Sammi: Good evening everybody and welcome to this evenings pharmacotherapy for smoking cessation webinar. We are joined tonight by our two presenters, Dr Tim Senior and Associate Professor, Renee Bittoun. So, Tim is a GP at Tharawal Aboriginal Corporation in South Western Sydney. He was originally trained in the UK. Tim is also an RACG 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 he is also an RACGP medical educator. Also we have Associate Professor Renee Bittoun. She is a Tobacco Treatment Specialist and she has a long history with smoking cessation since the inception of the first Quit campaign in the 1980s. She currently teaches research and is in clinical practice in the field of smoking cessation. She is President of the AASCP, The Australian Association of Smoking Cessation Professionals. She is the Founding Editor in Chief of the Journal of Smoking Cessation and is leaving on Saturday to take up a visiting professorship at the Sorbonne in Paris. So, welcome Renee and Tim and thank you for joining us tonight.
Tim: Thank you very much. Welcome, good evening everyone.
Sammi: Great. Before we make a start, I just want to make a quick Acknowledgement of Country. We recognise the traditional custodians of the land and sea on which we live and work. So in saying that now, I will hand over to Tim to take us through the learning outcomes for this evening. I will then hand over to Renee to start the presentation. So, thanks Tim.
Tim: Thank you very much. Good evening everyone. I hope we get through a lot of good information tonight for you. These are learning outcomes which are education speak for what we hope we will have covered tonight and that you will be able to do in your practice tomorrow as a result of this evening online QI and CPD activity. After this activity, you should be able to discuss the link between smoking rates within specific groups and social disadvantage, discuss the common barriers and myths related to smoking cessation, and understand nicotine withdrawal, routinely assess nicotine dependence using evidence based methods and engage patients to manage their smoking through realistic goals and expectations, discuss the evidence based smoking cessation treatment options available and where appropriate adjust drug dosages to be more effective, and provide practical tips related to the usage of the different forms of pharmacotherapy, particularly prescription medication. So hopefully that is all the things we will cover tonight. There is quite a lot there. We have got an hour and we shall try to get you away on time as well. So I shall hand over to Renee. A very big welcome to you tonight and no doubt we are all looking forward to tonight’s presentation. Feel free to put questions through in the chat box as well and we will endeavour to answer those questions.
Renee: Thank you and good evening everybody. Bonsoir. I am going straight to the first slide which is on the prevalence of smoking just to give you an overview of how well we have done in the last few years. You will all note the really precipitous drop in prevalence in Australia today and in New South Wales especially, you will see the decline. Since 2016 we have had some really great news with big drops in the prevalence in New South Wales. Of course, the job is not over and all of us are currently seeing smokers who are really a very different group, a very dependent group and I am going to talk about that and how to manage them in a few moments.
Just to look at that slide though, look at the difference between males and females. You can see it straight away; there is an assumption that there are more women than men. That is not correct. You can see there is a bit bulge in the ages of say, 25 to 55, and there is almost a steep decline. As you age, you are less likely to be a smoker really because people who went on smoking died from it. So this is just to remind you very brutally, that by the time you are over 75, you are very unlikely to be a smoker, so the prevalence is really quite low. That is a little thing to remind yourself of. There is this quite distinct, almost linear drop from the ages of say 35 right down to 75. The other point I want to make about this slide in particular, is what happens when you age. Now I do not want to I guess marginalise the men, but what happens with age, is there is less reinforcement. There is less reward. There is less drug reinforcement. So I want you to remember that. There are spontaneous quitters. The aged do not take drugs as readily as the young. We all know that, but keep in mind there might be a neurobiological aspect to that. The reward is not as great as you age. So there are spontaneous quitters of other drugs as well, not just nicotine. So I just wanted to remind you of that as we go forward. Something happens when you get older. It is not older and wiser, but there is that peak around the young and probably because they get a great deal of neurological reward from smoking.
So who is still smoking? People who are highly dependent. We see that all the time and I am going to show you how to measure dependence. People with mental health problems. Are they self-medicating with nicotine? Have they always had mental health concerns? Have they always had depression and are masking it by smoking? That is a really strong possibility. Obviously there are drug and alcohol comorbidities. Do people who use other substances smoke as well? The principal for those who are thinking about is almost 90% of other substance users and abusers are smoking as well. Are there concomitant benefits to do that? Does nicotine enhance, or other substances enhance each other? Do they have synergistic effects? They do, so do keep that in mind. That may be why they are smoking as well. We have had a question about marijuana smoking already straight up and yes, this relates dramatically to marijuana smoking. What I will tell you and talk to you about, there are a lot of interactions, and so once people stop smoking they tend to drop the other drugs as well. Do not be surprised. So it may go the other way. We may be able to address smoking to address other drugs. I will keep you posted on that one.
