Smoking cessation for people with mental illness

Sammi: Good evening everybody and welcome to this evening’s Smoking Cessation for people with mental illness webinar. My name is Samantha and I am your host for this evening. Before we jump in, I would like to just 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.

Alrighty, 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. Lyndon has worked part time in health promotion since 1993, and first started his smoking cessation interest in 1992 and has been working in the area ever since.

And our facilitator for this evening, Dr Tim Senior. Tim is a GP at Tharawal Aboriginal Corporation in South Western Sydney, and 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. So thank you Lyndon and Tim for joining us this evening, and welcome.

Tim: Thank you very much. It is good to be here. I hope everyone across the state is managing to stay cool. This first slide is the learning outcomes, which is education-speak for what we hope to have achieved by the end of this evening. So, by the end of this activity, we hope that you should be able to recognise the health-related risks associated with smoking for people with mental illness, and the benefits of quitting smoking. You should be able to explain the common myths and attitudes that act as barriers to people with mental illness being offered support and treatment for their nicotine dependence. We should be able to discuss the links between smoking and depression. We should be able to discuss tobacco treatment options and considerations for people who are highly nicotine dependent who are living with mental illness. And again, we will go through the five As model of smoking cessation and brief interventions to support people with mental illness to quit smoking. So I would invite Lyndon to continue with the next slide.

Lyndon: Thank you Samantha and Tim. Okay, we are just starting off now. I would just like to start off with a brief introduction. A lot of what we will be talking about today is probably new information, a little bit counter intuitive. People’s feeling and knowledge about how smoking and anxiety and depression interact with each other has changed a lot very recently, and there may even be psychiatrists in your area, other GPs who just do not believe you, it is so counter intuitive. So, throughout this presentation, there are some important evidence statements and it may be worth keeping these in mind. I think this is a really exciting presentation because it is so counter intuitive and because there is some really new and important information for people with mental health and smoking.

So to prevalence. The smoking rate is high and remains high in this group despite a steady decline in the general population. According to the National Drug Strategy Household Survey, daily smokers were more than twice as likely to be diagnosed or treated for a mental health condition. So that is 29% compared to 12% in the general population. If you add to that, people with a substance abuse problem, you are getting up to about a third of all your smokers probably have a mental health issue or a substance abuse problem. There is research from the US saying that over 35, this is not all ages, but over 35, nearly half of all people who smoke either have a diagnosable mental health problem or substance abuse problem. So if you do not look at this as a problem with your smokers, at least half of your smokers are not getting complete treatment. For people with schizophrenia, the rate is up to 66% and has remained steady since about 1997. Smoking prevalence tends to increase alongside severity of psychiatric disorder.

However, there has recently been some positive signs of decline of smoking rates within people with mental health and substance abuse disorders and there you can see the dark box being from 2011-2012, and the lighter box being 2014-2015. See how low the smoking rate is in the general population and then people with anxiety disorders substantially more and then other drug and alcohol problems, much more.

Now smokers often conceive their smoking to be helpful in relieving or managing psychiatric symptoms such as feelings of depression, anxiety or stress. And many mental health workers also believe this, including psychiatrists, and believe that smoking cessation will only exacerbate mental illness. And this is where the big change is. Recent evidence suggests that the reverse is true. Quitting smoking for at least six weeks actually improves mental health, mood and quality of life, both among the general population and also among people with psychiatric disorders, even people with severe psychiatric disorders. Smokers with mental illness are as motivated to quit as the general population despite so far having lower overall success rates. With proper support their success can be as good as in the general population. And that information you can see is from the Tobacco in Australia website from the Victorian Cancer Council.

Now, I am going to introduce a patient who we will call Jill, who quit smoking recently with us through Star Health. And she is a person who has a history of anxiety disorders, quite severe and requiring medication. So we will have her introduced throughout the presentation and here she is now.

Jill: “I started smoking when I was about 16. A girlfriend at school came over and said, why don’t you have a cigarette? I had never smoked before but my mother had, was a smoker. So I had a cigarette and blew the smoke out, and she said, no you do not do that, you draw it back. Well I felt so sick, but I persevered with it and I do not know why really now in hindsight when I look back, but I was not smoking all the time at that age, because I was at school. But then I left school and continued smoking. I think I stopped once when I was about 24 for about three months. I went overseas and started again.”

Lyndon: And, okay. So, now moving on. And how did smoking impact on your daughter? And this was how smoking is also impacting on her family?

Jill: “Psychologically it was affecting her because she was thinking about me dying of lung cancer and that is not a good thing for a child to think about. They should be thinking about, you know, all the good things that they are going to with their mum and not be thinking about them dying of lung cancer. So, her motivation, I think her telling me those things was a great motivation for me. Yeah.”

