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Counselling smoking cessation in a changing world

Welcome to this evening’s counselling smoking cessation in a changing world webinar.  My name is Dr Trish Kahawita, I will be your host for the evening.  Before we get started, I would like to acknowledge the traditional owners of the land from where each of us are enjoying this webinar today.  I wish to pay my respects to their elders, past, present and emerging.  Just a few housekeeping notes.  This webinar is being recorded and you will receive a copy in the coming weeks.  If you cannot see this control panel on your screen, move your cursor over the bottom of your screen and the panel will appear.  The control panel provides you with the audio tools for adjustment and it is where you can ask questions via the Q&A module.  We have put all attendees on mute tonight to ensure learning will not be disrupted by background noise.  As this is a webinar, we are unable to see you as participants so please interact with us using the Q&A box at the bottom of the screen.  Please do not enter any personal information outside your name and question as other attendees will be able to see this.  If someone else has asked a question that you would like answered please give it a thumbs up.  Questions that have more likes will move to the top of the list to be asked.  We have a dedicated Q&A session at the end of the webinar but please ask questions throughout and we will try answer them as we go.  Tonight’s webinar is proudly sponsored by Johnson & Johnson and our presenter for this evening is Dr Hester Wilson.  Dr Hester Wilson is a GP, addiction specialist and chair of the RACGP’s Specific Interest Addiction Medicine network.  Hester has many years’ experience working with people with addiction issues in both general practice and specialist settings.  She also works in a public drug and alcohol service in Southeast Sydney Local Health District.  She is a conjoint lecturer and PhD candidate at the School of Public Health and Community Medicine, University of NSW.  We will get started now and I will handover to Hester to commence her presentation, thanks Hester.
3:25
Thank you so much, I am just going to share my screen, great and welcome to everybody, I just want to acknowledge the traditional owners of the land on which I am and the Gadigal people of the Eora nation. We are going to be spending the next hour talking about the different kind of smoking cessation options that we have including e-cigarettes, because there are some really important changes that have happened, a lot to get through but I do want to make this interactive so please put your questions on the chat.  There would be a couple of polls and I will be asking for some feedback from you as well as we go along. So the idea of this is understanding effective smoking cessation strategies based on the evidence, understanding the options to assist our patients, identifying any risks and benefits with the different smoking cessation options including e-cigarettes, understanding the legislative changes that have just come in for e-cigarettes and resources to support that, how to manage refusing a prescription particular for the e-cigarette prescription if you feel it is inappropriate. So just a bit of prevalence I think this is really interesting, looking back at that old data, back in 1945, the end of world war II, 72% of men smoked 26% of women.  Men started decreasing, actually women went up as there were changing kind of societal values around women smoking but since that time, we have seen a really terrific decrease in rates and at the moment the rates are around 12.4% for people aged 14 and older in Australia so we have done incredibly well in terms of decreasing the prevalence of smoking. You know 22% of people are ex-smokers and a vast majority of people are never smokers.  I should flag but in our Aboriginal and Torres Strait Islander community the rate of smoking it has decrease but it is still extraordinarily high.  Also noting the group of people that I see in the drug and alcohol setting, their rate of smoking is about 91%.  It depends on the community that you are working with but overall, we have been very successful in getting our smoking rates down.  There is however more to do.  I just wanted to flag one of the concerns that I have, is around when young people start.  So we know that a small percentage of children start at age 12 and 6% have started by age 17 and will continue to smoke.  One of the really interesting things about young people is that even at what looks like a really low levels of consumption they are already starting to develop a dependence, so one cigarette a month, one cigarette a week already starts them very early on the train to dependant smoking. And starting earlier increases your risk of up taking regular smoking and they get it from their mates that is where they get them from. We know … I don’t need to talk to you about this in great detail, but basically, when I am talking about this, smoking affects just every organ in your body and has really significant affects, you know 1 in 10 deaths worldwide are caused by tobacco smoking and we do need to consider the risks of passive smoking in pregnancy. It is an interesting thing for me because you know the bottom line is it is one of the most cost-effective interventions that we can make with our patients.  We stop people smoking we save lives.  We increase life expectancy by up to 10 years and we know that our patients want to quit, and they trust us to give it give advice. It is core to our role. They do want to quit.  There is a bit of kind of story out there that we have got a group of hardcore smokers that do not want to quit. In fact, the research does not show that and I certainly do not see that in the group of people that I see. You know, that they may find it difficult and may have had more quite attempts and struggled to give up smoking but they do want to give up smoking.  I always think to myself the thing with someone who has had less success in giving up smoking is they need more support, not less.  Do not assume that they are hardcore smokers that do not want to stop, because they do and they find it hard.  So how we have those conversations to help those people is really important.  I’m just going to do a poll, just to get a bit of sense of where you are at, so we can just start poll up and just note that you might need to scroll down because there are two questions so that you can see the two there, so have a go.
8:26
I think we are around 70% now.
8:30
Beautiful okay, so I am really pleased to see that the vast majority of you strongly agree or agree.  One who is not sure and one person strongly disagrees, I would love to have a conversation with you that person that strongly disagrees, it may be because it is the _______ that you are working in but look I do consider that it is part of our role as the does the college of GPs. Looking down at confidence around success, lower rates, so majority agree that they are confident but not so strongly agreeing and there is a large proportion that are not sure and even one person that disagrees that they don’t have the skills or confidence.  Okay, let us move on from that.  So coming back to the guidelines that we have through the College of GPs, these were first put together 10 years ago they have been updated in 2014, 2016 and there is a new update that we have just gone through. We did a rapid review in August/September time to be released in October. But bottom line, it is our role and the recommendations from the college of GPs is that all people who smoke should be offered brief advice to quit smoking. Have a system in place for identifying and documenting tobacco use in every practice, offer that smoking advise in routine consultations and appointments whenever you can do it, you know do it opportunistically and offer follow-up to everybody that wants to try having a go.  So for me, one of the things that are always in my mind, I know I am super busy, I know all of us are super busy so having a quick 30 second way to approach this so that you can have it as part of every consultation. Doing it opportunistically. Ask everyone, document it in the medical record and in 30 seconds, so you can look at the medical record and you can see do we have a smoking status.  If it is new or unknown the first question is, do you smoke? If you know that they are smoking from the records, are you still smoking? If you know that they are an ex-smoker, how is it going, are you still not smoking and those that are not smoking or have never smoked, congratulate, well done guys, keep going.  If they are smokers or have relapsed to smoking you can really very quickly just flag the importance of this and that you want to help.  