People who smoke with diseases related to their smoking. So if you have got patients with COPD, with coronary artery disease, with cancers, do not be surprised if they smoke as well; if they continue to smoke these, they can barely breathe and they smoke anyway. That defines them as addicted to smoking. That is a definition. I cannot breathe. I have got asthma. I have had coronary artery disease. I have had my stents put in and I am still smoking. That is a patient who is unfortunately very significantly dependent. So keep that in mind. Do not always go “you must not quite understand the repercussions.” They quite fully understand the repercussions. They do it anyway and that is what addicts do, despite the consequences. They have tried multiple unsuccessful attempts. Do not go down that road thinking they are not motivated to quit. They are. People who are highly addicted need extra help. They are not terribly unfortunately very successful at doing it because they are highly dependent. They do have, because this is a socioeconomic concern, many life stressors. It is not like they do not have them. You and I can manage or deal with a big phone bill for example. Our smokers today, with other comorbidities, with drug and alcohol concerns, with mental health concerns, cannot pay that bill as readily, become more distressed by it and unfortunately, resort to smoking to manage or to self-medicate their anxiety.
We also have a group I am sure you all know, with higher prevalence in our indigenous populations and that is an unfortunate circumstance. The more remote the communities are, the higher the prevalence is, and that is brought together really with the socioeconomic status of the indigenous populations who are living in remote areas and also the culture of smoking. There are townships were just simply everybody is smoking and other townships where nobody is. So the culture also has a strong impact in this as well.
What we know has helped drive down the cost of smoking. For those who do not know, I am interested to know, who much is a packet of cigarettes today? That is a legal packet. Do you know the difference between a legal one and an illegal one? Just interested to know, does everybody know how much it costs now? Just your average. Let’s say the most popular brand might be Benson and Hedges. It might be an ultra-mild cigarette. By the way, ultra-mild is not better, we would never recommend a mild. So how much does it cost? Do you know? Should you know? Well, yes you should know, because it costs around about, legally, $35 a packet and there is going to be oohs and aahs in the audience from people who do not know that. You should know how much it costs, so stand at the checkout next time you are at the supermarket and see somebody buying a carton. It could cost them $250 a carton of cigarettes. And if you did not know that, now you know why some of our patients are spending a good part of their income, a good part of their pension – a big part of their pension – on tobacco. And it is always the highest priority. I am sure you know that. The increased cost has driven smoking down and it is by far now today the number one reason why people want to stop smoking. It does not mean they achieve it, but it is number one on their list. Health has now gone to number two. Number one is “I do not want to do this anymore because it costs so much.” There is nowhere to go to do it. You probably all know that. So having venues where you cannot smoke is terrifically important. It changes all the dynamics, the cues, the cue conditioning reactions you get. So venues where you cannot smoke, actually are helpful for our smokers. They are not as likely to smoke where you cannot smoke. They do not break the law. You do not see people getting on a bus and lighting up a cigarette. They are actually compliant with this. So in case you think it is a bit draconian to have no smoking everywhere, it is actually very helpful.
The graphic warnings on packaging I am sure you all know, they are changing the warnings, routinely rotating them. This is very impressive to smokers. They are impressed by that, and interestingly enough the brand name is very small on the actual package, so they do not recognise the brand as well. So that is also helpful, because brand recognition triggers off an urge to use. So that is just another side issue about the graphic warnings. It really is very helpful. We know all the marketing campaigns out there, all these things have a drip, drip effect. You know, you do not have the product available to you. There are restricted sales to minors and that is enforced. There is advice from yourselves. We are getting increasingly clients and patients who are very well aware of the medical consequences of smoking. Literally Blind Freddy should know the impact of smoking on your health. Of course, our pharmacotherapies unlike many other countries are heavily subsidised. Remind yourselves that every single smoker, it does not matter who it is, you or me, is entitled to a subsidy. It is not means tested. It is not Healthcare Card carriers, it is everybody. So our government is very supportive in helping subsidise our patients to quit. It is in their interest to do that, so we know that.
So what is a barrier? What is happening to our smokers who want to do this and cannot really get over the line? They are obviously very much addicted to this. This is not easy to manage themselves. It is not really a choice they are making. Now, there is good evidence to say that people find it very difficult, that they are not choosing to smoke. Their motivations are not really poor. What is going on is that the drive to use the drug really overwhelms them, and if we had time tonight I would show you some lovely neurobiology about this corruption of the neurological connections for you to make reasonable choices. Unfortunately this is what happens with drug addicts. They do what they should not do in the face of what they know to be conflicting imperatives. So they have got this conflicting drive. They love smoking but they should not do it. They love it. It is too expensive. So they are very confused with a need to smoke with a love to smoke. I love doing it but I hate doing it at the same time. All this is going on in the same head of the smoker. There is of course a fear of failure and they have had many of them. They will often know somebody who has quit smoking either spontaneously, it could be their partner just stopped like that, or using one patch and gave up smoking, and so what is wrong with you. You must not be strong. Your will power must be really weak. None of that is true. Do not blame the smoker. They do blame themselves because they hear from around them other people who have quit successfully, spontaneously. So there must be something wrong with them – which there is, but it is called nicotine addiction which is actually a significant problem. They might be using other substances that actually interact and I will talk to you about that a little later. Other substances like alcohol in particular, and caffeine in particular. I will mention that in a little while; why these things actually interact and have synergistic effects and make it difficult for them to stop.