Lyndon: So, despite the change of name, this is a real person and with real problems, just as the people that you see. Someone who is never going to have seen in-patient therapy, but still with really severe mental health problems and smoking. So, where are we now? And this is another one of those statements that you may well want to look up and keep. Change in mental health after smoking cessation: A systematic review of meta-analysis. And these are looking at people in all sorts of different situations, both as inpatients and outpatients. And the statement is that smoking cessation is associated with reduced depression, anxiety and stress, and improved positive mood and quality of life compared with continuing to smoke. The effect size seems as large for those with psychiatric disorders as those without. The effect sizes are equal or larger than those of anti-depressant treatment for mood and anxiety disorders. So counterintuitive to what our patients and what our psychiatrists and what we have been thinking. The evidence now is that, remove the smoking and people’s mood improves, quite dramatically. As much as if they are treated with an anti-depressant.

Now, Judith Prochaska and colleagues wrote a landmark paper in 2010, making some very important statements. In mental health and addiction treatment settings, failure to treat tobacco dependence has been rationalised by some as a clinical approach to harm reduction. That is, that tobacco is viewed as less harmful alternative to alcohol or illicit drug use or other self-harm behaviours. In other words, they felt that by either supporting, encouraging or turning a blind eye to smoking, that they actually performing a harm reduction and helping people to avoid those more harmful type outcomes. And look, as a GP I would feel the same way if the evidence was that my patients with mental health would do worse if they quit smoking, I would be turning a blind eye myself in many settings, because bad mental health problems as we all know can be really, really terrible. But the weight of the evidence now shows that if we can help those people to overcome withdrawal and to quit, that their mental health outcomes will improve dramatically.

And so, tobacco use is a leading cause of death in patients with psychiatric illness and addictive disorders. Tobacco use is associated with worsened substance abuse treatment outcomes. In other words, people are more likely to go back to drinking or drugging, whereas the use of treatment of tobacco dependence supports long time sobriety. Tobacco use is associated with increased, not decreased depressive symptoms and suicidal risk behaviour, so that tobacco has the opposite effect to what you would be thinking in the past. Tobacco use adversely impacts other psychiatric treatment. Tobacco use is lethal because of its, as we know, harmful effects and is ineffective in long term coping strategies for managing stress and other mental health illnesses. In fact, in a number of studies in non-smokers, nicotine was trialled as an anti-anxiety and an anti-depressant and had no useful effects whatsoever. Treatment of tobacco use does not harm mental health recovery. Now, I would have to say it with one proviso, and that is, with sophisticated cessation support. And the cornerstone of that is good pharmacotherapy. It is not good enough just to lock people away from their cigarettes, because that does cause a period of withdrawal and can cause some problems with their mental health in that acute period of withdrawal. But we now have some, a variety of support for people that can greatly or completely reduce withdrawal.

Tim: We have got a question come through about that. Just wondering if the psychiatrists accept this evidence. As GPs we are sort of focussed on people’s, on preventative health anyway and smoking cessation, but are there arguments with the psychiatrists or are they starting to accept this evidence too?

Lyndon: There is a real mixed bag. There are some psychiatrists that are really embracing it, and taking it very well. Others unfortunately are slower to come to the party. Some of them are quite surprised when I have first shown them this evidence. Colin Mendelsohn wrote a paper for one of the psychiatric journals. So it is an area we are really breaking into, and it is an area that you cannot assume the psychiatrist will be immediately on board. But the majority of people who are smokers with mental health issues are not in the hands of psychiatrists, they are in the hands of GPs. Mental health problems as all GPs know, is a big part of our work, and as I said probably around a third or in older patients as much as a half of our smokers will have either a mental health or a substance abuse problem. So we need to be able to work with that in general practice.

Tim: Absolutely. And it is our speciality after all.

Lyndon: Absolutely. Okay, so we are back to our patient Jill and her experience of quitting.

Jill: “I did before I quit, I think when I was thinking about it, I would get anxious because I would think it would be too difficult to do. I knew you could get patches and things that would assist you, but I really did not think that they would work as well as they did. So I was a bit anxious about going through the whole motion because I thought I would still feel withdrawals and want a cigarette. But it did not turn out like that at all. I was very surprised and happily surprised that it went so well.”

