Case studies in Smoking Cessation

Sammi: Good evening everybody and welcome to this evening’s Case Studies in Smoking Cessation webinar. My name is Samantha and I am your host for this evening. Before we make a start, I would just like to make a quick Acknowledgement 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.

So I would like to introduce our presenter for this evening, Dr Lyndon Bauer. Lyndon is a GP who works on the Central Coast in New South Wales and is a Conjoint Senior Lecturer with the University of Newcastle and has worked part time in health promotion since 1993. Lyndon first started his smoking cessation interest in 1992 and he has been working in the area ever since. And we are also joined by our facilitator for this evening, Dr Tim Senior. Tim is a GP at the Tharawal Aboriginal Corporation in South Western Sydney. Tim is also 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 at UWS, and an RACGP Medical Educator. So, welcome Lyndon and Tim and thank you for joining us tonight.

Lyndon: Thank you, Sammi.

Sammi: No worries. So I will hand over to our facilitator Tim now, to take us through our learning outcomes for this evening and then we will hand over to Lyndon to commence the rest of the presentation.

Tim: These are learning outcomes. So this is educational speak for what we want you to get out of this evening. So by the end of this online activity, you should be able to provide smoking cessation and advice and support to a range of different patient groups. You should be able to discuss tobacco treatment options and consideration for highly dependent smokers and teenagers and young people. You should be able to discuss practical ways of engaging and supporting patients who smoke within general practice. That is engaging with them in general practice, not smoking with them in general practice, obviously. I shall hand over to Lyndon. If you do have questions as we go through we will do our best to answer those as well go through. Just put those into your chat box. So, good evening Lyndon. Thank you for presenting to us tonight.

Lyndon: Hello, Tim. Thank you very much. Now I think we start out with my interest in smoking cessation, is that correct?

Sammi: It is.

Lyndon: Okay, so I will go right ahead. As Sammi mentioned, I have been working in the field of smoking cessation since 1992. Believe it or not, we had no pharmacotherapy at all way back then and I was introduced into the Robyn Richmond’s Smokescreen program that was before even nicotine replacement therapy was available. I think I was impacted very much at an impressionable age by a particular relatively young person with a lung cancer death sentence from smoking, and I think that had a really big impact on me. I then went on and I worked as a medical registrar in a respiratory term, and had wards of people all of which had basically smoking related disease and were suffering incredibly. I really was frustrated by the fact that we had diabetes educators, we had asthma educators, but we were doing nothing about this completely preventable and tragic disease process. So, yes, I have gotten into smoking since and have not been able to avoid it since. Not that I would want to, it is a great field.

Now the pictures that we are showing on the screen at the moment are from a very recent outreach that we did with a local Aboriginal Darkinjung community, and this was a result of a meeting that we had where some of the Aboriginal people said to us that it was quite different for them compared to the general population where we have a very supportive environment for people who want to quit smoking. But they felt within their community they often felt outcast and not supported, that they were made to feel different when they wanted to stop smoking. So we thought, well how can we engage just at that very initial level with the community to create a supportive environment for people to quit smoking and it is so many years behind what the general community is, but it does make it so much harder for people if they feel outcast if they do stop smoking. So the picture in the middle won the competition and it is an abstract Aboriginal art showing a heart with I guess coronary arteries in the centre and bits of smoke around the outside of the circle. And the circle represents a meeting, so the kidney shapes are actually people in a meeting. The little round pools are water pools that are usually at a meeting place and then you get the smoke and the shadows of more people around in this meeting. So it was an abstract Aboriginal art looking at the way that smoke impacts on their meetings and their groups.

Then the follow up second and third prizes was the Aboriginal flag and a very black and white image of death and the other was a smoking and the eleventh hour time to make a difference. So I just thought I would share that with you. That is some great input we have had from the Aboriginal community.

Okay, so taking a case study approach today. We will be presenting some cases of some, various typical sorts of cases that I have seen frequently in general practice and to try and make some real world suggestions for you in your own practice.

Okay, so let us just start with the basic fundamentals, and the first one is the five A’s. And the five A’s are a framework which in themselves you will not necessarily think of every day, but really underpin the way that you need to approach smoking. And the first of the A’s is Ask. Now, I know that we ask everyone who comes into our practice whether they smoke, but people change their smoking behaviour. They may well have quit when they first came into the practice. They may have started smoking from never having smoked before. So, if you do not ask again, after they first come into the practice, there are many times when you are going to miss someone who is smoking. So, as a system for me, whenever someone has a trigger such as a diabetes check, a blood pressure check, asthma, a cough, a child coming with an ear infection, I would throw out that question, “Just checking you are a non-smoker, you are in a non-smoking house” et cetera. And it is not a question that takes more than a quarter of a second and people do not find it an insulting question in any way, but it is an important question to just keep asking.