Living with a smoker, having other smokers around you, I mentioned the culture around you. If there is a lot of family members, friends who are smokers and it is the norm. You see that as what other people do, and reminding yourselves that I want you to remember, that other people’s cigarette smoke is itself a trigger to smoke. You simply breathe it in. This is not like alcohol that does not jump from one glass to another. If you are having water and your friend is drinking, you are not going to be a passive drinker. But if you are a passive smoker, when you are trying to stop smoking, that is nicotine entering your blood stream. We can measure it. So keep in mind, other people’s cigarette smoke has other components to it. Not just seeing them doing it but actually breathing it in and inhaling it in. That becomes the trigger. It is like a little bit of alcohol for an alcoholic. It is not on. So we have got to teach smokers what to do when other people are smoking around you and you are trying to quit. It is a barrier to helping you quit smoking. So we need to address that.
The other thing that is very interesting of late, is fairly newish data coming out, that nagging (we sort of knew this, didn’t we) by family, nagging by friends, nagging by your GP turns the patient off. We have got to have a better way of approaching it. Something a bit more sympathetic, understanding that they are dependent. Nagging not only is a turn-off, but can be unfortunately a trigger to smoke more. People get very agitated by being nagged and go away and smoke. Agitation or distress by being nagged, or literally somebody else being aggressive about your smoking actually puts you off. I wanted to remind you of that, to take a softer approach and perhaps be a bit more sympathetic approach to your smokers.
The hardest quitter is the one who wakes up within 30 minutes and smokes straight away. You have heard this question already. I hope you have. It is called “time to first cigarette.” Of all the questions you might ask your smoker, it would be the most important one. It is a giveaway. I wake up and I need to smoke straight away. Why do you need to do that? Think, liver metabolism. Do not think they are weak or this is a bad habit and that is what they do. They wake up because they have practically metabolised the lot. Fast metabolisers to that. I will tell you in a moment about fast metabolisers, but think as a question to ask your smoker now that you did not know before: When you wake up how soon do you smoke? If they do it almost immediately, that is a giveaway for a heavily dependent smoker really and a fast metaboliser. We talked about this earlier. They have tried before to stop smoking and they have not done well. That really is a giveaway too of a heavily dependent smoker who has got a lot of symptoms of withdrawal which I will talk about in a moment. For example, give this a thought. How many smokers do you know who have used NRT and smoked as well? They have not overdosed and they do not. And let me tell you now, straight up, they will not overdose. It just simply means their blood levels of nicotine are higher than the average smoker. Are they are getting withdrawals? Either on NRT and / or smoking at the same time? This is a person who is heavily dependent and needs more NRT. Simply a symptom of underdose of NRT, not overdose, but underdose. So keep that in mind. These are people who have been trying. They are not weak-willed. They are not unmotivated. They simply have had really poor experiences in the past trying to quit smoking and for them, all we can say is a little bit more sympathy to these poor people. As I said, they are likely to be fast metabolisers. They are doing something about it, they are just not getting very far with it.
I mentioned fast metabolisers and I want you to think about this. This is a liver enzyme function P450 system. CYP2A6 is the enzyme that metabolises nicotine and there is a range of 2A6 from slow to fast metabolisers and you are born with that. So this is a genetic predisposition. You cannot do a thing about it. You can up-manipulate if you like, or up-instigate more 2A6, but basically the type you are born with is the type you are born with and I want to point out something. I am looking at the list of doctors whose names I am reading here, and I noticed many from different countries. I want to point this out to you, if you did not know this before. Some of your patients are fast metabolisers. Some of them are slow metabolisers. Who are the fast metabolisers? If you do not know this already, you can look this up, but it would be your patients from the Middle East. I can see there are people from the Middle East. Think about it, are they smoking a lot of numbers per day? They are. Fast metabolisers smoke a lot of numbers. They excrete nicotine quickly. They get up in the morning and it is the number one thing they have to do. So do keep that in mind who they might be. For those who are Caucasians, they are in the middle somewhere. They are also faster metabolisers than Asians. South East Asia. Think about this group. Think about your Japanese, Chinese, South East Asians. Interestingly enough, the prevalence of smoking might be high in this group, think about that, but the numbers they actually smoke and the manner in which they smoke is very different. Think about, do they get up and smoke straight away? Probably not. Some of them do, some of them do not. But do think genetic differences. So if you are thinking of your clients from the whole of the Mediterranean rim, anybody here thinking southern Spain, southern Italy, southern Greece, Turkey, the Middle East and North Africa. If you have got patients from there, they are fast metabolisers of nicotine and they smoke a lot, even the women who do not smoke a lot as in percentage, but when they do, they smoke a lot. So keep that in mind. They are going to need more NRT. They do not do well on one form of NRT. They are going to need multiple forms. They inhale deeper. So I want you to think risk of lung cancer. Is it related to how you metabolise nicotine? It is complicated, but think of that. They are at higher risk of that as well. So they are going to be doing more numbers per day and they are going to be inhaling deeper than the slower metabolisers. So keep that in mind. I think it is a very interesting point you may not have heard before.
