There is so much we don't know in medicine that could make a difference, and often we focus on the big things, and the little things get forgotten. To highlight some smaller but important issues, we've put together a series of pearls that the Red Whale found at the bottom of the ocean of knowledge! Smoking cessation This is a summary of a BMJ clinical review about smoking cessation (BMJ 2014;348:f7535). But first, a quick summary of a DTB article on nicotine (DTB 2014;52(7):78). If nicotine is swallowed it undergoes first pass metabolism which reduces bio-availability, hence why nicotine replacement comes in multiple forms (gum, spray, patches, lozenges, etc.) but not pills. The pharmacokinetics of nicotine varies according to the product it is used in. o When cigarettes are inhaled the nicotine is rapidly absorbed reaching the brain within about 15sec. o Tobacco aken by a non-inhaled route (chewing, snuff, etc.), takes about 30min to reach peak nicotine levels. Nicotine is not a direct carcinogen although animal studies suggest it may be a tumour promoter. There is no evidence that medicinal nicotine is carcinogenic. But do remember that when nicotine is inhaled in tobacco, along with the nicotine you get another 4000 other substances, some of which are toxic! Nicotine has a negative effect on the vasculature and other systems: o It increases heart rate, restricts coronary and cutaneous blood flow and transiently increases blood pressure. o It may affect the endothelium and promote atherogenesis. o It reduces sensitivity to insulin. o It may aggravate or precipitate diabetes. o Despite this, a review of over 9000 people using NRT patches found no increase in cardiovascular events. Useful statistics We all know smoking is bad for us, but here are some facts that might surprise you: After 35 years of age, for each year you continue to smoke you lose about 3m of life. If you can stop before the age of 35, your risk of dying is not that different to those who never smoked. About 40% of smokers try to quit each year. Without support or drugs only 3 5% of people will remain stopped for 6 12m after a quit attempt. Brief intervention can increase this by 1 3%. Smoking cessation advice There are lots of different models, but one of the most common is the 5As brief advice model: Ask (about smoking and record smoking status). Advise (all smokers to quit). Stopping suddenly and cutting down gradually have been shown to have similar success rates (Cochrane meta-analysis). Assess (interest in quitting, nicotine dependence (see below)). A meta-analysis showed motivational interviewing can help those who are ambivalent about quitting, resulting in modest but significant increases in quitting. Assist (offer behavioural and drug therapy to help quitting). Arrange (follow up). Assessing nicotine dependence To assess nicotine dependence ask about: How soon after waking do you have your first cigarette? Smoking within 30min of waking is good sign of dependence. Smoking within 5min suggests more severe dependence. Cravings and withdrawal symptoms in previous attempts to quit: dependence is more likely if there have been significant cravings and withdrawal symptoms in previous quit attempts. The actual number smoked is not a good indicator, although addiction is less likely if fewer than 10/day are smoked.