The second of the A’s is Assess. And this is the A for me that I think is really important and many of the other presenters I have seen, do not present this is in quite as a comprehensive way. So if there is one slide that I would like you to come back to over and over, it will be this one. The first thing to assess in your smoking client, is readiness to quit. And this goes right back to the Robyn Richmond Smokescreen, before nicotine replacement. Essentially, depending on whether the person is not ready, unsure or ready to quit, you need to deliver a completely different intervention to that person. If you have not established where they are at in that cycle, you will be delivering the wrong thing to the wrong person. So for instance, for someone who is ready to quit, if you harp on about all of the health effects and make them feel bad about themselves, you are going to lose rapport and you might have lost a good opportunity to help them quit smoking. If someone is unsure about quitting, they already feel quite bad about their smoking. There is a limited amount that you need to do about making them feel bad about their smoking. You need to know what are their barriers? Why is it that they are not ready to quit? They feel bad about their smoking already but they are not ready to take that step. So what are the barriers? You have got to deal with them. Perhaps that is all you deal with them in that particular session and then have them come back later once you have addressed those barriers and then talk them through all of the steps of quitting. Someone who is ready to quit is someone who you focus almost entirely on teaching them how to quit, what is the quitting process. And then finally, the person who often makes people the most frustrated, is the one who is completely not ready, and they are the ones who are quite simple. Basically personalised medical advice. They are the ones who you do need to focus on all the scary stuff about why they need to quit.

Now, urgency of cessation. In the case studies today you will see that there is a very different urgency depending on the person, and unless you get in mind whether this person really needs to quit now or whether they can quit soon, or even in a few years’ time, it will help you very much with what you need to deliver to that person.

Nicotine dependency. A lot of people are familiar with this one. Its strongest indicator is time to first cigarette. That is what TTFC stands for. So, anyone who needs to smoke within the first half hour of waking has a strong nicotine dependence. Later on I will present a woman who actually had to wake up through the night to smoke. People who find that their nicotine levels have dropped very low through the night and have a very strong urge to smoke, are the people who will have the most trouble when they try to quit smoking. Also, previous attempts will give you an idea, and they can tell you whether they had terrible cravings, mood problems et cetera. The number of smokes per day is an indicator, but not the be all and end all. Changing your smoking style can make a very great difference to the amount of nicotine that you take in. If someone smokes 25 a day, I understand from nicotine output in the urine, that they need to get down to as little as five a day before they actually reduce that nicotine output. They can compensate for their reduced number of cigarettes simply by breathing that smoke in so much harder and holding it in so much longer. So when you get someone to actually cut down without the support of nicotine replacement therapy, in many ways you are saving them money but you are not really saving them the health process. All you are doing is really dragging the same amount of cigarette smoke and nicotine out of fewer cigarettes. So this is one of the reasons why cutting down without using nicotine replacement therapy has usually failed in the past. Past experience is very important. If they have used different types of pharmacotherapy, what has happened with them, particularly if they have used some of the tablets, you know how have they worked?

Now comorbidity. In Australia and also research from the United States, nearly half of all people over 35 who continue to smoke have a demonstrable comorbidity. Now many of these comorbidities are not diagnosed until the researcher has looked at them, but they will have a demonstrable comorbidity. Now, the sorts of comorbidities we are talking about here are anxiety or depression, alcohol problems, cannabis or other drug use. If you do not screen for those comorbidities, the chances of getting them to quit without addressing those comorbidities is really low. So, many people have say anxiety or depression and they find that they smoke to somehow or other ease the feelings of depression, or they mix their cigarettes to help them smoke their cannabis, or every time they use alcohol their will power to quit smoking drops and the triggers for smoking come back. You really need to screen for comorbidity and you need to address comorbidity if people are going to quit smoking.

The setting is important. Money is so important. If someone smokes 20 cigarettes a day for 10 years now at today’s prices, they are going to spend nearly $100,000 – it is $99, 900 – at today’s prices. Money is becoming a critical reason why people need to quit smoking. Also, children at home, workplace et cetera.

And then finally, a quick assessment, are there any risks here? Drug interactions are important and drug interactions are mainly due to the smoke rather than the nicotine. The smoke itself, the polyaromatic hydrocarbons induce liver enzymes and cause those liver enzymes to chew up drugs and to mean a dosage adjustment is needed when the smoking is stopped. Using nicotine replacement therapy does not buffer that interaction and that is very important. Also, if someone has a history of mood problems, history of suicide attempts, take that into account because whilst their risk of suicide is no greater with many of the drugs we use than smoking cessation alone, in that acute smoking cessation period there is a risk and people need to have special support if they have special needs.

Okay. So the next A is advise, and so advising you are going to be doing the things that are appropriate for that person’s stage of change, whether they are ready, unsure or not ready to quit. If they are unsure, you will be looking at their barriers and you will be addressing you know, for instance whether it is weight gain, whether it is addiction, whether it is stress. You will be advising them around that. If they are ready to quit, you will be advising them on how to quit, and of course if they are not ready to quit, you will be moving them closer to the day when they are ready to quit by talking to them about their personalised medical risks.