You do not eve have to talk about the risks and the harms because actually most of the time people are pretty aware.  There might be some situations where there are specific issues that you want to raise, the smoking risk from their particular clinical situation, but for most people, they know it is risky, so you do not even need to go there. What you say is, I am concerned about your risk of smoking, there are effective treatments and I can help you with this and then lets book an appointment, if you have got time in that consult of course go straight into it but most times we have not, but what you are flagging is this is important, there were effective treatments, I want to help you, book an appointment so we can talk about it, it is really important issue at another time.  If you have someone that wants to start telling you their whole smoking history and you have only got this very limited time, it is okay to stop them and say I do not have time today, however, this is super important, I do want to help you, let us book an appointment to have a look at this.  So let us go to a case study.  This is Jack age 53, who lives with his brother, he works in disability so he first started smoking at age 12, he was one of those young people that started young and he has his first cigarette on waking and he smokes 20 a day.  He drinks 6 to 8 standard drinks of alcohol three days a week.  He has a history of hypertension, hypercholesterolaemia, has bipolar affective disorder, asthma and has a family history.  He is on a number of medications and he has tried to give up in the past, so can I get you to put in the chat, what smoking cessation options would you advise for Jack.
12:36
Sorry if you could just put that in the question and answer section, that would be great.
12:44
So while we are waiting what do you recommend, what would be the smoking options that you would offer.
12:56
So from _____ Patel, we have got nicotine replacement therapy, Champix, Zyban.  We have also got a lot of votes for nicotine patches from _____. We have got NRT as well, Champix, Champix, Champix, nicotine or Champix.  Caroline has written, first explore what has and has not worked.  He is not so keen on Champix and Danielson has said NRT patch and quick acting NRT combo. Craig commented vaping or NRT. Nicotine replacement has been commented Becky but will be cautious with Champix given psychiatric history. Lots of NRT and Phardy has commented it depends on what the patient requests. Anonymous has said to try and instil some doubts and slow work and question why the motivation for smoking. A lot of NRT, Champix, Zyban.  Natasha has commented psychologist.  Stephanie’s comment would be concerned about the implications for his bipolar for some of the options.  Amanda has discussed, explore the stage, pre-contemplative, contemplative etc and yeah, a lot more NRT or Champix or a combination of both.
14:26
Fantastic, so a few important things that people have raised. First of all with Jack he started smoking very young, so he has had a 41-year history of smoking. He has his first cigarette on waking so he is likely to be highly dependent.  As soon as he wakes he is having his first cigarette and he is smoking 20 a day, now I am not so interested in the number, I am really interested in the time for a cigarette because that gives you an idea of the level of nicotine dependency.  He also has this cardiovascular history and he has his mental health history and his asthma, so he is someone who will benefit absolutely given his history and given his family history from changing his smoking.  You are right to have some concerns about particularly his antidepressant and he has tried to give up in the past, so really looking at and I think this idea that people are pre-contemplative, really examine that, because sometimes the pre-contemplative is about the fact that I tried and it did not work, I do not think I can do this. So building their confidence to make that change and we will talk a little in a moment about the things we can do to build that.  Look I am interested that only one person talked about psychology, core to giving up smoking is behavioural support so that does not necessarily mean psychology, but it does mean conversations around managing triggers, around being clear about what they want to achieve and how they are going to achieve it and look Quitline, Quitline is around Australia, it is fantastic, it is available, it is free and my sense is that we probably do not get our patients to go and check in with Quitline as often as we could.  In NSW we have a NSW health initiate called Get Healthy which is also great. We should flag as well for this patient the alcohol, so he is drinking at risky levels three times a week and quite often the risky drinking and smoking can be a bit of a combination as well. So core to whatever choice you provide is providing behavioural support and you can do that yourself if you have got time, or you can refer on to you know the Quitline or your local smoking cessation service if you have got one or your practice nurse, if you have got a practice nurse that likes to doing this as well. But really it is core to everything, it is really working with that person around helping them to put a plan together that is going to work for them around their smoking and as well combination NRT or varenicline or bupropion are the three first line agents.
17:12
Sorry, just pertinent to this slide, Caroline has also just asked, many patients report Quitline is not effective, do you know of the stats of it’s effectiveness.
17:26
I am afraid I do not but, on its own, behavioural support is not enough.  It is the combination of the evidence-based treatments and behavioural support that have the best outcomes. The other thing I would just question is what is success, I am thinking about that, because someone like this patient we are talking about is very likely to go, I failed, I did not give up. But you might find they were able to give up for a period of time or that they have cut down, or that they are not having a cigarette first thing in the morning, that they put it off for a couple of hours, they really starting to change what they are doing. So we do need to interrogate with them what is actually going on and what is failure and looking at building their strengths and their sense of their ability to make that change. So coming back to the behavioural supports as said by you, Quitline, there is online options, My QuitBuddy app. I had a look at it last night and it has been really good, at the moment they are doing some updates. But it is a really good app, your local smoking clinic if you have got one, give them information about smoking about what quitting feels like, about withdrawals, how to cope with triggers, addressing their barriers that they have to quitting. So for him it might be going down the pub and having some beers and smoking with mates, it may well be that there are some gambling in the picture there, that we need to check out as well.  Looking for support from family and friends.  For some people, looking at rewards can be really useful. One that has worked for a few of my patients is the idea that it’s around the money that they save or another really interesting one was a patient who said if I do not quit, I am going to give some money to a charity that I do not want to give to or an organisation that I do not want to give to.  Setting goals for quitting, you know really being realistic around what those goals are. So Nicotine replacement therapy, a lot of you talked about that, the bottom line is this is a very one of evidence-based smoking cessation treatment.  With behavioural support and combination NRT, the long acting patches and the short-acting; so you go a long acting patch that they put on, keep on and then on top of that when they get the cravings, they go for the gum, the _____, the inhalator or the oral spray. Unfortunately, they are not both covered by PBS, they are only on the PBS as a sole, you can either choose short-acting or long-acting. It does not make any sense but that is what on the PBS. But really encourage your patients to use both because that is where the evidence is. That is best chance of changing smoking by using a combination of NRT and behavioural support.  When they give up, you can actually give them an additional course through the PBS but there is no evidence of efficacy after about 24 weeks.  You do not need to taper, and there are those kits you can get in the pharmacy that taper down, you do not need to do that.  The other interesting thing is that quite often people will get some nicotine replacement therapy from the pharmacy without support through behavioural supports, but also from their doctor and people do not do well, just picking up NRT from the pharmacy so there is something really core about that behavioural support and the support that we provide as their GP.  