Behavioural approaches to smoking cessation Research shows that patients of nurses whose focus in the consultation is on the benefits of stopping smoking, rather than scaring patients with the risks of continuing to smoke, are significantly more likely to quit (J ADV NURS 2013;69(12):2665). So big up the benefits! Remember to cover the following as they may help: Agree on a quit date and a not-a-puff rule after that date. Deal with barriers such as stress management, concerns about weight gain (see below). Describe withdrawal symptoms and cravings and explore ways to manage these with distraction techniques. Offer a choice of drug therapy (see the section on drug therapy below). Calculate the financial annual gain of stopping smoking: for someone currently smoking 20 a day, this is around 3,500 a year: that s a pretty good incentive to stop smoking! Triggers and how to deal with them and in particular think about avoiding or minimising alcohol. Getting support enrol family and friends in the quit attempt, provide written information, tell them about the local and national quit support services. Most fail within the first week so think about how you offer support during this time. Promoting lifestyle changes encouraging exercise (reduces cravings, reduces withdrawal symptoms, reduces weight gain), and avoiding high risk situations (going out with other smokers, drinking alcohol). Relapse prevention. Drug therapy Drugs are most effective when given with behavioural support. A Cochrane review concluded that the most effective drug therapies were varenicline or using 2 forms of nicotine replacement (e.g. patches with gum for cravings). Nicotine replacement therapy (NRT) Nicotine patches can also be used for up to 2w before the quit date as this can increase the success rates. Side effects of NRT NRT is generally well tolerated. The main side-effects are: nausea, headaches and dizziness. These are usually mild and improve over time. Patches can also cause sleep disturbance and irritation at the site of the patch. Oral NRT can cause hiccups, mouth soreness and heartburn. NRT can be safely used in those with stable cardiovascular disease. Varenicline Varenicline (Champix) is a partial nicotine agonist which acts centrally to relieve cravings, reduce withdrawal symptoms and reduce the rewards of smoking. The commonest side-effect is nausea. This occurs in 30% but is usually mild and causes only 3% to stop using it. It can be reduced by gradual up-titration and taking with food. Dosing: the SPC recommends that varenicline be started 1 2w before the quit date and up-titrated as follows: o 0.5mg once daily for 3d o Then 0.5mg twice daily for 4d o Then 1mg twice daily for 12w o After which it can be continued for a further 12w if the patient has successfully quit. Varenicline and cardiovascular disease For some time, concerns have been expressed that varenicline may increase the risk of cardiovascular disease, however two large trials are reassuring: A large meta-analysis found no increased risk of CVD. (BMJ 2012;344:e2856). A large Danish real-life cohort study (17 000 people over 3y) also showed no increased CVD risk with varenicline (BMJ 2012;345:e7176).
Varenicline and depression and suicide The UK MHRA issued a warning in 2008 reminding us that there have been reports of increased incidence of depression and associated suicidal ideation in people on varenicline (Drug Safety Update 2008;1(7):3). However, the latest large-scale UK prospective cohort study refutes this (BMJ 2013;347:f5704). Compared with nicotine replacement, neither varenicline or bupropion were associated with an increased risk of depression, self-harm or suicide. What does this mean in practice? We need to balance any small absolute increased risk of CVD with the benefits of giving up smoking, remembering that there are other drug and non-drug methods to give up smoking! The latest evidence suggests that varenicline does not increase the risk of depression, self-harm or suicide. Now back to the BMJ review Bupropion Bupropion is an antidepressant. It should not be used in those with a history of seizures, on drugs that lower fit thresholds (other antidepressants, oral hypoglycaemic agents), with eating disorders or those on MAOIs. Alternative therapies Acupuncture and hypnotherapy have NOT been shown to be effective in smoking cessation. E-cigarettes Electronic cigarettes are now easily available for those wishing to give up smoking. Professor Robert West and Dr Jamie Brown from University College London say that, despite alarmist commentaries, toxicology studies show that while propylene glycol is an irritant and some toxins are measurably present, the concentrations are very low, in fact less than l/20th of that of cigarette smoke. (BJGP2014; DOI:10.3399/bjgp14X681253) And for friends and family of smokers, second-hand passive vapour from e-cigarettes has a tenth of the overall harmful particles and almost no organic carcinogens. (Environ Sci Processes Impact 2014;DOI: 10.1039/ C4EM00415A) But do they work? This trial from New Zealand randomised 650 people to nicotine patches, nicotine-containing e-cigarettes, placebo e- cigarettes or placebo patches for 12w. They were also offered telephone support via a nationally available quit line. Quit rates were assessed 6m later (Lancet 2013;382:1629). The trial showed that nicotine-containing e-cigarettes are at least as good as nicotine patches. There were no differences in adverse events between the groups. The accompanying editorial discussed the concerns some have over e-cigarettes that they might encourage a whole new generation of smokers who wouldn t smoke normal cigarettes but see these as a good, safe and acceptable alternative. However, making e-cigarettes a medicinal product whilst continuing to sell ordinary cigarettes over the counter, may stop this, but might also reduce the likelihood of someone trying (and succeeding) to quit with them (Lancet 2013:382:1614). A BMJ editorial raises similar issues and highlights how the products are being endorsed by celebrities and on TV (e.g. EastEnders) (BMJ 2013;347:f7473). The DTB reviewed the evidence around e-cigarettes and concluded that evidence of efficacy in smoking cessation is weak and inconclusive. (DTB 2014;52(11):126): The place of e-cigarettes in smoking and smoking cessation is yet to be fully established! And the philosophical debate about their place in our culture is only just beginning!