Lyndon: So there is a spectrum of people both with and without mental health problems in terms of the way they experience nicotine addiction. Within the group of people with mental health problems, just as within the group of people, the general population, there are some people who find nicotine very dependence-causing and very, very hard to quit without an enormous amount of sophisticated support and nicotine replacement therapy et cetera. But at the other end of the scale, there are a number of people who do not find it that hard to quit at all, even with just some cursory support. And that is true within the group of people with mental health problems as well. And yet we have been turning our backs on that group and telling them, well it is all too hard, and they still develop lung cancers and heart disease et cetera. So it is really important that we start to chip away at the group of people with mental health problems and encourage them to quit smoking. Now, some of them will need really sophisticated support and some will just need some basic support. Now we will go on and hear a little bit more from Jill, and this is what happened when she did quit smoking.

Jill: “But then I found when I had stopped smoking, I, that anxiety that extra little bit of anxiety that I get when I was smoking had gone away. So I was not putting things on the back burner any more, I would be able to deal with them straight away when they confronted me or, I would deal with it. And I think that was a big step for me because there were things that I probably should have dealt with that I did not at the time that I should have. And after I stopped, that was much more manageable for me. And my daughter really noticed that, too, that I was coping better with issues and things that were arising in my life. I did not realise, I really did not realise, that it would have such an impact in lessening things I knew that I was feeling, because I would take medication for it and I thought that should relieve it but it, I was really surprised at the difference I felt. Just waking up in the morning and feeling alert, not tired, not sleeping in as much on the weekend. It was just an amazing thing. Oh yes, I have reduced it. I have reduced it by 5 mg, so I have one and a half tablets a day now instead of two paroxetine, so it is really – my GP was really pleased as well. Yep. She was amazed.”

Lyndon: So there you go. There is both evidence and there is your anecdote as well, that in smoking cessation anxiety, which has crippled a patient potentially for life, and now she is even able to come, or well a reduction in her anti-depressants as a result of quitting smoking.

So let us look at some of the health impacts. Smoking is associated with serious health problems such as over a dozen cancers, coronary heart disease, emphysema, all these things you all know. Australian men with mental illness on average live 15.9 years less and women with mental illness live 12 years less than those without mental illness, also with excess morbidity particularly things like emphysema. And the majority of this is attributable to their excess smoking rates. Smoking is also associated with increased suicide risk and this is a multifactorial, complex association, however there are some studies that do show a decrease in that suicide risk after smoking cessation. So the weight of the evidence in the literature indicates that tobacco use is a leading cause of death with psychiatric illness and addictive disorders.

Quality of life is really badly affected. It puts an enormous financial burden. We are looking at someone who smokes 20 cigarettes a day, they put it off for a year, that is another $8,500 gone. So, and we are also running a project at Central Coast we are training financial counsellors to do Quit Line referrals because it impacts not just the health, but also the financial health of people. So there are lots of barriers and myths among the health profession and that makes them reluctant to offer treatment for nicotine dependence. For instance “My doctor told me I am too stressed out to quit” remarked a woman in hospital for severe depression. Well, 43 years later on I am still stressed and I am still smoking. So you know, when is that time going to be right? And it is not so much the time as the support and you really do need some sophisticated support and pharmacotherapy.

Okay, now myth 1. Smoking is a necessary self-medication for people with mental illness. Well, certainly people feel that way about it because when they start withdrawing they feel an increase in stress. But it seems that smoking gives you a little lift in your mood, a little increase in your attention but it does not in the long run remove your stress and anxiety and in fact once you stop smoking, those things improve. Adequate nicotine replacement can overt the withdrawal feelings of quitting and we will talk about the Renee Bittoun method of getting people up to enough nicotine replacement and sometimes it is surprisingly large amounts of nicotine replacement that are needed.

So, myth 2. People with mental illness are not interested in quitting smoking. Look, cost is a really major motivator. Health fears are also evident as we heard with Jill. Her daughter was worried about her dying. She was also, and we will hear this a little later on, worried about starting to become breathless. I have a colleague in a clozapine clinic who has been telling me how many of her patients are quite interested in quitting. Within patients there will be different experience of nicotine dependency. Some may find it easy, some may find it hard. But there still is that interest.

So quitting smoking interferes with recovery from mental illness. As you have heard today, clearly it is the opposite except potentially in that immediate withdrawal period where adequate nicotine replacement is required. Clozapine which is a drug used in schizophrenia needs to be closely monitored. With clozapine and as with many other drugs that are liver metabolised, smoke not the nicotine, but the smoke induces liver enzymes and causes clozapine and some other drugs to be metabolised more quickly when people are smoking. This is not buffered by using nicotine replacement. Clozapine has a very narrow therapeutic range and needs to be adjusted each time a person starts or stops smoking. People can either experience more psychosis or can even have quite bad toxicity or death if they start and stop smoking without adjusting clozapine levels. The evidence indicates that individuals with psychiatric disorders can be aided in quitting smoking without threat to their mental health recovery. Once again there is paper evidence for that.