You can use NRT therapy in pregnancy.  So from my point of view, we always are concerned about exposure to anything in pregnancy but if somebody is smoking during pregnancy that baby is passively smoking and getting a lot of nicotine.  If we can cut that down, if we can replace it with nicotine and ideally we start with short-acting but with patients if does not work going to the long acting is a harm reduction strategy for that baby.  NRT can be used in people that have cardiovascular illness, be careful if they just have an acute cardiovascular event.  If somebody is in hospital with that, it still can be used, but you just have to be a bit more careful. We do not know about its use in children under the age of 12 but it can be used in teenagers. Varenicline, once again the behavioural support is core to this, this is a nicotinic receptor partial agonist that acts on those reward centres and cravings centres of the brain, once again it is used for three months and you can give up to a six month script to support ongoing cessation.  There is some evidence that NRT and varenicline may improve quit rates. The data is not great but there is some. One of the issues with varenicline is nausea so you start them on low-dose with the starter pack and build it up. A group of people will have insomnia and vivid dreams. I think sometimes those vivid dreams are actually about nicotine withdrawal and so there are some patients where I have combined the two and that has been really useful for them, so this is a high evidenced based treatment, behavioural support, nicotine replacement therapy or behavioural support and varenicline are both highly evidence-based and equivalent.  Look, you can use it with mental health issues, you know given his bipolar and his SSRI we do need to keep an eye on that but you absolutely can use it.  There are big studies done that looked at long-term outcomes for people who have significant mental health issues using varenicline and they are very good. You do need to monitor, it can destabilise their mental health for a short period of time. My sense more than anything else is that it is actually about changing the nicotine.  If I am seeing someone who has significant mental health issues, I do not want to be starting the varenicline if they are very unwell with their mental health. But I am very happy to start it fairly early if they are stable. But I would offer them more support and see them more often.  At the moment it is B3 in pregnancy so once again you are looking at whether it is the best option and I would generally go for NRT in pregnancy at the moment. Breastfeeding and adolescence we are not clear.  Trish you have just turned your camera on.
23:25
Yeah, I have a few comments from the attendees regarding the varenicline or the Champix availability, apparently it is not available at the moment, have you noticed that and has it impacted your practice.
23:40
I have not actually, I have not, interesting, I was not aware of that.  I do not know if it is a particular state or what is happening there, we have had other medicines that have been affected by COVID but look you know if you cannot get it, then use NRT.  The third one is bupropion, now for this person who is already on an SSRI you would not use bupropion. Once again, behavioural support, it is effective, but it is not as good as combined NRT or varenicline and there is no evidence that it is useful to combine it with either NRT or varenicline.  It is contraindicated in people that have history of seizures, eating disorders who are on monoamine oxidase inhibitors, pregnancy and breastfeeding so then there is also the cautions as I said with your antidepressants. But in a group of people it can be quite useful, and it is one of the options that you can consider.  Okay, so once again, what I want to say here is I want you to think about being really upbeat and supportive around people having a go. You know and look if somebody is saying, I do not want to do it today, get out of my face, I would say that is fine, but I want to let you know is that I am here to help you if and when you are ready, so please come back, this is important I want to help you.  Once again, the behavioural support is core to this and giving up can take time and it is not unusual for people to have repeated quit attempts and you know the thing that I often say to people is, every cigarette you do not have is doing you good you know. So every change that you can make towards achieving this goal is fantastic and if you have periods of time where you are not smoking at all, that is fantastic and if you have a lapse back to smoking, that is okay because you have got skills that you have built and we can get you back on that track again. So relapse is common, relapse is normal in any dependency or addiction and it is around flagging that, helping people to become aware of what their triggers or the risks might be and helping them to keep on their track towards becoming a non-smoker or ex-smoker. And as I said before, people who are highly dependent they need additional support, so we will see them more often, get them involved in Quitline I would get them seeing a counsellor, I would get them having a talk to my nurse, whatever worked to help them to achieve their goal.  So just a few different ways that you can work with people around quitting. The classic one is set a quit date, now with varenicline it is day eight, with NRT it could be, put your patch on for a week get it all started in place and then stop where you can set a quit date when you start your patch, that can work really well.  The other one is a cut down to quit, so the idea is you start either the medication or the patch and the short-acting NRT and what you do is you just set a time where you are going to slowly cut that dose down to quit. That can work really well for people as well.  The third one, particularly if you have got someone that goes, I have tried so hard to do this and nothing has worked, is to say, lets not set a quit date, lets not try to do a cut do to quit, lets just start the treatment, start you on the patch and you know, what do you want, the gum, lozenges, the inhalator or the spray which one of those do you want to choose, or lets start you on the varenicline, either is fine. Just do not do anything just start the treatment and let us see how you are in a week, let see if you have actually changed how much you are smoking. If you are putting off your first cigarette of the day, if you have cut down the number you have smoking and this is a point where the carbon monoxide monitors, my son who is a chemist would be horrified. Yeah so it is the carbon monoxide monitors and there is not a lot of evidence to support it, but I certainly know anecdotally that it can be really useful if you do have access to one of those or you want to buy one for your practice. That is has really good buyer feedback, so if you have got someone when they are smoking who has a CO of 50 which is quite high, you know non-smokers in Australia would have a CO of 2 or 3, non-smokers in Shanghai would probably have a CO of 12 because they are living in perhaps more pollution, but a CO of 50 is significant. So what you can see with the start treatment and see what happens is that when they do the CO monitor you will find that number has come down, you can say it was 50, now it is 15, you have made a huge change to the amount you are smoking. You know so then it gives them that sense of confidence so that they can then take the next sept, perhaps going to cut down to quit. But what you have done there is their exposure to tobacco has decreased and that is really really important, coming back to behavioural support that are core to all of this. Okay, second line options, nortriptyline is used as a second line option, it is off label, so you do need to let your patients know if you are going to try nortriptyline because the other ones are not appropriate or have not worked, that it is off label.  Clonidine once again off label, Cystisine not available in Australia and vaccines, there is quite a lot of work looking at vaccines for nicotine dependence, there is not any successful or effective vaccine as yet.  E-cigarettes we will come back too.  Other methods like acupuncture, hypnosis, the Allen Carr method are out there but there is not a lot of evidence to support their efficacy.  Now I do have some patients who swear by those methods.  If the patient wants to try, they can give it a go, what I would say to them is there is not much evidence and it is going to cost you money but if it works, brilliant. But bottom line is there is not much evidence and generally I would go for the evidence-based options which is the combined NRT, your varenicline or as a third option bupropion.  