Now I talked a little while ago about some of the drug interactions. I do not want to spend a lot of time on this one, because there are some excellent handouts around. One of those is on this slide, but you really only need to google and look for that and there is lots of paperwork around. The one to keep in mind as the very, very most dangerous is clozapine. Clozapine is a drug which is used in the psychiatric field and usually used in people with quite difficult to control schizophrenia. However, dosage adjustment is almost always required when a person starts or stops smoking. Remember again, the nicotine does not buffer this, it is the cigarette smoke that is the problem. So when they stop smoking the liver enzymes are not induced any longer and so the dosage of clozapine has to be reduced. Otherwise it can be toxic to the point of death. However, when they go home and start smoking again, the drug will become chewed up by the induced liver enzymes and their schizophrenia will return.

There are some other effects as well, for instance alcohol is affected by smoking, and when people stop smoking the alcohol is less metabolised by the liver and so they need to drink less alcohol. If they drink the same amount of alcohol, they are going to have more effects from that alcohol. Caffeine as well needs to be adjusted and so, if people quit smoking they need to cut back on their caffeine.

Now the next A is Assist after we have advised, and I just want to say do not forget the Quit Line. A lot of people have the impression that the Quit Line is a service that sends out pamphlets and is a bit of a soft service. It is not. It is something that if it were any other service we would have to pay money for it. It has well qualified counsellors. That counsellor engages the person. They then follow them up. They have the option of being followed up through SMS rather than telephone if they wish. I cannot say enough and the guys at Quit Line know so much about all the different ins and outs of all the behavioural stuff and also about dealing particularly with nicotine replacement therapy but also with varenicline et cetera. So the support of the Quit Line is a real must. It is a good way to complete the requirements for the authority drugs, but look it is just a great thing to do as well. Now, if you asked the person to ring the Quit Line, in my experience they usually do not. If you do the fax off, and then the Quit Line person contacts them, you have gotten over that first barrier and they can chose then how much engagement they want to have with the Quit Line. However, the more follow ups the person has, the more likely they are to actually eventually be successful and they just cannot come back to see us in general practice enough times to really get that thorough.

Tim: We have got an interesting question about the Quit Line. What happens when the advice you give conflicts with the advice from Quit Line? Has that happened to you? Does that happen much?

Lyndon: The only advice that I have found is that Quit Line being a bit in front of me, they started using nicotine replacement combined with varenicline before I thought that was a safe thing to do. So I rang them up and we had a good old chat about it, and yes it was a learning experience for me. But, if, certainly if there is something that is being said by Quit Line which is wrong, then yes, I think it is important that it is addressed. So I guess that would be contact through the Cancer Council initially since they auspice the Quit Line. However, it has not been my experience. It has been much more my experience that they are ahead of the game. They are trained very much on evidence based policies, so I do not think it is impossible, but I would be surprised if they are doing things that are too outrageous. And Assist I Can Quit, so I Can Quit is a website which first of all has lots of information and people can also then sign up and do a computer based support service.

Now, if a patient refuses the Quit Line then offer four to five smoking cessation visits and for myself, that initial visit is generally billed however I bulk bill all the follow up visits because I really do need to get them to come back that four or five times. Now, research from the early days of smoking cessation showed evidence that people who came back less than four times had a really low cessation rate, down around the 10% or less. Whereas the really good cessation rates were up around the four or five follow up visits. The first two weeks are also an important time for follow ups because that is where most people will have the most failures and the most times when they go back to smoking.

The next A is to Arrange. So most relapses happen in the first two weeks and to have someone following them up, whether it be yourself or to have Quit Line following them up. Of course there are the required follow ups if you are using the authority pharmacotherapy and that is helpful as well, but yes as I said it is important to get those at least four visits in.

Now, engaging and supporting patients. Be aware that everyone experiences smoking cessation in different ways and the drugs will work differently with different people, and some people as some of the cases will demonstrate for you, find it an incredibly difficult process to actually quit smoking and to go through nicotine withdrawal. Other people find it quite simple. People who themselves have quit smoking often frown on others as not having will power. It is that they are experiencing the smoking in a different way. So be aware that smoking can often be associated with feelings of shame, especially now in pregnancy, people who are pregnant who find they cannot stop smoking. It really is of the level of feeling like they are using illicit drugs and there is terrible pressure on them. If people feel judged or shamed, then they will not divulge their smoking and they will not be able to seek your support. So the sort of thing I say to my patients is, “I hope for your sake, that this attempt will be your last and I fully understand that most people need many serious attempts to quit and you need never be fearful or ashamed to admit to me that you have slipped and I will always be guided by you when you are ready to take it on.” So, yes, that is the sort of thing that I would guide you to be running with so that you can maintain the rapport. More often than not they are going to fail. Even in the best of research studies we are looking at something like 25 perhaps of the very best studies, 30% quit rates at 12 months. So the majority of people are going to fail and if you make them feel shameful about that, that is it you do not engage them again.