The other liver enzyme effect that is dear to my heart and I talk about every time I talk about smoking, is the smoke itself contains a chemical. It is a gas phase. They are polycyclic aromatic hydrocarbons. Some of you have heard of this before. You might know what it is. It is the charcoal on the steak that you are not supposed to eat a lot of. I am sure you know all that. You have heard this all before. But that actual chemical when you inhale it in gas phase, induces the liver enzymes as well, in particular liver enzyme 1A2 which you may be interested in knowing, metabolises caffeine. Now, if you ever care to ask and we always do, and I want you to be aware that there is a website now, the College has a website, with all the medications that are involved. But particularly dear to my heart are caffeine and alcohol. What happens with smokers, is they tend to drink a lot more coffee and most people do not think twice about it. Now you will. Always, always ask you smokers how much caffeine do they use. And that includes all caffeinated drinks. You will be astonished to hear five or six cappuccinos a day and that might include Coca-Cola, Pepsi-Cola and Red Bull. Ask them how much caffeine they use, because these PAHs will induce this liver enzyme 1A2 such that most smokers will need to drink two or three caffeinated drinks for every one a non-smoker has. So remind yourself of that. Ask them that. What happens then if you do not smoke anymore? You can become caffeine toxic. This is not a small matter. They will tell you I have got the jitters when I try to stop smoking. These patches are keeping me awake at night. Common comment, “These patches are keeping me awake at night.” This is not patches, this is caffeine toxicity. It is a common problem when you stop smoking and it is not the patches that are doing it and it is not the Champix that is doing it, it is actually the caffeine. Alcohol is the same. Unfortunately, smokers drink a great deal more alcohol and you will know that is why the pubs want you to stay smoking, because you will drink three times more. Again, this is because these PAHs and nicotine also in this case, induces alcohol dehydrogenates, and I want you to think about that. These interactions are not just synergistic in the brain, but they have liver enzyme interactions.
There are many medications you need to be aware of. If you are not, shame on you that you do not know that Clozapine is affected by smoking, that Olanzapine is, that warfarin is. We also know that methadone is. Pain killers are. There are many medications that are affected by smoking. Most of your patients will need higher doses to get the positive effect of their medications and when they quit, you will need to reduce the dose. So I am being pretty quick about this, but do look this up. It is accessible to you.
Okay, so what do we say about smoking? We always ask about smoking. I am sure you all know that, but remind yourself to ask about caffeine and alcohol and remind them why they are drinking so much coffee compared to you, a non-smoker. It will be cheaper once they stop smoking, because less coffee and less alcohol you need to buy for the same blood levels. So remind them to reduce it. We also reduce certainly the caffeine and adjust their medications. Keep that in mind.
Assessing a smoker. I talked about time to first cigarette, which is very important to ask. Ask them about their pharmacological failures. Ask them about their quitting. Ask them about family history, because that is the part about the inheritability. This liver function thing is an inherited trait. Smokers breed smokers unfortunately. Heavily addicted ones do as well. I have not got time to talk about smoking in pregnancy. Those who are logged on know all about this, but you can pass on nicotine addiction. It is an inherited trait. Remind yourself of their medical history. Psychiatric patients who need to smoke may be self-medicating and have high levels of nicotine in their bloodstream.
I want you to think about daily smoking. Do not be so fussed about numbers of cigarettes per day. Do keep in mind, people who do cut down might smoke differently, inhale deeper, titrate or compensate for smoking less by dragging harder and their carbon monoxide levels go up.
So the things we would not really recommend is lowering the nicotine content of the cigarette. A weaker cigarette is not a better cigarette. It is distinctly a worse cigarette because you have to inhale deeper and if you ask them to cut down, they will smoke differently too and their carbon monoxide levels will go up. That is why we recommend carbon monoxide measurements all the time which we do.
I just want to remind you about what nicotine withdrawals are and reminding yourselves that I have seen this since the 1980s, before I even had NRT in my hands. No gums, no patches, no Champix. People became when they stopped smoking irritable, anxious, distressed, and depressed and could not sleep. I want you to think about that. Do not assign these side effects to overdose or a medication side effect. The classic one is Champix. Do not go, my patient is depressed because they are on Champix. Wrong. Think, depression because you are not treating them well enough for the withdrawals. So the Champix is not doing it, you might have to add in NRT. I am just giving you a little hint here. Please keep that in mind.
So talking points for yourselves, is do not be judgemental, do not nag the patient, inform yourself about the biological basis for smoking and nicotine addiction and inform them, because the more they know the better they do. They know that. We know that. We do not say people fail. We talk about managing your smoking. It is complex, I would like to manage it better. And remember their motivation vacillates and do keep in mind it is not one size fits all treatment at all any more. It used to be, you know, you would wave your finger and say stop smoking. Now we do not. We know that there are a variety of things that suit some people, and that how they metabolise this drug matters a lot. So we know that counselling helps. We know that pharmacotherapy helps and we know that the Quit Line helps. We know to combine all these things together to give your patient the best outcome. Again, without nagging and being a great deal more sympathetic.
So, I want to remind you that there is no scientific evidence to support hypnotherapy or acupuncture, psychotherapy. This is for quitting smoking. Maybe for other things, but not for this. Negative affect counselling, stress management. There is no evidence. We love it, but there is not. Self-help books. You have always got somebody who knows somebody who quit using them, but we have not really got the science to support any of these and the trials have been done, so do not think they have not. They have. So there are a lot of things for remembering. That cutting down might not be helpful and that weaker and milder cigarettes might be worse. So we would not recommend to support any of these as strategies at all.