So now coming to the next case study, Joy age 38 attends your surgery and requests a prescription of e-cigarettes.  Joy says she wants to stop smoking tobacco and tried a friends vape and wants to get a prescription.  So let us go to the second poll we just open that one up if everybody can just have a look at that one and just scroll down for the second question. Yeah okay so what we have got going on there, 43% who were not sure, we have got a maybe 20% to 22% who strongly agree that they plan to prescribe and 33% to 34% who disagree or strongly disagree that they are going to prescribe. Moving down to confident assisting, there is a small group 10% who strongly agree or agree that they are confident using e-cigarettes for smoking cessation, a sizable minority who are not sure and a larger group who are really not very confident. Fantastic, so I really hope the next half-hour will help you just understand all the issues around e-cigarettes you know to help you make a decision in your practice with your patients and their particular clinical situation.  So Joy attends your surgery, requests the prescription for e-cigarettes, what do you need to know, what do you do, I think some people are putting some answers in the Q&A, Trish if you can feed that back to me when you are ready, just thinking about for you and your surgery, Joy has come in, she is a young woman, what do you need to know, what do you do in this situation. I do understand from the poll before that there is some of you that do not know, I do not want to have anything to do with this … but I would just really like to get a bit of feedback from you all on this.  You got much coming through that Trish.
32:17
Yes, so Steph has commented, is she a smoker and her smoking history. Craig, what are her views of the safety of e-cigarettes. ______ details about her smoking habits and dependence.  Caroline, firstly assess nicotine addiction severity, what it was before, why, why not, have they tried vaping before. Anonymous has said, why, why not try to reduce or stop.  _____ has said, I feel given the evidence and the damage of e-cigarettes I would not feel happy prescribing.  Natasha wants to know about pregnancy plans. Kye is also concerned from second hand smoke of e-cigarettes similarly as bad as tobacco cigarettes, maybe that is a new question. Louise has mentioned that it is important to acknowledge the patient for their efforts for wanting to quit smoking. Dan again asked what are the plans, cut down, quit or alternative of smoking, the patient’s motivations, perceptions, smoking history, risk of _____ associative lung injury, other addictions, previous trials, what she was using in the past and yeah and patient centred approach.
33:44
Thanks guys, you have basically given a very good kind of round of the issues that you have got to think through with e-cigarettes. So just a bit of background, so e-cigarettes have actually been illegal in Australia under state laws for I do not know how long, but I did not realise this, but they actually are illegal. It was not until the federal government that manages borders with border force, that they became illegal federally.  So as from the beginning of October 2021 you need a valid prescription an S4 prescription and anybody can prescribe, you can become an authorised prescriber, you can use the special access scheme or you can use the personal implication scheme. Now generally what the TGA would like us to do is to become authorised prescribers.  The issue with the special access scheme is … having used it a few times it is a lot of paperwork and it is very slow. With the personal implication scheme there is a risk of noncompliant products. So we will talk a little bit about the products so what they are saying is become an authorised prescriber, and it is not hard, it is very easy. You sign up then the TGA has your name, you do not need to give the patient name to the TGA as you do with a special access scheme. I should flag that this particular approach is unique, nowhere in the world has decided to take this approach. So they are being managed through the therapeutic goods administration but they are unapproved and they are not registered, they have not been assessed by the TGA for safety or efficacy or quality so they are unapproved but they are managing it, they are using a regulatory process to manage how e-cigarette come into the country.  The TGA has set the base for the nicotine liquid at 100mg/ml but what they say is to avoid free base of concentration by over 20mg/ml because that larger dose may not be safe. I will talk a little bit more about that in the moment.  The other thing is avoiding flavours.  There is a tobacco nicotine cigarette flavour, sorry I am not a smoker, it sounds revolting to me. And the other one that there is some evidence around is may be menthol is okay as a cigarette kind of flavour but avoid flavours because you are putting another chemical in there that you just do not know what the risks are and also for me, if you have got a nicotine containing fluid that taste really yummy like strawberry or something that a young person or a child might want to drink or smoke.  So what to do if a patient asks you for the e-cigarette script. First of all, you can choose not to. From the point of view of the TGA, it is not a licenced product it is an experimental product, so for us we work in general practice, we are independent with doctors and prescribers, we can choose what we want to do in our practice, you can choose to prescribe absolutely or you can choose not to. You could refer to someone else, I want to talk to you about the options of prescribing and the risks and benefits from the evidence that we have now.
36:58
I think one of the really important things for me around the prescribing of e-cigarettes is the issue of harm minimisation. So if I have someone like our first fellow who is highly dependent, has been smoking for a long time, has cardiovascular risk, has found it really hard to give up and if he has given NRT combined NRT and varenicline a red hot go you know with that behavioural support and I followed up and it has not worked, then going to e-cigarette is a harm minimisation strategy.  Now ideally, I want to do that as another smoking cessation strategy, not for long-term use. But there may well be a group of people who does turn out that this is a harm minimisation strategy because their risk of burnt tobacco of inhaling tobacco is so high that e-cigarettes are a better option.  We think that short-term use is probably okay, we do not know what the long-term risks are, we really do not know, it is going to take us a couple of decades before we get to know those, so that is the trickiness, we do not know what the long-term risks are. So when I am working with patients what I would be saying to them is, this is for smoking cessation, it is not for long-term use, we do not know what the risks are.  There is base, pre base versus salts and there are issues around having an open cartridge versus a closed pod which is prefilled and disposable.  The issue with the open is getting the proportions, the concentration right and also the risk of child poisoning.  The issue with free versus salts, is the salts have a smoother smoke and they are possibly more addictive. So ideally if you can, you want to go for base in a closed cartridge to kind of limit the risk.  There is an issue here around the group of people who have dual use of tobacco and of e-cigarettes and back in 2016 that was almost half and ideally you want to avoid that, ideally you want to be moving away from tobacco use completely to e-cigarettes and a smoking cessation option, but then to stop e-cigarettes.  There have been concerns raised about diversion and certainly we see this in countries that have very minimal regulation that there are a large number I think, if I have got the stats right, I think it is about 20% of young people using e-cigarettes in the US. So we are starting a group of never smokers, starting to use e-cigarettes. It might also be a gateway to use, so this is one of the concerns that people start on e-cigarettes and the move across to tobacco.  The other thing that really worries a group of health practitioners that have been forefront in this space in terms of tobacco cessation is that we normalise the nicotine use. Nicotine has no value in terms of it is not nutritious in any way and is clearly addictive and so does this re-normalise it and make it kind of cool and you look at some of the devices as you saw in the previous screen and some of them look really quite sexy and cool. Risk around the use of children in young people, young brains, lot of the risks we do not know, do not use it in the under 18s.  