal cannabis. And certainly smoking any burnt organic matter is not good for you. The role of cannabis in pregnancy is controversial. You know, the bottom line is ideally, what you want if you have got someone that is using cannabis and nicotine you want to help them give up both. And using pharmacotherapy for nicotine will help them. We do not have good pharmacotherapies for cannabis, so they do need to do through cannabis withdrawal if they have a dependency, lots of support, lots of encouragement, and helping them to build their skills and their motivation are a really important part of that.
Tim: Lovely. And a final question which I suspect we were expecting. What is the role of e-cigarettes?
Hester: Yes. So, I think that e-cigarettes can be very useful in a very high-risk person, very high nicotine dependent who has not succeeded with smoking cessation through other means. E-cigarettes may be a harm minimisation for someone like that. I just need to flag that they are currently not legal. You cannot legally buy e-cigarettes with nicotine in them in Australia. You have to import them as a smoker yourself. I have to say that what we see is people will use their e-cigarettes and they will continue to smoke. But the reality is that they may well be cutting down the amount of tobacco which is a good thing. I have to say that I am concerned that we really do not know what the long term risks with e-cigarettes are, and I am concerned that they are becoming popular and cool with young people. I am concerned that there are people who can make money out of moving people from tobacco to e-cigarettes and particularly another generation of young people who are using this cool thing called Juul, or e-cigarettes. That is a concern. But they do have a place and there are certainly some of my patients who have tried really hard every other way, they are high risk, where it is a harm minimisation approach to assist them to use e-cigarettes. I just have not found that it has actually particularly assisted them to stop completely, and ideally, that is what I want to do, is move them from the e-cigarettes to actually stopping completely if I can.
Tim: Thank you very much. We have hit the 8.30 mark, so if we put up the learning outcomes again, I hope we have achieved all of those learning outcomes. Thank you very much everyone for your attention and for your questions that have come through too. You can see the learning objectives there. I think we have achieved all of those. Thank you very much, Hester for an excellent presentation tonight and thank you as ever, Sammi for running all the technology for us and coordinating us this evening.
Sammi: That is wonderful. Again a big thank you to Hester and Tim for presenting for us this evening and also to everybody that joined us online. We really hope that you enjoyed the session, and enjoy the rest of your evening.
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