The pharmacotherapies we know are the first line treatments and I would like to say I declare I have no conflicts of interest. I do not work for the pharmaceutical companies, nor do I work, evidently not, for the tobacco companies. But I just thought I’d mention that. No conflicts of interest and I am not on any of their boards. So I can strongly recommend NRT and a lot of it. We grossly underdose our smokers with one form of NRT. Combinations are much better. Champix, varenicline alone or with combinations with NRT are great. Zyban (bupropion) alone or combined with NRT. So combinations are looking better and better in our more difficult if you want to call them, recalcitrant smokers. We do use nortriptyline anxiolytic, Naltrexone. They are not registered for use for smoking cessation but they are used and some of you might have used them in the past or currently. If it was me, if I was trying to stop smoking, I would probably try Champix first and see how I go. If it is great I will use it. If it does not work do not blame the patient, move on to something else.
So what is the right pharmacotherapy? If they have used Champix before and it has not worked, do not bother this time. Truly. If they have used NRT and it has not worked, get out some more information. Find out what they tried. It is usually underdose. A major problem is underdose. I want to remind you of one other thing. Women metabolise nicotine faster than men. Look at how their past outcomes have been and remind yourself of maybe not using it correctly, but mostly it is underdose. I just want to reiterate that obviously today. So with NRT, we do not see any side effects. I have never seen a case of a nicotine patch addict on the planet, and I read a lot on the topic. We also do not see nicotine overdose, so do not be fearful of overdosing people. They do not overdose. Is it safe to wear a patch and smoke at the same time? Yes it is. I am just telling you this right up front because I know I am very pressed for time. I want you to know it is approved by the TGA.
NRT in pregnancy. What we find is that women metabolise faster and need often to use more NRT.
Be aware that I recommend patches over other forms of NRT simply because they put it on and that is the end of compliance. If you are going to use gum or lozenges or anything else, you really need to use a lot of it, not a lot of it. 25 cigarettes a day, 25 gums a day. Now, would you do that? Probably not. So the idea is a lot of it. Patches and gums at the same time is probably better. There is no evidence to support going down from 21 to 14 to 7. There never has been. We would not use anything weaker than a 21 mg patch. There is no evidence to start on lower doses. Do not do it. Lower doses for some reason historically were developed but myself and colleagues all over the world know there is no evidence to start anybody, especially you smoke less so you need a weaker dose. There is no evidence for that, so do not do it. Pretty straight forward.
So just to remind you, plasma levels of nicotine are pretty low. I want to point out in the left hand column, the X axis that nicotine blood levels in smokers is in nanograms not in milligrams. Nobody ever gets 21 milligrams from a patch. You would die. 1 milligram of nicotine will kill you outright. So obviously we are not delivering these doses to patients. It is very, very weak. So just to point out on the red line across over time, this would be a nicotine patch, very slow, very low. Look at the levels. Look at the smoker’s level. Look at the patch level. That is why we do those combination treatments. I want you to have a good look at that and remind yourself of that. We are underdosing smokers, we are not giving them what should be called nicotine replacement therapy.
So avoiding underdosing, combination treatments. We do carbon dioxide monitoring for feedback all the time and it is a great motivator if you can do it. We do not recommend stopping too early. We do NRT for six months ideally. If you can do six months, your smoker will have changed not just the manner in which they have smoked from the beginning but absolutely the nicotine receptors in the brain for those who know about them, down regulate. In other words, it is nicotine receptors being produced as you A) Cut down smoking with NRT and then stop. So the longer you do this the better. So longer, better. Higher dose, better. So these are the harm reduction strategies that I really do want to remind you of for your difficult patient who does not want to stop, who is not interested in quitting. Do not even go down the path of using the word quitting. Tell them you will do less harm. You will do less harm. You want to smoke, fine. Put on a patch and smoke anyway. That is what I tell them and off you go. And it might increase it for another patch. We use multiples. For those who do not know, multiple patching, lots of nicotine replacement therapy all going on at the same time. Mix and match. It is fine. Patients do not overdose. You cannot dispatch a patch wearer, got it? Little joke. The benefits of this is that smokers realise that they can wear a patch and they can manage their smoking. It is not like a hard thing to do. In fact, encourage it. It allows them to gain a little bit of autonomy over their smoking and they are not aware that they can do this. Is it safe to do this? Absolutely. And I want you to encourage your difficult smokers that it is safe to do this and they will not compensate their smoking. So if they are going to start smoking less which they sometimes just spontaneously do because they are wearing a patch, you do not tell them to quit or stop or cut down or anything. They just do not smoke as much. And when they do that you will notice they do not compensate. They do not drag harder on a cigarette, because they do not need to do that. Just reminding yourself that there is no fear of overdosing and in fact the addiction actually starts to go down, and go away which is great. They may not know that or understand it, but you do.