Smoking cessation in pregnancy Giving up smoking is even more important in pregnancy than at other times. The consensus is that the harms of smoking are greater than any potential harms from NRT and therefore it can be used in pregnancy. Intermittent oral NRT (e.g. using gum/lozenges to manage cravings) is usually the method that is recommended as it gives the lowest total exposure over time. However, the results may be disappointing: A French RCT of NRT patches vs. placebo patches in pregnancy (400 women) showed disappointing results (BMJ 2014;348:g1622). There was no difference in abstinence rates. There were no differences in time to first cigarette after target quit date. There was no difference in average birth weight. On a positive note, there were no serious adverse events! Varenicline and bupropion should not be used in pregnancy. Smoking cessation and mental health A meta-analysis has also shown that giving up smoking is good for your mental health (BMJ 2014;348:g1151). Smoking cessation was associated with: Reduced depression, anxiety and stress (measures were taken between 7w and 9y after quitting). In those with pre-existing depression or anxiety, the benefit was just as great, if not greater. Perhaps something to share with those who are reluctant to give up because they feel it might make them more anxious/depressed. Smoking cessation and weight gain A meta-analysis of 62 (often small) high quality trials assessed average weight loss in the 12m following smoking cessation (BMJ 2012;345:e4439). The trials they combined were usually RCT of placebo vs. a drug (varenicline, any type of nicotine replacement therapy (NRT) and bupropion). The treatment you had, whether placebo or drug, made no difference to your weight gain. On average, weight gain was about 1kg/m in the first 3m and then this slowed to an average of 4 5kg gain over the 12m. However, at 12m: o around 20% had lost weight o about 35% had gained less than 5kg o 30% had gained 5 10kg o 15% had gained more than 10kg. Going smoke free: have there been health benefits? The Institute for Policy Research published a review of the impact of the smoke-free legislation (banning smoking in public places) in 2012 (5 years after the ban) (The impact of smokefree legislation: evidence from research, Institute for Policy Research, 2012). This showed: A reduction in hospital admission for MI of 1200 in the first year alone. Almost 2000 fewer asthma admissions each year. Further data from the WHO has also shown a reduction in pre-term births (Lancet 2014;383:1549). This is all good news!