So people with mental illness cannot quit. And well, in fact the opposite has been shown. A number of papers are showing that with the right sort of pharmacotherapy and support people can quit.

Smoking is the least of their problems and we should not take this away from these people. Well, truly in terms of their long term mortality and morbidity, it does appear that smoking is the big killer. Even in people with other types of substance abuse, they live through their alcohol or their other drugs and finally die from lung cancer or heart disease, so it is really important that we do start to address the smoking. Also, for instance in substance abuse it has been shown that people are more likely to quit their other drugs and alcohol if they also quit their smoking. Perhaps it is just the improvement in mood that allows them to quit some of their other drugs.

Other misplaced concerns are that smoking cessation will impact negatively on psychiatric medication. Well yes some dosage adjustments are needed for many of the drugs. That is related to the smoke and the liver enzyme induction. Most of the drugs will need to have a small dosage reduction as the liver enzyme is no longer being induced by the smoke, and so they will need a little bit less of many of the drugs. One of the drugs that they need less of also, is caffeine and so people who drink a lot of caffeine will need to reduce their caffeine or they actually start suffering from overdosing of their own caffeine. So raising the issue of smoking cessation may elicit an aggressive reaction from the patient or doctor or doctor – patient relationship. Well look, to be honest what happens nowadays, I am a bit concerned with and that is in many inpatient facilities, they smoke-free. Some people are in there against their will because for their own safety. And they are not going the support in a very sophisticated way. There is usually a little bit of haphazard nicotine replacement therapy. And often no long term ideas about quitting. And to me that is a bigger problem, where you put people in that situation without adequate support. We really need to start improving the support and offering cessation as a long term outcome. Smoking is a chronic relapsing illness. People will go back to smoking in the majority of cases. But you keep chipping away and eventually they do quit.

So another misplaced concern, varenicline and bupropion are unsafe for people with mental illness. We will talk about those specifically later on. There are a few provisos, but both of those can be used for people with mental illness. Smoking cessation will not worsen depression once again except in that acute withdrawal period where if people are not adequately supported it can be a problem. But outside that in the long run, their mood, their depression, their anxiety will be improved.

So depression overall is two to three times more common in smokers than non-smokers. In an 11 year population follow up, tobacco use was identified as a significant predictor for first depression episode with evidence of dose response relationships. So more smoking, more likely to be depressed. Both with respect to the number of cigarettes and the amount of time one had been smoking. So right throughout the world, people in populations that are smoker are more depressed than the non-smokers. In the past, the idea was that they were self-medicating as a type of anti-depressant but now that relationship may be part of the answer, but given how much mood improves when people quit smoking, the smoking itself may be implicated in some of the mood problems. Also, smoking tobacco has been one of the strongest predictors of future suicidal behaviour as well, and obviously that is not true in every patient, but on the whole people with mental health issues who smoke are more likely to suicide.

So, it is important to integrate these smoking cessation into the total psychiatric care and evidence supports the use of most of the recommended cessation treatments as we have talked about before, nicotine replacement, varenicline and bupropion. And nearly half of all smokers have some degree of mental illness and we have talked about that as well.

So, how do we get people to quit? Well, back to the basics, the five As. First of all, we need to ask all of our clients and patients whether or not they are smokers. And we need to be non-judgmental and we also need to have them understand that we understand that it is more likely that there will be failures before there will be success and they need to be happy to come back to us. Now in assessing people, one of the first things you need to know is at this point, how ready are they to quit? If they are at this point, ready to quit, then what you deliver to them is you teach them how to quit. You do not do a whole lot of scare tactics. They are ready to quit, so what you should be doing is teaching them how to quit. If they are unsure, and most of your mental health patients after all are going to be unsure, then you need to clearly determine what their barriers are. So unsure means they would rather not be smoking but they have some barriers to quitting. For mental health patients addressing this idea of improving their mental health is going to be really critical for you in future. And not ready. Well this often puts a lot of people off, you know, someone who is just not at all ready to start thinking about quitting. Well basically there is personalised medical advice and make sure that you see them again, follow them up. But what you can offer them is cut down to quit which essentially means wearing a patch and trying to cut down the number of cigarettes you smoke while you are wearing the patch. Somehow or other the brain starts to accept a new source of nicotine and it actually empowers people to realise that they can actually escape from their nicotine sentence. And the research on that study showed that even in people who were not ready to quit, using that strategy at 12 months you had 4% of smoking cessation. Which is pretty good in a group of people who are not ready to quit.