There is also a potential medicolegal risk for prescribers. And the way that I approach this is, if I am going to prescribe a vape, I am going to document it very well, I am going to follow up, I am going to support that person, I am going to make sure that I am making that decision with as much information evidence I have that it is a reasonable decision to make.  So coming back to Joy, you know, so really, for me it is only for patients who have not been able to stop with the evidence based treatments we have spoken about. Provide the behavioural support, you need to liaise with your local pharmacy to find out what is available and there is a bewildering array of devices and doses and the free base and the salts and the closed and the open, so do have a chat to your local pharmacy and workout what they are actually supplying, but ideally free base, closed system and notate your script for local supply only and note nicotine concentration.  So they are looking at probably only taking a dose up to about 20mg/ml with the free base, with the nicotine salt it can go a little higher than that. But you know, notate your script for local supply only, the concentration of nicotine, recommended daily dose.  For the TGA they say a maximum of three months.  I would suggest put it for one week, so you have made the plan you are going to prescribe e-cigarettes, make the plan, I want to be clear that I want to help you to actually change your smoking and stop all smoking in the longer term, so let us followup and see how you go. And then review, you may setup a situation where you say to them if it becomes clear to me that you are not stopping I may decide that I can no longer prescribe for you. You are totally within your rights to have that conversation and set that up before you start this treatment with someone.  The TGA suggests the longest period of time you should prescribe e-cigarettes for an individual is one year.  As I said before, avoiding the flavourings because we do not know what the risks are, you know, follow up as I said before with short-term use for smoking cessation and people can transition to NRT to assist them with ceasing from vaping, that certainly can be effective. So Joy comes in, she smokes 15 a day, has her first fifteen minutes after waking, she bought _____ gum from the chemist and tried hypnosis, but she want to go for e-cigarettes.  In this situation, I would be strongly supporting her to have a real red hot go at the combined NRT or the varenicline or the bupropion if that were appropriate, because we have evidence that they do help, whereas with e-cigarettes we do not actually know yet. And you know I would be talking through her the different options, I would really want her to try the strongly evidenced-base treatment before I move to e-cigarettes. And you know really what I am saying is only prescribe if it is clinically indicated and it is okay if you feel … look I am just not comfortable, she has not tried the other treatments, she does not want to try those, she really wants e-cigarettes, it is okay if you say I am sorry, this is an experimental treatment, I really do feel that you need to try the other options first, or you may decide given the situation and all the information you got from Joy that this is an appropriate option. Once again I would be saying to you that this is short-term for smoking cessation, not for long-term use. So in summary, we have got a little bit of time, it is our role and really we do and it is really clear that you guys do consider this our role and I would be asking about smoking as I said before, ask everyone, you know record it in yours notes and when you are seeing someone just check yeah okay so what are you up to with smoking, just so that she can keep checking in because we know that ex-smokers do not always stay ex-smokers, we know that people want to give up, we know that 12% of our community are still smoking, and if you are in a higher risk groups working with Aboriginal or Torres Straits Islander groups or with people that have drug and alcohol issues, it is even higher. We know they want to give up and they need our support to do it. There are effective treatments and behavioural supports are really important in supporting that and for me it is part of a really lovely support story where I am seeing people overtime, I am supporting them to change this really harmful health behaviour and I know that doing it will have a huge impact on their health and well-being. Relapse is common and it is okay when that happens, people do kind of come back and go, I am just so disappointed with myself, I did not manage, I failed. And I say well tell me what you did, actually it turns out that they actually stopped smoking for two weeks and then cut them out down and they are not having cigarettes for the first three hours when they get up, fantastic, they have made a really big shift there, and we can work on that. And even if they have relapsed back to their usual amount, we can continue working together to make that change and understand that it does take time but that is okay, that is what I am here for and that is one of the real advantages that we have as GPs is we see people over time, we know them, we know their families, we are part of their community and we can see people overtime to help them to change this really important behaviour, it is going to have such a tremendous outcome for their health. So we are there for support do follow up, do work with them, do see them frequently and provide the support that they need. I just have a few resources there, so once again if you wanted to go back and have a look at the supporting cessation guide for health professionals on the RACGP website, there has been an update that particularly looks at e-cigarettes and their place, really good summation of tobacco in Australia put together through the Cancer Council. And the Australian National University has done a summary report on the use of e-cigarettes and has looked at the evidence.  There are the RACGP guidelines as I said, there is Australian government quit guidelines, smoking and mental illness which has some really great pamphlets for carers, patients themselves and families, and as I said that summary report. So we have a few minutes Trish, I was just concerned I was going to run out of time so I moved through that quite quickly, are there any questions.
47:25
There is quite an active question Q&A board so we have got quite a lot of questions, I will try and summarise, so to start simply someone has asked is vaping and e-cigarettes the same.
47:36
Yes.
47:36
Yeah excellent, and then there are a lot of questions regarding how to become an authorised prescriber and also the liabilities regarding that, around prescribing e-cigarettes.
47:50
Yeah so to become an authorised prescriber is very simple, just go to the TGA website, it takes about five minutes to become an authorised prescriber. In terms of the medicolegal, we prescribe off label not uncommonly, you know so this is a little different because it is not actually a registered or licenced medicine but it is being regulated through the TGA and the TGA have made quite an interesting decision and the idea is that it is around the limiting the amount of the e-cigarettes that are out there free-flowing in the community with trying to decrease the risk of young people and never smokers taking this behaviour up, that is really what it is about. There is also the issue around child poisoning so you know that free-base open systems with high dose nicotine are a risk for children if they happen to swallow it. But it really is around trying to get a balance between providing an option for smoking cessation that may well be very very useful and we think the short-term risks are actually quite low, we just do not know what the long-term risks are. We do not yet know, there is some emerging evidence around efficacy for smoking cessation but we just do not have the evidence as compared to those first line ones that I spoke about. So for me in terms of medicolegal you know I would say, you just have to have good notes, you have got to make it clear that you have done a good assessment that you have got informed consent from your patient that you have been through.  This is an experimental treatment, you do not what the long-term risks are.  This is for smoking cessation, we are going to be working together, you had a go, you had a red hot go at the others and they have not worked for you or you cannot take them because of other issues. You know they are not appropriate for you, so it is the documentation of it and the follow-up that is so important and that is what will cover you.
 