Tim: We have got an interesting question as well in terms of engaging and supporting patients. What about patients who ask for hypnotherapy? What is your take on the evidence around hypnotherapy for smoking cessation?

Lyndon: Hypnotherapy has some very mixed evidence and my take on that ultimately is that hypnotherapy can work really well for people who believe in it. So hypnotherapy to my understanding is a process of suggestibility and implanting confidence and thoughts in people but it only works if the person themselves strongly believes in it. So, I have sent people for hypnotherapy but only if they come to me and show a real belief that that will work. It is not something that I would ever suggest to someone who had any doubts at all.

Okay, so tips for using nicotine replacement. The average smoker likes to have a blood level up around the 30 nanograms per mil and one patch after four hours gets up to about 15 nanograms per mil. So one patch is underdosing most smokers who quit smoking. We will talk about the way in which we have a protocol for upscaling the nicotine to the way the person needs it in just a moment. Often, we need the use of combination nicotine replacement therapy. As I mentioned, if you are going to take a patch off at night and put it on in the morning, four hours before that patch is getting up to even a half reasonable level, so you are up to lunchtime. So in that period you definitely need something that works a little faster. The fastest type of nicotine replacement therapy that we have at the moment is the oral spray and that will work within a couple of minutes and get levels that are coming up and around that of the patch. However the faster the nicotine works, the more likely the person is to become dependent on that. Now, becoming dependent on nicotine replacement therapy has never happened in the literature for anyone on patches, because it does not have that rapid surge, that rapid uptake. However, the faster the uptake of the nicotine, the more likely dependence. Dependence in itself is not a great problem. Nicotine in itself is nowhere near as harmful – I would not quite say harmless, but nowhere near as harmful as smoking itself. So we do not have to be too fearful about dependency, but it is something to think about. Night patching can be used, where as I said, your patch takes four hours before it reaches a reasonable level, so take the patch off at say five or six o’clock and then last thing before you go to sleep, put another patch on. You are not reaching reasonable levels until the early hours of the morning and then you wake up fully charged. Carbon monoxide monitoring is used in many of the rehabs that I have worked with and we also use it as promotion and health promotion. I think the machines are probably a little expensive for the average general practitioner to have in their practice, but what I actually use myself for screening is a rapid mini spirometer type machine which rather than doing full spirometry which takes quite a while, simply measures the ratio of FEV1 to the six second vital capacity and it screens very much for people who have early signs of emphysema. Now everyone who smokes does not develop emphysema. There is a small group of people who are prone to it and you can pick them up as early as in their thirties and certainly in their forties. Those people have a real urgency for cessation because they are the ones who are going to go on and have the COPD and emphysema later on. It has often been suggested that we should screen everyone, but the trouble is, if you do thorough testing on people and then tell them, oh no you are fine, there may be a subliminal message there that it is okay to keep smoking which of course it is not for all the other problems. But I still think it is a great help to me to be able to screen my smoking clients to see if they are one of the ones that emphysema in their future. So for NRT again, is do not stop too early. Whilst the Cochrane studies show that for your average basic smoker, two months is enough and then stopping suddenly is okay, that is for people who are just using one patch, and it is for people really from I believe, the earlier days where we did not have those last remaining people who are finding it really hard to quit. So there is not really a harm in extending the nicotine replacement therapy out for a few months beyond that to reduce the chances of them going back to smoking.

Tim: Sorry just a quick question here which I just confirmed is nicotine replacement safe to use with people with cardiac disease?

Lyndon: Okay. So someone who has been smoking and has cardiac disease is always safer on nicotine replacement therapy than on smoking. They get much more nicotine from the cigarettes and they also get carbon monoxide and the polyaromatic hydrocarbons do cause the platelets to get sticky and cause them to get thrombi in their vessels. So, someone who smokes is always safer to go from smoking on to nicotine replacement therapy. There are research studies showing it is also safe to use nicotine replacements on people with angina et cetera who have stopped smoking post-surgery. Personally, I do not use nicotine replacement in those people without the support of their cardiologists or also until they have their first cigarette. Once they have that first cigarette there is no question for me that the nicotine replacement is much, much safer. But someone who is in that sort of unstable situation and they have not been smoking, really the evidence is it probably is safe but you know, just in case they are going to go on to have another heart attack, I do not want them blaming my nicotine replacement therapy. So that is really my feeling on that one.