Okay, so what is the next thing? Well, assess nicotine dependency and the most important question there is time to first cigarette. Anyone who needs to smoke in the first half hour or hour is going to be strongly nicotine dependent and you are going to need lots of nicotine. And also because of today’s talk, think about comorbidity. Probably half of your smokers will have some sort of either mental health, alcohol or often cannabis comorbidity. After all, tobacco is often used in helping cannabis to burn.

So advice about quitting. Advice about the harms of smoking, the benefits of quitting, and the medications. There are lots of different supports out there and as GPs, we need to recognise that people are much more likely to quit if they get a number of follow ups. I think the research shows that good rates start to occur around four follow ups, and you know, even myself with my great interest in smoking cessation finds it hard to get people coming back four times for one smoking cessation attempt. So, utilise Quit Line, utilise supports so that you are getting those extra supports and extra visits through other support measures. So, we have talked about debunking the myths and the various lifestyle interactions et cetera with nicotine.

Quit Line. Now I guess a lot of people think that Quit Line is just sort of a phone number that you ring and people get some pamphlets or something but it is much more than that. People are linked up to a counsellor and they continue to be linked up to the same counsellor. They get ongoing support from that person. It is you know, it is almost like setting someone up with a psychologist and having to do a mental health care plan to get that done, but you do not have to do any of that. All you have to do is send the fax off. For people who do not like talking, they like texting, then they can go through texting instead of talking. There is also computer based support for people, so it really, whatever people enjoy as support is all offered in Quit Line. Of course that helps you with your authorities if you are doing varenicline and bupropion but even if you are doing nicotine replacement therapy I would recommend it. And here is a website, iCanQuit, is also very useful.

Okay, so the most relapses occur in the first two weeks so make sure you are seeing people at least a few times in the first two weeks. Quit Line and I talked about the four visits.

So we are back to Jill and we will see how she got on.

Jill: “My daughter is honest, she did not like the idea of me smoking. She kept saying to me, mum I do not want you to die of lung cancer, and it really makes you stop and think when your children say that to you. And my mother stopped when she was 60 and looking at her now, she is 91 next month, and she is going well. She has got a little bit of emphysema but does not need home oxygen. I think it was time, getting too expensive and I really felt that I was getting a bit puffed when I was walking up hills or upstairs and I just felt, no it is time. I have a friend at work who wanted to quit at the same time, got patches and got on the Quit Line and got the App for the phone, and it was very, very helpful. And it worked. The patches really work. That was how my mum stopped so it was a good kind of example to learn from. Yeah. So when I got the patches, they also gave me like an inhaler with it and that really helped in the first couple of weeks. Just when you feel the urge that you wanted a cigarette, I would have a puff on one of the inhalers and it instantly stopped the craving, so that was a really big help. Because it would have been really easy to just start a cigarette but I was not going to buy any. I really was determined. Yeah.”

Lyndon: So Jill is nicotine replacement. As GPs I guess many of use the first line varenicline and have not sort of learnt to be fairly sophisticated in nicotine replacement. I think with people with mental health, your first port of call probably should be nicotine replacement therapy but with the others certainly our second lines. We will talk about that now.

So tips for using nicotine replacement. So, a single patch is to be honest quite a low dose, even the full strength patch and we will talk about the Renee Bittoun method of scaling up to find out how many patches et cetera are needed. But we do in principle, need to use combination nicotine replacement therapy. Once you put a patch on it takes around about four hours before that patch gets up to a steady state. So it really is very slow and much of the morning after people put patches on are spent without much at all support, so combination therapy is really important. Also understanding the way the different types of combination therapy work. For instance the inhalator that Jill spoke about then is really useful in terms of the hand to mouth feeling of actually smoking. It is like similar to smoking but they do not deliver a whole lot of nicotine whereas the new oral sprays in fact deliver a really big dose of nicotine much more than most of the others and much more quickly than most of the others. Now the down side on that, is that because they give a surge of nicotine, a rapid surge, they are most likely for people to ultimately become dependent on them. That is not a huge problem but just to recognise that that is the sort of difference. I will talk a little bit more about that now.

So, when you have someone who is smoking the chart here shows the nicotine blood levels going up and down and across the page is time. As you can see, people, the distance between each of those peaks and those smokers will be around about 20 minutes or half an hour because that is how long it takes for them to want another cigarette. Now, in this smoker let us say that around about this level here is where they start feeling a craving at this point, and then they move on to getting another cigarette.