49:58
Yeah so you mentioned we know the short-term but not so much in the long-term side effects so just also talking about what are maybe some contraindications or restrictions from using products or drug interactions.
 
50:10
Yeah so basically it is nicotine. So really when I think about it, it is the same as NRT but it is nicotine you know. So we are anxious about using nicotine in pregnancy but nicotine alone is safer in pregnancy than tobacco.  I flag at this point this is what I think about it is heated tobacco is another product that we are going to have to deal with in the future but that is not the focus but just another thing to think of. Yes e-cigarettes and vapes are one but then there is heated tobacco which is smoked through an inhalator as well. So what was I talking about, I got off track there with heated tobacco.
50:56
You were talking about nicotine and then someone has asked you what is actually in an e-cigarette if you do not have the flavour component, I think another person says there is about 400 extra chemicals when you have a flavour, is it just nicotine otherwise.
51:12
Yeah, it is just the nicotine and then it is got some carrier things like _____ glycol and those kinds of things in there. So once again there are the career molecules, do not ask me about the chemistry, you know once again we just do not know what the long-term risks for that are. There is a difference between the salts and the base but as I said the salts are a smoother smoke and people quite like them. The other thing about e-cigarettes is that they give the smoker a real smoking experience so they still get that hit on the back of the throat that people will talk about. You know any smokers here among will know that or any of us who have tried it will know that you do get that hit on the back of your throat and when you first start smoking. That is not pleasant but it actually becomes quite pleasant and is part of that smoking experience and certainly my patients would talk about that, the hit on the back of the throat and certainly I think it is an important thing to talk about it and to talk about how they can let go of that kind of pleasurable experience because they want to give it up.
52:18
Lots of questions regarding not being quite certain about the dose, you know in terms of also transitioning off one and on to the other and how to titrate that down or is there guidelines regarding that.
52:35
Yes there are some guidelines on the new RACGP guidelines and they suggest you know starting off with a dose for someone that has not used vapes of around six to twelve, people that are already using vapes will know what their dose is, so you can work with them around that dose. And they would say for the free based it is only up to about 20mg with the salts you can go a little high around 30 to 36, the issue here is really I cannot give you a specific product as there are so many products and so that is why I am saying you know have a talk to your local pharmacist, if you planning to do this, have a talk to your local pharmacy that you are going to work with and just find out what they are planning to have or you can have a conversation about what you are hoping they will have so it is starting that conversation so you can be clear on your script that that is what you are asking for. But people who are already on vapes will have a very clear idea of what they are looking for. That can be tricky because sometimes they will come in and you will think, god that is a huge dose, we need to get that dose down. One of the things that I find as coming back to NRT, combined NRT is that in some of the people that I am seeing one patch is not enough, I have never prescribed a 7 or 14mg patch, I have always gone for the 21s or 25s in my patients and there are sometimes when I will use two patches or maybe even three. And that is particularly with the people who are highly dependent, have had limited success giving up, where you are saying let us just start treatment and see where that gets us. And you know you will see, you’ll put one patch on, using your gum and it has shifted it, the numbers have come down and you are not smoking as soon as you wake up. You know it might be half an hour after waking, but really that level of baseline nicotine is not hitting the spot for you in terms of the amount of nicotine dependence that you have, so put on a second patch.  Unfortunately, that is not covered by PBS so they do use up their patches at twice the rate, but it is something that is worthwhile thinking about, is actually increasing that dose of NRT and that is the same with e-cigarettes as well. The other thing I just wanted to flag and this is something that does come up occasionally in terms of the gum, the chew and park. That sometimes people do not realise that and then they will chew on it and then it starts to make them sick, so the idea is you just give it a couple of chews whenever you have that craving to have a cigarette put the gum in your mouth and have a couple of chews and then just park it down in your cheek, so that you can kind of bring it up at later time if you get that craving again.  The tricky thing with both short-term NRT options is that they do not have that same quick onset, they are quicker than the patch which gives  you that baseline, but they are not quite as quick as having a cigarette. So always tell people it just takes a little bit longer if you can just hang in there with your craving. Have a chew of your chewing gum and then park it down in your gum or using your inhalator or using your spray, you take that a little bit longer, just sit with it and allow it to kick in to relieve that craving.
55:58
There has been quite a few questions that have been upvoted, I might just ask you so in your slide you mentioned TGA has recommended no more than one year, for prescribed vaping, what do we do after that.
56:18
Look it is a tricky one, it is a tricky one and e- cigarettes are a really contested area and there are some health professionals who are totally out, there you know e-cigarettes are harm minimisation, people should be allowed to use them forever, I am not totally comfortable with that. But for me I am in the middle you know and if I have got someone you know after having that conversation, I want them to give up tobacco, tobacco is bad for you, you know, and e-cigarette is the way to go but I would be very clearly saying to them, this is short-term because we do not know what the long-term effects are. You know, until we know that I am not in a position to continue prescribing for you, so this will have an end date, write that in your notes and stick to it and let people know so that when they are signing up front with you, they know that that is what they are committing to.  I should flag that there a number of websites, where people can actually access e-cigarette scripts and amongst vaping circles people are aware of these websites and they pay a small amount to get a year supply.  So people can access that and it is clearly not about cessation, those sites are clearly about allowing people to continue with e-cigarettes long-term. We do not know what the long-term risks are and there may well be some of you particular those of you who are very keen to start prescribing or who are already prescribing, who have made your own kind of professional decision that we think it is okay to continue for long-term and that is up to you. But for me, I am still cautious because we do not know what those long-term risks are, and I also do not like the fact that you have a group of people who are dependent on a substance that has absolutely no value.
58:05
There are a lot of questions regarding approximate cost to monthly cost for vaping to the patient.
58:08
Yeah look that will depend on what your pharmacy is charging, now that is one of the issues, at the moment it is one of the drivers and it is a good driver because it is moving people from tobacco to e-cigarettes is that e-cigarettes are cheaper so there is a concern that if e-cigarettes are expensive then people will shift back to the tobacco, so there is a concern there.  So depending on where you get them from and what you are buying and whether they are disposable, the pods, the closed system or the free base open.  There is a difference in cost, but it is cheaper than tobacco which is very very expensive.
58:53
And then generally for writing a script, is there any way that we can get an idea of how to write that script.
59:00
That is a good thought, I do not know the answer to that I will have a look and see there may be something on the TGA website I have not seen it, there is certainly nothing on the RACGP guidelines that give you a model script, it is a good question, really good question, I will talk to the college and see if that is something that they can provide, yeah.
59:26
That is okay we have got plenty of questions so I might just keep going until we run out of time so one of the upvoted ones is regarding CO monitoring, what happens if you are smoking cannabis, does this affect your CO monitoring and also what is the cost roughly for a CO monitor.
59:48
Yeah they are carbon monoxide sorry that was my mistake it is not carbon dioxide, it is carbon monoxide and it is a proxy measure for your level of nicotine addiction, yeah so the higher your CO the higher your level of addiction.  Look you can buy them from around about $600 to $1000 so it is a significant amount. I am fortunate in one of my jobs that I actually have access to one, actually at the moment we are not using it because of COVID but we will get back to using it and so what was the first part of the question.
60:28
Does cannabis smoking affect that.
60:30