Okay, so the combination nicotine algorithm from Renee Bittoun. This looks complicated but it can be summarised quite easily and that is that you let someone continue to smoke while they are wearing a patch. Yes, I did say that. They are not going to die from it. In fact people now self-regulate their nicotine intake very strongly. If they wear a patch, they will reduce the time that they hold the smoke in. They will reduce the number of cigarettes and the output in the urine does not change. So they self-regulate their nicotine very strongly. So it is not dangerous. But what happens, is if they need 10 cigarettes on top of a patch, they are going to need another patch. So let them go away again now with two patches and smoke if they really need to and if they continue to need 10 cigarettes a day on top of two patches, they need another patch. So you can continue to increase. Now my record here was someone who got up to four patches. But two is really common, probably the norm. Three is reasonably high. Four is my absolute record, so that has happened only once for me. Once the person is able to easily be satisfied with just a few cigarettes a day, that is less than 10, let us say five cigarettes a day on top of whatever patches they need, then just bring in some gum, some lozenges or some oral spray or the inhalers. We will say one thing about the inhalers. They are great because people feel that they have got a replacement for the cigarette to hold in their hand, but they do deliver a really low dose of nicotine. They also still taste like the menthol flavour but they lose their nicotine very quickly within about 20 minutes. So, if you are really looking for nicotine replacement, the inhalers are a good hand-mouth replacement but they do not deliver terribly much nicotine and you will always need to have the back up of at least patches with the inhaler.

Okay, so case 1. Is it okay to go ahead with the cases now?

Sammi: Absolutely, let’s go.

Tim: Let’s go.

Lyndon: Um now I am starting out with a fairly simple case and the more interesting unusual cases coming up in just a moment. So we have a 19-year-old female who at this point sees herself as a social smoker and she is coming in for contraceptive advice. We are probably going to be looking at the oral contraceptive pill. She smokes five to eight cigarettes on a Friday and Saturday night and occasionally she is smoking during the week. She has been smoking for about the last six months. She started smoking to fit in with friends. At this point, she does not think that she will progress to daily smoking and she believes she will be unable to quit before it does her any damage. And I think that the point that I want to make here, is that in the vast majority of cases, this is going to progress on to daily smoking and at least a substantial degree of nicotine dependency. There probably is not a great deal of nicotine dependency yet as she is able to go for several days without smoking, however sometimes there is and that may need to be addressed. We are looking more and more at the problem of smoking during pregnancy. The child in utero is actually being pre-programed with the nicotine so that later in life they may well become addicted quicker and also all of the birth outcomes for the child, including many other unusual things such as they are born underweight but as a result they seem to go on to be more obese and the number of cigarettes smoked is directly proportional to the obesity of children at five years of age from two studies, one here in Australia. So we are looking towards young women and smoking and you think, well we just get them to quit when they are pregnant. But it is terribly, terribly difficult. The research shows that around 45% of women quit as soon as they find out they are pregnant. It is a big thing for them to find out they are pregnant. That is still less than half. And the remainder it is just incredibly difficult to get them to quit smoking. We brought in nicotine replacement therapy in the hope that we would double the quit rate at the end of their pregnancy as has happened with all other classes of people, smokers where we have brought in nicotine replacement therapy. But the results from the research have not been reassuring on that, and whilst the birth outcomes seem to improve with nicotine replacement therapy, the quit rate is not improving much at all. So the whole area of smoking and pregnancy is really difficult and I am more and more focussing on women to quit smoking before pregnancy because it can be so difficult. But why is it so difficult for women to quit smoking during pregnancy? As some of the previous webinars have discussed, women seem to find it in many cases harder to quit smoking than men, as opposite to alcohol where men metabolise alcohol faster than women. Women metabolise nicotine faster than men, and as a result they find they bring on their cravings much more acutely and quickly. Also, it seems to be worse when the hormones kick in and seems to get even worse during pregnancy which may be why they find it so hard to quit smoking during pregnancy. So this is a case example where I think using your leverage on, well it is not good to be smoking and on the pill, whilst I would go ahead and prescribe the pill to a young smoker, it certainly is something that I would say is a risk and that I really want them to think about that. And I would also focus very much on the cessation and how they might quit. So, we are always asking young people about smoking. We are talking about the risks of smoking and the contraceptive pill, quickly can become a daily smoker, and then the stages of dependency kicking in. Best to quit now. Pregnant later and it will be harder. And if she is starting to find cravings even at this fairly early age, some intermittent NRT would not be out of the question. Any questions?