So this is a quick case study of somebody whose carbon monoxide levels I measured. This is somebody uninterested in quitting. No way was he interested. He tried other substances in the past, that is to help him stop smoking and it did not help him. He had not tried NRT but he was a significant alcohol user and he was underweight. He came in with an acute exacerbation. Carers brought him in. He was in a facility where you are not allowed to smoke. They were fairly draconian there. They were saying you are not allowed to smoke. You have an acute exacerbation of COPD and frankly the facility group there said, “That is it. You have got to stop smoking.” They were on his case. Every minute he lit a cigarette they were on his case. So I am not quite like that. He smoked 50 rollies a day. There is no evidence that rollies are any better for you, or greener or herbal or anything. You will know that. You inhale, you are going to have higher carbon monoxide because you roll your own. So never recommend that ever to a patient. So I said to him, his carbon monoxide was 30, “How about you wear a patch and smoke anyway?” The carer with him, went “Oh no he will overdose.” And the thing to say to the carer and the family is no he will not. It is really safe. It is fine. I recommend that you do that and put it on just before you go to bed at night. The point of that is, if you remember that graph with the blood levels are very slow with patches, putting it on just before you go to bed at night, ironically saves people from nightmares at night and when they wake up in the morning, they have a reasonable blood level, it is not great, a reasonable blood level of nicotine to wake up with so the time to first cigarette changes. And it changed everything for this man. He is a typical case. He came in the next week saying I only smoked about 20 a day. I was not forcing myself – I do not want him to force himself to not smoke. If you smoke, you smoke. Fine. He comes back and it has gone to 21 parts per million. His CO levels dropped hugely. This was his own. You know it is a bit like measuring with a breathalyser. They are chuffed. They think it is fantastic and then I add another patch. But can you do that? Is it safe? Yes, you can. Can you smoke as well? Yes, you can. Off he goes and he can do all of this and he comes back smoking eight a day and 10 parts per million. Fantastic. Next time I add another one. Now, no overdose here folks so do not be worried about that. What we do do, is we are giving him the right amount of nicotine replacement therapy. His flag for me was that he had a history of alcohol abuse. Usually any drug and alcohol user, anybody with a mental health disorder, they are going to have a higher level of nicotine replacement required. Their blood levels of nicotine are higher. He smokes in the face of his COPD. All of this tells, me high levels of nicotine, give him more not less. And I then weaned him off his patches in reverse and he stayed on one patch for more than three months. He remains a non-smoker, really chuffed and did not have to do anything. He did not have to force himself or go through withdrawals or anything, and that is really the strategy we are using today.
Just moving on to Champix while I can. It is currently the best odds ratio for helping people to stop smoking. If it was you or me, that is probably what we would try. It depends on your age I might add. I am a bit out of that age group now. Interestingly enough, we know the younger seem to do better on Champix. This is a recent finding. Also that women do a tad better than men. These are also fairly recent findings and I just want to suggest that you try it out. You do better if you stay on it longer. But not everyone does well on Champix so we have a certain criteria, really a strategy if you like. I have developed a little flow chart for deciding who is going to be on Champix. For those who know, this is a slide on the safety issues if you are concerned about Champix. We are not particularly concerned at all. I would not say there was any exclusions except really in pregnancy. If any of you look through the safety aspects of this, we have got the Eagles study. We know that the College has actually put together quite a nice report on this for you to look up. So we are really not concerned. There is a lot of bad press. Keep in mind, I have no connections with the drug companies that make this. I just want you to be aware, remembering that we have seen patients with these symptoms of withdrawal before we ever had Champix. We have seen that we can manage it better. If they are symptomatic but they are not smoking for example we would add NRT and I will show you that in a flow chart in a second. So we can actually combine treatments with all of these things and do better with our outcomes. So I just wanted to tell you not to be concerned. There is a lot of bad press out there, not really valid at all. You know that a lot of people on Champix do become nauseated. Remember it is really poor usage themselves. 35% to even 40% say nausea is the major side effect for them. Remind them to take this with food. I tell them with food and for a smoker that may be a cup of coffee for breakfast. That is not food. You have got to have something in your stomach and we would suggest that you have it in the middle of your breakfast, like giving a tablet to a dog. In the middle of it, not after it, not before it and not on an empty stomach. If they have sleep disturbances and this has occurred with some of your patients, the eight hour difference between the first tablet and the second, bring it on a bit earlier. Just to remind you, you do not have to set a quit date either with Champix. We learnt this almost immediately I have to say. We learnt straight away that people had a delayed response. So it might not be you know, quit on this day. Do not pick a quit day. I tell them a quit day will pick you. If this works within about four to six weeks of using Champix, they will get the notion that it is less and less interesting. It is not as rewarding as it used to be. They are smoking less of the actual cigarettes. Things are starting to change without them having to force it. Do not force it. It will come to you. As I said, a quit day will pick you and that is usually how I like to address it for them. If it does not, do not panic. Move on. This is my little flow chart about it. It is very new to me. I have tried to put together what we might do for recommending Champix. I said it will pick you, the quit day will pick you. You will see on the right-hand side that if it has absolutely no effect and they are still smoking exactly what they ever did and they are loving it to bits and it is still exactly as rewarding as ever, move on to another pharmacotherapy. It is not going to work and it is not the patient’s fault. Do not go there. It has got to do with brain receptors. Some types have got these nicotine acetylcholine receptors sub-types which is genetic, about which you can do nothing. There are a proportion, probably one in three smokers who will not get a response to Champix. Do not blame them, move on. If they do, you have got this choice that you can either go for the other scripts or add NRT as well. So we do that very commonly now. I know there is a cost involved here. Not everybody of course gets all the subsidies for all of it, some of it. So Champix is usually the best choice to start with.