Yeah yeah, so yes it does and this is a really important group, the group that have cannabis and nicotine co-dependency. Because you need to treat both those dependencies at the same time and if somebody is coming to you saying I want to stop my cannabis and they are mixing tobacco into their mix for their smoking, you are going to have to deal with their tobacco with their nicotine dependency and the first-line agents are really good for that. Sometimes what people would decide is that they are going to get rid of the tobacco and just have the cannabis, ideally with cannabis what I would be asking them to do is move to an inhalator, a vape for their cannabis or even stop inhaling it and go for ingested cannabis or cannabis ______. If there is a medicinal reason for the cannabis that is a whole other issue and once again I do flag that we do not know what the long-term risks of the cannabis are if you are it through an inhalator. There were those cases in the States where there was significant lung damage, the vast majority of those were co-administration of cannabis and nicotine through a vape.
64:40
And lots of comments about the concern of passive smoking with people vaping, do you know of any data on that.
61:52
Look once again it appears that it is lower risk but we do not know what the long-term risks are and certainly when e-cigarettes first came on the scene there was this kind of sense of, oh they are safer. But what we are finding more and more is that there are more limits around where people can vape and I think that is appropriate. I think it is appropriate in terms of this not being something that is a socially acceptable.  I might be angering some people in the audience but I really do not think it is around making it a socially acceptable social habit, so yeah once again we do not know but it is likely to be less than tobacco.
62:29
Just a few more questions, the question board is going crazy and we are definitely seeing the divide of people who are for harm minimisation and then people concerned about the medicolegal liability and so.
62:45
My response to that each of us as individuals need to assess the evidence for ourselves and we make a decision about whether this is the right thing for us to do. Just as we do with every other part of medicine, but the difference with this one is that it is not a licenced or registered medicine so it is a little different. So you kind of need to decide your reading of the evidence and look the experts talk about it in really different ways, you know so there are some that clearly say no we should not use this and others saying we should go for it and that the rules in Australia are ridiculous and you know, encouraging people to keep on smoking, I get the differences in opinion. You know certainly for me I sit in the middle there somewhere around, there are times when it is useful but you need to be careful. I am quite a cautious prescriber, I am later doctor, I have to acknowledge that for myself but it is really working with my patients for the best outcomes and there is no doubt the best outcome is not using nicotine at all.
63:49
Craig _____ has just put a comment that Aus Doc has an article called a GP guide for vaping and nicotine prescribing, which has some sample prescriptions so go check that out if you are watching and then yeah combination therapies again with the vaping and the NRT and other methods any advice you have on that.
64:10
Yeah so it was not that long ago, there was no evidence around shifting from vaping to NRT but there is some evidence now and it is certainly something that I have used in my practice and it has been a few times that I have done it so far, has been quite successful with people moving away from their vaping using NRT to stop.
64:34
Excellent so someone mentioned about PBS smoking cessation item, could you just comment on that.
64:39
Yeah on the PBS, I am thinking Medicare items, no, wouldn’t it be brilliant if we had a smoking cessation item number.  Are you listening, are you listening government no no no the PBS yes, so at the moment on the PBS, close the gap means that Aboriginal and Torres Strait Islander people get the prescriptions on the PBS for free, so make sure that you use that for your indigenous patients. But for the others it is monotherapy.  So it is varenicline or it is monotherapy of NRT.  To me that makes no sense. I would love the PBS to reconsider that and make combined NRT you know co-therapy, but it is not at the moment and the same with varenicline. We are starting to see and it was not that long ago that the evidence was saying NRT combined with varenicline, really no benefit, but we are starting to see some evidence that there may be some. It is pretty low level evidence at the moment but it is certainly worth a try. You know these are pretty safe treatments and smoking is really not great for you, so if you want to give those a try but you cannot get them both on the PBS at the same time.
65:58
And a comment here was that varenicline has been taken off the market. Two of the products have been contaminated, so will not be around for at least a year they say.
66:07
Oh wow okay there you go alright, so varenicline is out of the picture then it we will be back to combined NRT which is a great therapy.
66:10
Yeah and then Craig has also asked with NRT, in past there was a concern of whether it caused vasospasm, is still the advice.
66:21
Vasospasm I am not sure if that is still an issue, I mean certainly there is the concern around using NRT in the acute post you know AMI situation. But you know it is not an absolute contraindication because smoking once again is so harmful, I am not sure.
66:45
Just having a quick look I am sure if anyone has any burning questions Hester will not mind answering them or having an email. There is quite a lot here … anonymous has asked, smoking not advised with the contraceptive pill, what about the nicotine replacement therapies and vaping I guess.
67:22
Yeah so once again, there is a risk there and so I am very cautious about prescribing the pill in older women who are smokers. You know but once again you have got to run through that with your patient and look at what the risk is you know I would be strongly encouraging them to use another form of contraception and to work with them to stop smoking. And combined NRT is great for stopping smoking, it is another reason that I will be going, oh you want to use e-cigarette and you are on the pill and you are 35, you know it is probably less damaging than smoking but we do not know and that is the thing, there are unknowns. So you know, watch this space because there is new evidence coming out all the time and certainly in terms of RACGP really you know want to take my hat off to them for you know really pushing ahead with getting some updated guidelines out around e-cigarettes on what is currently known. You know in this setting, so we would have as GPs would have advantage of that advice. So once again if you are worried about medicolegal have a look at what is on the RACGP website around e-cigarettes so which you can base what you do around those recommendations you know and very clearly from the medicolegal point of view, if your professional body is clearly giving that advice then you know there is some comfort in knowing that.
68:50
Whist I ask the next question if everyone could just have a look through the questions and upvote anything that you really want answered in the last one or two minutes, someone here has just written what is the difference between a Nicorete inhaler and a vaping product.
69:10
Yeah so a vaping product is you are heating up and making it into a vaper, an inhalator is actually a liquid that goes into your mouth, so they are not the same, they do not feel the same.
69:23
So just waiting for any more upvotes, so yeah, generally quite a tricky topic.
69:34
I think sometimes you can, you know if you have got someone, it can put in you in a tricky situation if you are thinking I am not 100% comfortable, this person is coming in kind of you know saying, I have been using e-cigarettes, I have read the literature, you know I believe it is what I want to do and I want to continue doing it, it can be a difficult conversation but in the end we are the ones that are prescribing and I would be having exactly the same conversation with them as I have said to you guys, I am sorry I do not feel, I am not comfortable, I just do not feel with the evidence out to continue prescribing for you long-term. But there would other doctors that would be happy to do that you know but unfortunately I am not able to.  I do not think that you need to actually know who those other doctors are or make a referral because this is not a validated or you know evidence based or registered treatment. You know but it is okay to say no and it is okay to prescribe if you document well, follow the kind of guidelines and you have got that therapeutic alliance with your patient to get the best outcomes for them.  There is no right answer, there is no black and white.
70:48
Excellent, I am learning so much, someone here in the comments has also said there is an MBS item for smoking cessation counselling 93680.
70:56
Oh, yeah.
70:58
So that is new, new to me, but otherwise I think I will leave it there, lots of good resources from Aus Doc available and RCGP as well as item numbers on Medicare and it looks like there is also an article coming out by the Australian Journal of GP as well, regarding this and regarding how to write those scripts as well.  But yeah, learned lots and I think everything has learned a lot from each other and the question and answer chat as well so it has been a very interesting topic but I think at the moment we have a gone a little bit overtime and that is really all we have time for in terms of question. I just want to say a big thank you to our presenter Hester for sharing her knowledge today and time and thank you also to our webinar partner Johnson & Johnson.  Thanks everyone for joining us.
72:05
Thank you so much.