Lyndon: Okay, I will move on to the next example. Now, this example I drew from a woman that I looked after who was actually in an inpatient facility that went smoke-free. And it was an extraordinary case which for me illustrates very much this, what I was saying about the difference between different people’s experience of smoking cessation. And having seen this woman, I now know that no patient who ever went through this could go through it without going back to smoking, unless they were you know basically in a place that they could not escape from, which is what this woman was in. So she was smoking 45 rollies a day. She had a time to first cigarette of negative four hours, because she actually got up in the middle of the night to smoke and needed to do that every night. She was terrified at the prospect of quitting. She did think that rollies were safer and rollies I will say is often a sign for people who are having financial difficulties affording their cigarettes and sometimes they will go on to buy the illicit tobacco from the markets. Sometimes rollies are a sign of people using cannabis. But the rollies are a bit of a warning sign there as well. Now, this woman when she was forced to quit smoking in the facility going smoke-free got extraordinarily sick and some of your patients will be like that as well. There is no possibility without adequate support that a person could go through what this woman went through without going back to smoking. I can tell you that. It is not about will power, it is that physiologically it just would be impossible. She looked like she had a horrible flu. She was diaphoretic. She was incredibly angry. And she was completely unable to sleep and was incredibly sick. Now quickly, we got her up to four patches plus quite a few lozenges each day and with that she reached complete satiation. She was as happy as could be and really did not need to smoke at all. In fact she described having some great nights where she did not wake up through the night to have to go and smoke. It was just an incredible thing to see. Now, many of your patients may not be quite that bad, but if they experience smoking in that way and they stop smoking without enough nicotine replacement therapy they are going to have to go back to smoking. It is not just about will power, it is an incredibly difficult withdrawal for some people. Not everyone has the same receptors and not everyone goes through the same experience, but for someone who does go through this experience, it is incredible.

Tim: So, just some questions coming through. Just to confirm, when you talk about intermittent nicotine replacement, that is via gum or using an inhaler, those short term action ones.

Lyndon: That is right. Including the oral spray.

Tim: Yes, and the oral spray. And is, are there any contraindications to nicotine replacement therapy?

Lyndon: Yes, the only contraindication at this point would be pregnancy, and it can be used in pregnancy with supervision and under certain circumstances and guidelines. Since you have raised the question, I will cover that and we will jump over it when it comes up a bit later. So the guidelines essentially are the woman needs to have had two weeks of supervision and trying to quit smoking unsuccessfully without nicotine replacement. At that point the guidelines say that she can be offered nicotine replacement therapy. The first line of nicotine replacement therapy should be intermittent therapy rather than patches because we want to minimise the total dose of nicotine. As some women suffer from nausea with oral types of nicotine, you can go on to patches as a second line. It should be for two months and then you should stop. Why are we so strict about this? Because of the nicotine affecting the baby’s brain, and it may have lots of impacts that are not so important in adults but are very important in the baby. So, if they are going to smoke anyway, the nicotine is certainly the lesser of two evils. Smoking, maternal blood, sorry the foetal blood concentrates and drags it off the maternal blood. Unfortunately that means the foetal blood also concentrates carbon monoxide, and the mother, although she is not poisoned with carbon monoxide, the baby is. The baby is concentrating the cigarette carbon monoxide and is being damaged by that concentration as well as the placenta being damaged. So lots of horrible effects to the baby during pregnancy and smoking. Really difficult dilemma. You should not go straight in with replacement unless you are using 41.41, but it is available and the research on it shows improved birth outcomes. Unfortunately though, as I said pregnant women still find it very difficult to quit altogether.

Tim: Um, there is a few questions coming through about the other treatments that we will get on to including e-cigarettes which we will cover at the end. And just I note there is a couple of different brands of nicotine replacement patch. People who react, have like a contact allergic reaction to one of the brands, is the other brand okay, or are there any other alternatives for them?

Lyndon: So first of all, nicotine is an irritant and everyone will get a bit of a red tingle and you are supposed to move the patch around. That does not mean that they have an allergy, it is just irritation. Secondly, if you are not allergic to, sorry if it is a true allergy, it is most likely to be to the glue and the different brands use different glues. So if you had a bad reaction to one, I would not put another patch fully on, but I would try say an eighth of a patch in a test area and see whether or not you are going to react to a different glue. So that is possible. It is unlikely to be directly allergic to the nicotine itself, but the nicotine is poison and it is an irritant so it will make the skin a bit red and so you do need to move that perhaps around.

Tim: Lovely. I think it is probably time to move on.

Lyndon: Okay. So, yes that was the end there. Four patches and lozenges, very good. Highly dependent. Now, the next case is a highly dependent smoker and they have had a bad reaction to varenicline. Their first cigarette is within ten minutes of waking. They smoke 25 a day. They had varenicline and had a bad reaction with vivid dreams and anger. Now I have seen this quite a few times in patients that I have looked after, and I would like to offer my thoughts on the issue. I have looked through the evidence. I cannot find anything to directly support my thinking, but I do have a valid argument on the way that this may be occurring. Now, it is not going to happen to everyone. Some people can have varenicline and still smoke their cigarettes and enjoy them. So varenicline is not completely blocking the nicotine they are getting from the cigarettes. But other people, when they are on varenicline it completely blocks their ability to have a sneaky cigarette. Many people do have a sneaky cigarette and in fact if varenicline is working well which it does for the majority of people, then in fact you know, you like them to have a sneaky cigarette because it actually they do not enjoy it and it helps their brain to disconnect from wanting to smoke. It is completely the opposite with someone who is using nicotine replacement or going to places that might trigger them to smoke and saying well try and avoid that in the first phases. With varenicline, having them triggered to smoke and not enjoy it is actually a really good thing and then they can learn not to smoke in those settings.

