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Tobacco: One of the big issues Part 2 |
Part 2: GPs and nicotine replacement therapy
As highlighted in part one of this article, spending some time helping our patients to quit is one of the most cost effective interventions we can do as GPs (Miller and Wood 2002). This is true for very brief advice as well as for longer, more complex counselling. More time spent on advice and support for cessation increases the likelihood of cessation (Fiore, Bailey et al. 2000). The addition of nicotine replacement therapy (NRT) approximately doubles the likelihood of cessation. This is true for very brief or longer interventions. (Miller and Wood 2002)
Most smokers expect their doctor to advise them to quit as part of good health care and most smokers want to quit, but don’t feel ready yet. Hence we should not feel as though we are being inappropriately intrusive when raising the importance of quitting.
Nicotine replacement therapy
A number of products for NRT (see table) are now available over the counter, but are only subsidised for DVA patients. They can be thought of in two main groups, those to be actively used, intermittently topping up the nicotine levels to prevent withdrawal symptoms, and those passively used in a standard way through the day.
My personal view is that the passive (patches) are going to be easier to use as you don’t have to remember to do it so many times a day. However some people may prefer a more active role in their quitting program, with the recurrent decision to use NRT gum, inhaler, lozenge, or spray reinforcing their sense of control over tobacco.
The NRT systems with rapid delivery such as nasal spray or inhaler may have a greater potential for dependence, though there is limited data to support this as being clinically important, especially when the product is not free. Given that many decisions on NRT use are determined by the consumer themselves, with OTC supply, it seems that inadequate dose and duration of NRT is most common.
In general, NRT delivers 1/3-1/2 of the plasma nicotine levels achieved by smoking.
A number of (but not all) studies have found that a combination of fixed dose (patch) together with prn ‘active’ NRT is more effective than one for alone. This would appear to be a good option for those who have failed on monotherapy.
NRT can and should be used for the temporary prevention and relief of withdrawal symptoms in people who have to temporarily abstain, eg. inpatients or at work. This helps maintain prescribed smoke free environments and is appropriate even for those not intending to quit yet. This is also important for the health of staff and other clients or patients.
Special groups
The guiding principal here is that NRT is less harmful than smoking. This applies to pregnant women, lactating women and just about anyone with cardiovascular disease. Quitting without NRT is logically preferable, however most smokers will have failed to quit in the past and we could expect NRT to improve their chances of success in the future.
Pregnancy
The WHO expert consensus of 2001 recommends allowing NRT use in pregnant smokers who have failed to quit without it (with medical involvement). There is a theoretical benefit for breast feeding mothers to use intermittent NRT such as lozenge, gum, inhaler after feeds rather than before feeds as the plasma levels may have declined by the time of the next feed. Again, overall NRT is safer than smoking.
Ischaemic heart disease
Don’t be put off by the various product information warnings. The WHO expert consensus of 2001 recommends allowing NRT use in smokers with stable CVD who have failed to quit without it. Further, the warnings should be removed for stable CVD. For those with unstable CVD or recent (4 weeks) events, NRT should be used in consultation with the consultant. Clearly these people are at highest risk for further CVD events and have the most to gain from assisted quitting. They should be offered intensive support to quit.
There is a high degree of agreement between international and Australian expert reviews on the safety of NRT in those with known CVD.
A few un-truths
A recent prospective cohort study of 940,000 people for six years (25% smokers) found that lower tar cigarettes did not reduce the risk of dying from lung cancer (BMJ 328:10-1-04).
Cutting down is not an effective quitting strategy.
Low tar or low nicotine cigarettes are not an effective quitting strategy.
| Active NRT |
Comments |
Cost per packet* |
Cost per day* |
| Inhaler |
A cigarette like activity/ritual for the hands |
$9.00 for 6 pack, $40 per 42 refills |
Apprx $10.00 |
| Gum |
Nicotine loaded saliva can lead to gut symptoms |
2mg $12.95 pk 30, 4mg $15.95 pk 30 |
Apprx $6.00, Apprx $7.00 |
| Lozenges |
|
$29.95 pk 36 |
Apprx $10.00 |
| Nasal spray |
New in Australia, acceptability not clear |
Apprx. $20-30 (Not available at present) |
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| Passive NRT |
Patch. If bad dreams are a problem, remove patch overnight otherwise change each morning |
$27.95 per week pk - Requires 3 steps totalling 10 weeks. |
$4.00 |
| Smoking 20-25/d |
For comparison |
$9.95 PJ 30s, $8.75 Win. 25s |
$6.60 - $8.75
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* cost may vary from different retailers and assumes typical use pattern for an ex 20-25/d smoker. Cost updated 7-1-04.
Further references available on request.
Fiore, M., W. Bailey, et al. (2000). Treating tobacco use and dependence: clinical practice guideline. Rockville, US department of Health and Human Services, Public Health Service.
Miller, M. and L. Wood (2002). Smoking cessation interventions. Review of evidence and implications for best practice in health care settings., Commonwealth of Australia.
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