A little bit about Zyban. You know it was originally an antidepressant but there was this finding that suddenly people were doing well stopping smoking spontaneously who were being treated for depression so that is a very interesting fact about this came about. It used to be called Wellbutrin if you did not know that. But it is the liver enzyme again. Sub-type 2B6 metabolises bupropion to its active ingredient, hydroxybupropion. Again, you might not have known that. If you do not know that, it is why some people do well on Zyban and some people do not. The ones who do not, have probably not metabolised it correctly and that is not their doing it is genetically determined. There is not much you can do about that. Reminding you that there are contraindications like seizure threshold. Some of you have heard a history of epilepsy, fitting and fainting. There might be drug interactions with Zyban. So it is not as widely used and certainly not as good as varenicline so we tend not to be not using it as much as we used to in the past or recommending its use or recommending GPs prescribe it as much. But still some will see that they have done very well.
Okay, just moving on to E-cigarettes because I know there was some commentary about this. I am sure you know that this is very controversial and the effectiveness as a cessation aid is very limited. We now even see that it may be an instigator in young people to go on to smoking, so that they may initiate of flavoured E-cigarettes and then go on to smoking cigarettes. This is a very divisive, very effectively divisive in the tobacco control movement. I think the tobacco industry would probably be thrilled to bits. You probably all know, I am assuming you all know, that nicotine comes from no other source than the tobacco plant. And who owns the tobacco plants but the tobacco industry. So I am personally very opposed to E-cigarettes. You obviously can make up your own minds about it, but I think there is really no evidence to support scientifically yet that it is safe or a suitable quitting aid. Is the handling and holding of that sort of analogous cigarette, is there something that might be there? Maybe, but really I believe that it is the cigarette of the 21st Century and as I said I think the tobacco industry is delighted.
I wanted to remind you that you can refer to the Quit Lines and the Quit Line staff are very well trained in smoking and smoking cessation, and have learnt a great deal more for those who know, about some of the topics I have mentioned tonight, drug interactions, metabolising nicotine and are very effective in helping you. So there is a way as you know of ordering Quit Line referral forms.
Just to remind you what to say to your patients. Your role is huge. I think we have now learned not to wag the finger any more, to show empathy to our smokers, to dispel some myths and misconceptions. There are so many out there. You know, the healthiest cigarette, the mildest cigarette, and the roll-your-owns. You have got to dispel these myths and remind your patients why they are doing what they are doing.
I did want to mention something quickly about carbon monoxide and cannabis for the question that came up earlier. People who smoke cannabis, mull their – that is the term for it I believe – mull their cannabis, so mix it up with tobacco, not just to thin it out, but to make it more inhalable. They tell you it is harsher if you take away the tobacco. Straight marijuana, smoking it, makes you cough. I want to remind you if you did not know this already, evidence to support this, that nicotine is actually a cough suppressant and that is why most smokers do not cough when they are actually smoking, but as soon as they quit, they get a cough reflex back. So if you have got a smoker who says “I have got a cough now that I have stopped smoking,” you are right, that is absolutely correct. They will be coughing up phlegm and that is a good sign. It will not go on indefinitely but it is a very good sign. Now your marijuana smoker is using that mechanism of suppressing your cough by adding it to their marijuana. One of the ways, and remember nicotine is very addictive, that we get people off marijuana is using NRT to help them get off the marijuana. There is even evidence that Champix might do it too, simply because their interest is in the nicotine. They are dependent on the nicotine and they do not know it. Remember they have also got that caffeine interaction too, so I want to remind you of those things too. Understand the liver interactions with smoking. Remember the caffeine. Remember the alcohol. It is not a glass of milk and a cigarette, is it? It is not an orange juice and a cigarette. It is alcohol. It is caffeinated drinks, particularly because of those interactions. Keep those in mind. The synergistic effects in the brain and the liver reactions. Put your smokers in touch with the Quit Line and for yourselves, be better informed, reminding yourselves or learning potentially for the first time, some of these aspects in have been talking about tonight. Remember your patient is chronically dependent. This is an illness like all the others. This is a chronic relapsing disorder. This is not something that is just going to go away. People do relapse. They are not weak-willed. This what illnesses are like. This is what happens with your diabetics. This is what happens with patients with chronic respiratory illness. We try to find a cure and we are working very hard at it. Reminding yourself that this treatment advice is not a one size fits all any more. We have learnt that there are different smokers. They have nicotine in their bodies which pharmacokinetically is different, it is not the same. If you can use a medical model for yourselves it would be so much better. Please do consider these harm reduction strategies because they are safe and our patients love it. We have done studies enough to show that they like this strategy. You know, everybody wants to quit smoking, but they may not want to do that today. Do they want to cut down? Yes, they do want to do that too. So how about this strategy, you could do this well. And please remind yourself that their environmental cues are really important in all of this.
So if we can have our moderator.
Tim: I was going to pose the question to you that has come through from a lot of people about using carbon monoxide monitoring and how GPs can do that in their rooms.