Okay, so what is happening with this person who has had this terrible response to varenicline? Varenicline can in some people and in the ideal, block the receptor completely. Now, for your average smoker who is not terribly nicotine dependent, it has an effect which stimulates the receptor partially and relieves their cravings. But I propose, and as I say, not evidence based at this stage, but I propose that those people who are completely blocked and very heavily nicotine dependent are having a precipitated withdrawal and that is why they are having the vivid dreams, the anger, potentially the mental health outcomes with varenicline. So as a result, and it has served me well in my practice, I am very cautious with anyone who is highly nicotine dependent who is going to go straight on to varenicline. And I prefer to reduce their nicotine dependency by using some nicotine replacement therapy over a period of time until they are not so nicotine dependent and then finally when they are ready to quit altogether, that is when I bring in the varenicline. Now, for some people who do not have that complete blockade from varenicline, they are still a heavy smoker, you might be able to get away with it and it does not happen to all of them. But in my experience for those people that come in saying that they have had this terrible reaction, it has probably worked really well, too well and it has actually precipitated a withdrawal in those people. So, yes look varenicline is probably the first best drug that we can use. It is the one that is most likely to be successful because they actually have this blockade of their receptor, and so when they do have their obligatory sneaky cigarette they do not enjoy it. So I would encourage you to use varenicline. However, I would also encourage you just to have a little bit of, particularly someone who has had previous mental health issues, like someone who had maybe suicide attempts and they are a very heavy smoker, personally I would go nicotine replacement therapy for a little while before we finally brought in the varenicline. Just with that, we talked about cutting down does not work. Unless you support the person with nicotine replacement, they just change their smoking style. If you have anyone who is smoking and not ready to absolutely quit just yet, you can still always use the cut down to quit strategy where you use a patch and get them to try and halve the number of cigarettes. Now, whilst we say cutting down does not work, cutting down with nicotine replacement therapy does work and even in people who were not intending to quit who were given a cut down to quit strategy, somewhere around 4% to 5% had quit at 12 months. Now this is in a group of people who had no intention of quitting. So you know, we now have a strategy for everyone, even the ones who are not ready to quit yet should be given the cut down to quit. Do not give it to someone who is ready to quit, but certainly to someone who is wanting to continue smoking.

Okay, we will move on. Case three. We have got a patient who started nicotine replacement and yes, sorry we have gone over all of that. Now the varenicline flow chart is the next flow chart and I think we have covered all of that. Most of you will have prescribed it and know that it is a tablet that starts out, builds up and then if it works properly the people stop enjoying their cigarettes. For people who have that slightly different receptor who continue to enjoy their cigarettes, as you go on you can add in some nicotine replacement therapy and if there is absolutely no reduction in their smoking after four weeks then you probably need to move on to a different type of pharmacotherapy. I would say that no effect is probably only around 10% of people in my experience but it certainly does happen and they just have different receptors. It just does not work for them.

Okay. So it is important to have a personalised approach as I said. It needs to be tailored to the individual and where they are in their smoking cessation flow through their life. Now the next example is about bupropion. Many people were turned off bupropion when it first came out. In Australia there were associated sudden deaths. All of that data has been refuted and it was really only that a large number of people took up bupropion and all of the sudden deaths were through smoking related illness. The only real risk with bupropion is that it does lower seizure threshold. So, personally I am a little prudent on that and I do not prescribe it to people who are drivers for their living and certainly never prescribe it to anyone who has a history of seizures in any way. However, around about a quarter of people have this amazing effect with bupropion where they just stop smoking. They have no interest in smoking, and for those people, it is probably the first line drug. So do not throw it out. Certainly consider it for people who have failed with other things and for someone who comes to you who has tried it in the past and they said it worked for them, I think that is probably your best bet.

Okay. The next case is something that I have been asked to face quite a number of times through my health promotion job. And that is the person who is at school. They are dependent on cigarettes. They are getting expelled and what are we going to do to make this kid quit? And this is where I am talking about the issue of assessing the urgency of cessation. And for someone, now as opposed to the woman we looked at in the first case who has not yet become dependent, this young man is already very dependent and he is getting the likelihood of not being able to complete his education because of his smoking addiction. And the research shows that the chances of getting us to get him to quit smoking are, is really low. So, the focus here needs to change, and that focus is to get a rapport going, to look for what this smoking is a flag for. What other problems are happening in this young man’s life, and to get him some nicotine replacement therapy with his parent’s approval so that he stops being suspended from school. He is needing to smoke at school because of his withdrawal. The chances of getting him to quit are poor. He probably has other risks and flags, whether it be cannabis or worse, and you need to get a rapport and continue with this young man and use nicotine replacement while he is at school so he can get through his day.