Other RACGP online events

Originally recorded:

10 November 2021

This webinar provides GPs with information and education on:

  • smoking cessation guidelines
  • patient health outcomes
  • changes in nicotine e-cigarette laws and how this may impact practices
  • counselling patients to get the most from NRT or other evidence-based treatments
  • what to do if a patient asks you for an e-cigarette script

Learning outcomes

  1. Provide education to increase the understanding of effective smoking cessation strategies using evidence-based practices
  2. Understand the options to assist patients with smoking cessation
  3. Identify risks and benefits associated with different smoking cessation options including e-cigarettes
  4. Understanding of legislative changes as of 1 October 2021 for e-cigarettes and resources available for support including the RACGP guidelines
  5. How to manage refusing a prescription if it is inappropriate
This event attracts 2 CPD points

This event attracts 2 CPD points

Facilitator

Dr Trish Kahawita

Trish is a new GP fellow who is passionate about digital health, medical education, and doctor wellbeing. She has been practicing medicine for the last ten years and has worked all around Australia, in both urban and remote areas. Her main clinical interests include Women's and Children's Health, Mental Health, Neurology, Geriatrics / Palliative Care, and Tropical Medicine. She has just moved to Sydney where she will work as a medical educator for GP Synergy as well as being a community Palliative Care GP. She also volunteers as a peer support facilitator for junior doctors. She is excited about the future of primary care and the use of innovative health technologies.

Presenter

Dr Hester Wilson
FAChAM, Chair RACGP Specific Interests Addiction Medicine

Dr Hester Wilson is a GP, addiction specialist and Chair of RACGP Specific Interests Addiction Medicine. Hester has many years’ experience working with people with addiction issues in both general practice and specialist settings and the lead clinician in the GP liaison in alcohol and other drugs (GLAD) project in South East Sydney Local Health District. She is a Conjoint Lecturer and PhD candidate, School of Public Health and Community Medicine, University of New South Wales.

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