Renee: Look, I think it is the equipment. For me personally it is the equivalent of a stethoscope for people who are cardiologists. People measuring blood pressure cannot live without it. I personally cannot live without mine. It is not cheap so it depends on how you view this. It is about $1,000 to buy. There are some on the market in Australia and there even some that you might know about that do an extrapolation and measure or extrapolate to foetal carboxyhaemoglobin which is incredible because the mum does not realise that the foetus has got carbon monoxide as well. So you buy these pieces of equipment. I think it would be wonderful if GPs had them, and some GPs do and they absolutely swear by them. It is A) a motivational tool and as I showed you in that case it is not just a motivational tool, it actually shows them reductions as times passes. They are thrilled to bits to see a personal reduction. Warning a smoker that they are going to get sicker or that it is impacting on their health is one thing, but here you have got this direct response to their smoking today which is really very good to do. That is how can measure carbon monoxide levels.
Tim: I presume there is no Medicare rebate for doing it?
Renee: I am afraid not. We have tried. If all of you can pull together and do this it would be great. When you think about, it is rather shameful isn’t it, that this is the most likely cause of death of any of your smoking patients. Of any of your patients really, smoking is the most likely cause of their death.
Tim: Yes, absolutely. And all of the devices on the market are reliable and similar? There is not one that better than the other?
Renee: Yes. Correct.
Tim: One of the other questions that has come through a few times is that combination tablet treatment, so using combination of Champix and Zyban or using combination of say Champix with an NSRI to treat people’s depression.
Renee: Absolutely all of the above. There is this myth out there that you cannot combine SSRIs. It is a myth. With Champix that is just not correct. You can literally prescribe anything with Champix. There is no contraindication with any medication at all.
Tim: Because I think that will be something that is very commonly seen in general practice, is a combination of those.
Renee: You get these concerns and warnings about depression and anxiety, but you get that if you look up NRT as well. If you look it all up, the pharmaceutical companies will often say, you know, caution depression and anxiety or suicidal ideation. I think we have clenched it now that there is no evidence to support that one particular thing causes more than the other. So there are good studies that show NRT equally the same as Champix. It is a big rumour that has been going on far too long. And to our detriment because Champix works, and again I have got no conflicts of interest at all.
Renee: Weekend smoker? Well ironically, you know you do get (ah thank you very much these resources are great). The weekend smoker is the Friday nighter. I had a patient who when she drank she smoked. She said I cannot help myself. It is out of control. What will I do, what will I do? And I put her on a patch just on Friday. That is it. Put it on in the morning and it peaks at night. It took care of her urges to smoke when she was drinking. A social drinker with her friends does not want to give up social drinking, you know, does not want to give up her lifestyle which is, you know you do not really want to say do not go to the pub ever again, which would be the alternative. So we do know that if you can treat it like, that she really had overwhelming urges to smoke every time she was drinking. And now she is not on patches anymore and she goes to the pub and has a drink. So there you go. You can treat it just for the one day. I do want to point out, you have got in front of you these resources New South Wales Health has. Please look at them. These particular pages: you have got tool kits page 6, page 7 is just shown to you right on the screen. New South Wales has that. You can access that. It is terribly important, especially about medications. There are algorithms in there about how to use NRT, how to add NRT. There are flow charts about what to do when a patient goes into hospital. Imagine this, your patient is about to be admitted, who is on warfarin. So imagine a patient who has had a DVT who is on warfarin. INR is perfectly normal. Everything is perfectly good and they come into hospital. He is a smoker. That is why he has had a DVT, but okay. He comes into the hospital for something totally unrelated to any of that, a broken toe and needs a surgical procedure and may have unexpected bleeding. Why? Overnight, because they cannot smoke in the hospital this is not nicotine that is doing it. This is the smoke that is doing it. So NRT is not going to help this. They come into hospital overnight. They are given NRT and they start to bleed and the bleeding is due to the fact that their warfarin is going up while they cannot smoke. Bummer.
I just wanted to say that these are important facts that you must think about. Some of you know the clozapine effect. All the GPs out there might know the Theophylline effect. That was the same thing happening with theophylline if you remember that. You needed to increase the dose of theophylline for a smoker and if they stopped smoking you had to decrease it. If you remember that, the same applies to many, many medications. The bummer we have got with our patients, is that they go into hospital and they are absolutely not allowed. They are put on NRT in the hospital. You adjust the dose and then they are discharged. So what about your patients on anti-psychotics. You have to change the dose and then you have to change it again because they got home and smoke again. And that needs to be adjusted. You need to think this through and hopefully you will.
Tim: So that is the page of our learning outcomes again. Our hour is just about up. One thing that I think is important, someone is just confirming a clarification that nicotine replacement is safe it pregnancy. It is safe in pregnancy and it is much safer than smoking in pregnancy too.
Renee: I see I have a colleague on line who is Karen Counter, a wonderful GP. Karen probably does not mind me mentioning her name because I know her very well, and Karen has her own carbon monoxide meter and would not live without one. I am sure Karen does not mind me saying that and she is giving you some comments at the bottom. She is extremely adept at helping smokers quit smoking. Thank you Karen.
Sammi: I just wanted to also add, I have seen quite a few questions come through regarding pregnancy. We actually did a webinar last year in August on smoking cessation in pregnancy and there is a recording of that webinar on the RACGP website that you can go view. It is not restricted, so hopefully if you have got more questions around that, that recording should be able to provide you with some answers.
That brings us tonight to the end of our webinar. I just want to say a huge thank you to Tim and Renee for joining us tonight, and I hope you all really enjoyed the session.
Renee: Thank you.
Tim: Thank you very much Renee. Thank you very much everyone. Have a good evening.