Summary Smoking cessation Assess nicotine dependence. Use drugs alongside behavioural support Varenicline or 2 forms of NRT are the most effective drug therapies Latest evidence suggests that varenicline doesn t increase the risk of CVD, depression, self-harm or suicide. E-cigarettes seem to be as good as nicotine patches in one trial, however, there is concern that they may breed a new generation who would never smoke but do take up e-smoking. Professional development Audit the number of patients who smoke in your practice you can also do a retrospective audit, to compare how many were smoking last year, and the year before that, to see whether your trend is going in the right direction. You can set audits to re-run annually, to continue to monitor your practices success in helping your community to stop smoking. Practical tools If patients want help stopping, text support is available (text TXTHELP to 63818). In an RCT this was shown to double successful quit rates at 6m (from 4.9% to 10.7%) (BJGP 2013;63:588). NHS smoking cessation advice online: www.smokefree.nhs.uk We make every effort to ensure the information in these pages is accurate and correct at the date of publication, but it is of necessity of a brief and general nature, and this should not replace your own good clinical judgement, or be regarded as a substitute for taking professional advice in appropriate circumstances. In particular check drug doses, side effects and interactions with the British National Formulary. Save insofar as any such liability cannot be excluded at law, we do not accept any liability for loss of any type caused by reliance on the information in these pages. GP Update Limited April 2016
The NEW one-day course for all nurses in primary care Feeling overwhelmed at the prospect of revalidation? Swamped by new clinical information and latest guidance? Too much for you to read and too little time to read it? Need to give evidence-based advice to patients, carers and colleagues? We trawl through all the relevant journals to bring you right up to speed on the latest issues, literature, research and guidelines. We are completely free from pharmaceutical company sponsorship so give you an independent, unbiased view of all of the latest evidence. What will be covered? This one-day course offers a wide-ranging, evidence-based programme, including all you need to know about: NMC Revalidation A range of long-term conditions important to primary care nurses FGM & the Law Suspected cancer And top-to-toe topics from rhinitis to vaginal discharge to verrucas! This is not a watered down version of GP Update! It s a dynamic and engaging course that will focus on the most relevant aspects of Nursing in Primary Care. Who is this course for? All General Practice Nurses. We understand the importance of nurses and doctors sharing knowledge and skills to improve care. Our course is both written and presented by our resident ANP Debra Sprague and GP Sharon Dixon. Matt/The Daily Telegraph 2016 Telegraph Media Group Ltd Important note: This course contains no theorists, gurus or sponsors. It is brought to you by real-life nurses and doctors, who will be back at the coal face once the course has finished! www.gp-update.co.uk/nurses
What will you get on our course? A broad update on the latest evidence, research and guidance in the management of both chronic and acute conditions. Great tips and tools for improving patients engagement with their long-term conditions. Lots of ideas, practical guidance and reassurance on how to make CPD part of everyday practice. How best to approach your CPD to meet the new NMC guidelines on Revalidation. Ways to move things forward in your practice area. Tips to help you work effectively with your colleagues across the primary healthcare team. Expertise and practical tools to share with your practice and support patients with managing their health. Lots of humour and fun to help get through everything in one day without compromising the content of course! The GPN Update Handbook Delegates receive a copy of the GPN Update Handbook. This fully-referenced handbook covers the most important research, policy and guidance relevant to primary care nursing over the last 5 years. GPN CPD Delegates all receive a year s subscription to GPN-CPD.com, home of the GPN Update Handbook online and CPD tracker system. The tracker makes it easy to document your CPD as well as your practice hours, reflective accounts, and all other activities needed for Revalidation. Who are we? Red Whale is one of the leading providers of primary care medical and nursing education in the UK with over 13,000 primary care practitioners attending our courses each year. We specialise in producing courses that are evidence-based, highly relevant to everyday practice and full of actions that delegates can take away and implement immediately. You may well have already heard great things about the GP Update Course from your GP colleagues. The GPN Update Course keeps that fast-moving and fun format, with material focused on the priorities for nursing in primary care: to support YOU in supporting your patients. For more details, go to www.gp-update.co.uk/nurses The GPN Update Course dates Manchester London Fri 22 Apr Fri 29 Apr Price: 195 To book: Online at www.gp-update.co.uk or use the form below or call us on 0118 960 7077 I would like to come on the following GPN Update Course (please write legibly!): Course location... Course date... Name... Address...... Email... (Please write your email address clearly as we ll use it to send your confirmation letter and receipt.) I can t attend a course, but I would like to order the 2016 GPN Handbook and 12 months access to GPN CPD. 150 Please send this form with your cheque payable to GP Update Limited to: GP Update, The Science and Technology Centre, Earley Gate, Whiteknights Road, Reading RG6 6BZ GP Update Limited, registered in England and Wales No. 7135974. Registered Office: Prospect House, 58 Queens Road, Reading RG1 4RP Full terms and conditions are available at www.gp-update.co.uk HC/012016 Relevant challenging and fun!