Now what I have drawn in here is someone using a lozenge or gum, and you can see that has taken a lot longer to get up to that craving point and it is not going anywhere near as high. So, the smoker enjoys that surge, that is the part that causes them this upwards surge part. That is the part that causes them to have some enjoyment from the cigarette each time. Because that is dulled very much in the gum or the lozenge, they do not enjoy it anywhere near as much, and so the psychological dependency is much less likely. But here you can see that lozenge is only just barely covering their craving level.

Now the next line is actually a patch and you can see that the patch is taking a long, long time to get up to a level, but it is way below their craving level. There is no surge of any type in that patch, it is very slow so there is actually no one in history ever reported as becoming dependent on patches. People do become dependent as you probably know on lozenges and gum from time to time, but not on patches. And what you can see there is that if you did have several patches you could push that line all the way up to that level where the craving is and stop the person from craving but still have no surge. And even though you are doing that, and the person is not having any surge, every day they are missing out on all of that extra nicotine. So they are not craving but they are still missing out on all of that extra nicotine every day. And that is why you do not have to wean them off the patches, because they are actually weaning off the nicotine themselves, just on a steady state of patches. So, the red line here is where the cravings were starting at the beginning and now after being on patches for a while, the carving level drops right down and here we have gone even below the level of one patch. So that one patch now is covering all their cravings.

Just bear with me while I get the computer working. So, I have spoken a couple of times about the algorithm from Renee Bittoun and this is really a tremendous algorithm. I will summarise it though, and that is that you let someone head off home wearing one patch and allowed to continue smoking but they need to keep a diary for a few days, say four days as to how many cigarettes they need. If they need 10 or more cigarettes on top of that patch they are going to need another patch. Then you go back to square one and do it again. So now we have got two patches on. If they need 10 or more cigarettes on top of those two patches they are going to need another patch. Now, my record with this working in a rehab unit was one woman who needed four patches, however I have seen it go as high in a detox unit as five patches plus other intermittent NRT. So that is really the extreme, but just to give you the idea of how high it can be necessary to go. In many smokers though, you are looking at two patches plus other types of NRT whether it be oral spray, inhalator, lozenge et cetera. Now, once you are down to one patch, you really do not need to wean through 14 mg, 7 mg et cetera. One patch is already very low and as I described you are missing out on all the surges so you really can come off at that point. But I do cut down on patches one at a time over a few weeks.

Tim: Just a few questions about the patches have come through. Do, the patches that you use are all the 24 hour patches not the 16 hour patches?

Lyndon: Negotiate with the patients individually. Not everyone suffers from bad dreams with patches, some people do. If they can tolerate wearing one patch for 24 hours overnight, that is fantastic and then you can add the next patch on first thing in the morning. One other potential method if you want to get really sophisticated is to take the patches off at around about 6 or 7 o’clock in the evening, remember the four hour delay, so then last thing before you go to bed, say at 10 o’clock you put one patch on and that patch has not reached a sort of reasonable level until the early hours of the morning. Usually people by that time are well and truly asleep and not suffering and they wake up already fully charged with some nicotine on board which is really helpful first thing in the morning. Usually though you would be only having one patch on overnight in that sort of circumstance. If you are going to use no nicotine through the night which is fine, you definitely need to have some fast relief nicotine first thing in the morning.

Tim: And are there many people, I have seen people asking about rashes with nicotine patches and I know some people say they sweat excessively and they do not stay on. Are those common problems?

Lyndon: Oh absolutely and you know, with people on various types of anti-depressant they often sweat more. Sometimes you need to pop a Tegaderm over the top. Sometimes you need to search around for some skin that does not sweat as much. There are various issues. I have had some people who just cannot use patches. But there are lots of choices of different types of nicotine replacement therapy so you can still use it if you cannot use the patches. Just remember that everyone, nicotine is a poisonous substance and everyone gets a bit of redness from a patch. That is not allergy. So just move the patch around. Expect a little bit of redness, but certainly if there is blistering et cetera well, there is a problem. It is usually to the glue rather than to the nicotine and sometimes they can tolerate a different brand of patch.

Tim: Yes. And just to be clear, patches are PBS subsidised, aren’t they.

Lyndon: That is right, yes. Only one patch at a time officially. For multiple patches usually you are going to have to either pay for them or do private scripts. But yes, one patch certainly is covered.