And bringing up case number six. And this is the cannabis one which I am sure everyone is always interested in. People who smoke cannabis almost always combine cannabis with tobacco and the tobacco makes the cannabis burn better and it gives them a much better hit from their cannabis. And now, I am increasingly seeing particularly people in their forties and fifties coming to me that are doing this and they are ready to quit smoking tobacco, and maybe not ready to quit smoking cannabis perhaps on the weekends. The other case is of young people like the person we just looked at, who are smoking way too much cannabis and their life is getting into trouble. Now the take home message here is that they need to separate the two drugs. They are frequently addicted to the nicotine which is making them smoke way more cannabis than they really would otherwise. They need to use something other than tobacco to make their cannabis burn properly, and then they may find that they only need to smoke the cannabis on the weekends and they can get away with it a lot less. And then, we can actually address the tobacco addiction. They need to know though, that they must never mix tobacco with their cannabis in the future, because tobacco is a drug that upregulates the receptors immediately and one cigarette and they might as well smoke a pack. And it is even different than alcohol and the narcotics in its speed of making people dependent again. So if they do continue to use cannabis they need to know they must never put tobacco with their cannabis again. Then, you can address the cannabis use. Now I have no magical cures for cannabis, but I do know of many clients who have been able to dramatically reduce their cannabis use simply by working out what it was that was driving them towards this behaviour, and in fact it was the nicotine rather than the cannabis.

I think I have covered all of that in what I just said. Now there are a few Apps that we would like to tell you about. Your Room. I had a good look at that just before we came in here today. I had a recent case that I was looking at who was using GHB which is something I did not know much about. I had a good look at Your Room and that helped me quite a lot. It is actually designed not for the doctors but for the young people themselves. Lots of good information there and lots of referral services for them to get to. And there are a lot of other resources here on this slide, and I think that is probably close to the end unless we are dealing with some questions.

Sammi: Yes, it is. So before we get Tim to review out learning outcomes, Tim was there any more questions that had come through?

Tim: No. I think the most important thing are those are the learning outcomes that I hope we have covered for you. But those two extra slides we have had a few questions about though so if they are still in people would like to hear a little bit about e-cigarettes.

Sammi: Absolutely. So we will jump to those slides quickly now and we can just have a look at them and read through those two slides on e-cigarettes.

Lyndon: Can I talk about it?

Sammi: Absolutely.

Lyndon: Okay.

Tim: Yes, please.

Lyndon: So, e-cigarettes is a bit of a battle. We have got some of the lead practitioners that are saying that they need to be forwarded and some that are saying absolutely no way. Where I stand on it, is that we cannot support e-cigarettes in the way that the industry is putting them forward at the moment. If you look at the way they are putting the e-cigarettes into movie placements, they are flavouring it with a young person, attractive flavours, they are making the big statements with the puffy stuff that comes out. The new trendy word “vaping” and the devices. And when you look at their adverts, they are saying you can vape so that you can smoke when you really want to. It is a way for them to continue smoking and stop people from having to quit smoking. They are placing it not as a way to quit. They are placing it as a way to save their industry and to perpetuate people smoking. The evidence of people using e-cigarettes as a smoking cessation tool is really quite poor. Look it may be successful it is placed in the right context, but that is not the context that the industry is putting it in at the moment. Now, having said that, there may well be the occasional really end stage person who for instance I have someone with bladder cancer and peripheral vascular disease and COPD and heart disease and he still smokes. He has quit numbers of times but he goes back to smoking and I have done everything possible. It may be for that individual, that end of the line e-cigarettes are probably better than going back to smoking. However, that one person is probably where I draw the line and for the rest of it, it has really been placed as a way to continue the smoking game for the industry, not to stop it. They are not making any attempt to bring it in as a regulated medication and to dull it down so it is not attractive for young people and to stop all the flavours and the movie placements et cetera. So no, look I have to say e-cigarettes are a real problem.

Sammi: Fantastic. And we have got one more slide there that has the New South Wales Ministry of Health and also the RACGPs position statement that you can have a look at as well.

And Tim, if you want to take us back to the learning outcomes and then we can wrap up.

Tim: Yes, so just to cover again, this is what we hope to achieve from this evening. That you will be able to provide smoking cessation advice and support to a range of different patients groups. Discuss tobacco treatment options and considerations for highly dependent smokers like teenagers and young people, and discuss practical ways of engaging and supporting patients who smoke within our general practices. So, it is 8.30, so I would like to thank Lyndon very much. That was really informative. I have certainly learnt a lot. Thank you everyone for participating tonight and for joining us and asking your questions, that was really good. And thank you Sammi so much for once again operating all the technology so smoothly. Thank you very much and everyone have a good evening and do fill out your evaluation forms that you will get when you close the window.

Sammi: That’s great, thank you Tim and thank you Lyndon for joining us tonight and everybody online, we hope you enjoyed the session.