Okay, so the next medication many GPs are very familiar with using, varenicline. We have all had issues, or heard of issues with people having either suicidal thoughts or problems on varenicline. The consensus statement which I think is here from the RACGP is that on average there is no higher rates of suicidal events, depression, agitation et cetera with varenicline than there is with other types of cessation. However, there are anecdotes and you know, just to be cautious, my practice is that if someone has had strong suicidal ideation, suicide attempts et cetera I prefer to avoid varenicline. I just, I would not like even if varenicline had nothing to do with it if there was an event I just would not like the two to be mixing together. That is why I say probably first line for mental health is still your nicotine replacement and it is very effective as long as you use enough of it. You have to often use a lot. Varenicline works really well for many people but there are still some people whose receptors are a little different and they can continue to smoke and enjoy their cigarettes, with the benefit of varenicline for most people is that it blocks their ability to enjoy a sneaky cigarette and so they learn not to want to smoke because when they smoke they do not enjoy it. So you know, people experience not only nicotine but also the nicotine pharmacotherapy drugs differently and if they come in and say they are still smoking happily despite taking varenicline well they are one of the few people that it is probably not going to be very helpful with. But nicotine replacement therapy certainly will be. One option which is sometimes used is a combination of nicotine replacement therapy with varenicline and there is a flow chart for that. Personally I just feel that I like to just use nicotine replacement therapy on its own if varenicline has not worked, but the option is there.

Now this is a tip from myself and not evidence based, but just from the ones that I have seen. If I have a patient who is smoking 35 cigarettes a day and really strongly nicotine dependent, I am also a bit cautious about varenicline. And remember if they get the right response from varenicline, they are going to not be able to have a sneaky cigarette and I feel that they may be having a sort of an excessive withdrawal from nicotine. I wonder whether some of these anecdotes are people actually having excessive withdrawal where the varenicline in those people is not quite enough to stimulate the receptor in its way to reduce their withdrawal. So I guess my tip is, not only people who might have suicidal ideation but also people who are very heavy smokers, 35 a day, very nicotine dependent, probably just be very cautious with varenicline.

Once again, you can start out with nicotine replacement. You can use cut down to quit. You can do that to cut them down to a really small number of cigarettes and then you may be using varenicline to really to get them to finally quit. To get them to stop that last 10 cigarettes or whatever. Just be a bit cautious having someone who is smoking 40 a day and putting them straight on varenicline.

And here is a flow chart for varenicline and essentially that just says that it either works or it does not and if it does not then you can add some nicotine replacement therapy. And then we have got bupropion which it was the first drug to become available in Australia as a subsidised smoking cessation. A very large number of people used it and there were sudden deaths associated with it and unfortunately that put everyone off the drug and in retrospect it appears that all of those sudden deaths were just the normal expected sudden deaths that you would get from a large population of smokers. In fact there were less sudden deaths than there should have been. So, in that term bupropion is off the hook. Why is it a problem in mental health though, is that it itself is an anti-depressant and you really can be increasing your seizure threshold if you are combining several different anti-depressants, so that is a problem. Also, if you put someone on this for smoking cessation and they improve their mood dramatically, you are not going to be able to use it because it is actually not on label for mood disorders in Australia. So that is sort of a practical problem with it. And anyone with alcohol withdrawal et cetera you should not use it. Once again, it does lower seizure threshold. Eating disorders for some reason get seizures on bupropion as well. Having said that though, we cannot predict who it is going to work really well for and it may be around a quarter or a third of people and this is why it was first prescribed. They just do not want to smoke anymore once they take the drug. A large proportion get no help from it whatsoever, but a small group just get this wonderful no interest in smoking whatsoever once they go on the drug. If you have someone that has had a history of it having that effect, then it may well be your best drug. On the other hand, if you have someone who has gone through multiple failed quit attempts it could be worth a try. However caution, do not have two anti-depressant drugs combined. It is not a strongly serotonergic drug so it is not so much the serotonin syndrome as the seizure threshold. I have seen some psychiatrists use it in combination but I would be cautious.

Okay, so there are some more resources for you to come back to, fact sheets et cetera and I think we are coming close to the end in our learning outcomes and addressing any questions.

Tim: Yes. So one of the questions that I think the five As approach does help with, but is just around how we can gain patient support and confidence if the mental health teams are not supporting that. There is a bit of contradiction in the advice that we are giving and they are giving.

Lyndon: I would print some of these papers out and get the highlighter pen out and show that look, this is the new thinking and people may not have caught up with the idea yet. But at this stage I am describing rather than talking about clear evidence, but there are many other stimulants that give you an instantaneous mood lift but in the long run cause you to be more depressed and we know that very well from things like ecstasy and amphetamines. The picture is more and more drawing that way with nicotine that it is a drug which makes people feel that they are improving themselves when they take it but in the long run it is making them worse. And that is part of the addiction cycle. They are getting deeper and deeper into mood disorder and taking more and more of the drug which is causing it.

Tim: My sense is that very few patients, most patients with and without mental health problems do know that smoking is bad for them and that they will need to quit at some point even if they are going to find it difficult right now. And I think people are often well disposed to GPs in a way that they might not be to mental health services. So I think there is a real opportunity there as a GP to provide care that the mental health teams often are not able to.

We have got a question come through about electronic cigarettes and the side effects of that, and I guess wondering whether that, if there is any evidence about that being helpful in smoking cessation for people with mental health problems?

Lyndon: So, e-cigarettes are a little controversial. I think firstly I would applaud New South Wales Health in terms of public health. In the United States where e-cigarettes have been released and promoted to the general public, chiefly in younger people, as many as 30% of young people who are using e-cigarettes have never been smokers, and because smoking is a better way to deliver nicotine ultimately many of those will become smokers. So I think the approach to not having e-cigarettes promoted largely across the community is a really good one. But the spin-off from that has been that people in the tobacco treatment industry have been concerned that maybe we could use e-cigarettes for people as harm minimisation. And look, that is something to think about but the problem is that particularly in mental health here, you may be dooming them to having ongoing problems with their mental health. In fact, by getting them to quit their nicotine addiction they may benefit greatly from that in terms of not only stopping their smoking habit but also improving their mental health. Now the outcomes on e-cigarettes being good for cessation just are not there. The tobacco industry have been supporting vaping as the thing you do when you cannot smoke, so that you can smoke when you get the chance to. And that seems to be the way that many people approach it, when they are with their family or in a confined space they will vape, but ultimately they do not quit smoking. They usually go back to the cigarettes at some stage. So it is a little bit controversial. There certainly are people out there who it just seems nothing we can do will get them to stop smoking and maybe e-cigarettes might help those few people. But let’s not give up on people so quickly. I really think we have not done nicotine replacement therapy properly in a sophisticated way. We have not even been promoting the idea of mood improvement. Though I would say if I had a patient who is using e-cigarettes, I do not tell them to stop it, but I certainly do not promote it. And it is also difficult if you do promote it, because there is no really easy legal way of getting it. It has to either be got from some sort of clandestine tobacconist or brought in from overseas. So, complicated answer, but I think we have got a lot of other ways of dealing with it.

 

Tim: We often see, someone was asking about combination anti-depressants. We often see people on for example Effexor and mirtazapine as the example given. Is there a problem with adding bupropion into a mix like that?

Lyndon: Yes, while I said that bupropion is not particularly serotonergic you are starting to run the risk of serotonin syndrome, particularly if you add in a pain killer or something on top, a narcotic analgesic. But more importantly, is each of those do slightly decrease seizure threshold and bupropion is one of the most potent decreasers of seizure threshold, so your person could have a seizure. I am a little cautious of using bupropion in commercial drivers as well just in case there is a seizure. Yes.

Tim: Yes. We have got a few questions come through that I am actually not going to put to you. They are on the use on nicotine replacement in pregnancy. We have had a previous webinar about exactly that topic, so the recordings are available I believe Sammi on the college website. So go back and have a look at the recordings about nicotine replacement and smoking cessation in pregnancy because it is not quite on our topic this evening.

And someone was asking about nortriptyline. I think that is sometimes used in helping people stop smoking and maybe cannabis cessation as well.

Lyndon: Yes, there is actually a Cochrane review of it and quite supportive of it. I guess I would be putting it as a fourth sort of line, because it is a tricyclic anti-depressant with all the side effects and risks you know it is a nasty drug to overdose on. However, it certainly is available and it is not expensive and it would be worth a shot. With all those provisos.

Tim: So it is actually recommended in the therapeutic guidelines for smoking cessation treatment as well, so that is another option.

The final question to end on. Do many people manage to stop going cold turkey or without pharmaceutical support?

Lyndon: So use of nicotine replacement therapy on average doubles your quit rate at 12 months. So, if you have got a group of people who on average have a 10% quit rate without pharmacotherapy, it would be 20% with nicotine replacement therapy. And you know, even better if you are going to be using it in a fairly sophisticated way with really, you really can reach complete satiation. I have worked in two different rehabs, and had people come in and as I say my record was with that person with four patches plus lozenges. I have got recordings of them describing their experiences. It is just totally different than just whacking one patch on and saying good luck. You can reach complete satiation but you are still weaning because they are not getting all of those peaks. So it is really doable.

Tim: Excellent. And so on that note, we have reached 8.30. Thank you very much for an excellent presentation. I think people very much appreciated what was presented there. Thank you very much Sammi for all the technology and introducing us at the beginning and I hope you all got a lot out of it and have a good rest of your evening. Thank you very much indeed.