SMOKING CESSATION 08 Recommendations 5As Approach to Intervention Stages of Change Assisting the Smoker Pharmacotherapy Contributor Dr. Saifuz Sulami Advisor Dr. Audrey Tan 79 nhg_guideline_14102010_1112.indd 79
Recommendations All patients should be asked if they use tobacco and should have their tobacco use status documented on a regular basis. Clinicians and healthcare delivery systems should institutionalize the consistent identification, documentation, and treatment of every tobacco user seen in a healthcare setting. All clinicians should strongly advise every patient who smokes to quit Tobacco dependence is a chronic condition that often requires repeated intervention. Effective treatments exist that can produce long-term or even permanent abstinence Treatment for tobacco dependence is clinically effective and cost-effective relative to other medical and disease prevention interventions Brief tobacco dependence treatment is effective and every patient who uses tobacco should be offered at least brief treatment There is a strong dose-response relation between the session length of person-to-person contact and successful treatment outcomes. Intensive interventions are more effective than less intensive interventions and should be used whenever possible Nicotine replacement therapy (NRT) is safe and effective for smoking cessation There is no difference in efficacy between various forms of nicotine replacement There is currently no evidence that nicotine replacement therapy increases cardiovascular risk Bupropion Slow-release (SR) is safe and effective for smoking cessation Once a tobacco user is identified and advised to quit, the clinician should assess the patient s willingness to quit at this time: - Patients willing to try to quit tobacco use should be provided effective treatments - Patients unwilling to try to quit tobacco use should be provided a brief intervention designed to increase their motivation to quit 80 nhg_guideline_14102010_1112.indd 80
5As Approach to Intervention ASK About Tobacco Use Current user Ex-user Never used ADVISE to quit ASSESS willingness to quit Pre-contemplation Contemplation Action Maintenance ASSIST in quit attempt Promote motivation to quit Options to stop Prevent relapse ARRANGE follow up 81 nhg_guideline_14102010_1112.indd 81
Stages of Change (Prochaska & diclemente s Transtheoretical Model) Smokers are at different stages of readiness to change and different strategies should be used to assist them. Pre-contemplation Stage: Contemplation Stage: Action Stage: Maintenance Stage: The smoker is not motivated to stop smoking. The smoker is motivated to stop smoking but has not set a quit date. The smoker plans to stop smoking within one month or has already stopped for less than a month. The smoker has stopped smoking for at least a month. Identifying the Stages 1. Have you ever thought about stopping smoking? No Pre-contemplator Yes at least a contemplator (proceed to the following questions) 2. Would you like to stop smoking? Yes At least a contemplator 3. Do you plan to stop smoking in the next one month? No Contemplator Yes Action 4. How long have you stopped smoking? Less than a month Action More than a month Maintenance 82 nhg_guideline_14102010_1112.indd 82
Assisting the Smoker (a) For patients in the pre-contemplation stages: Provide motivational intervention (5Rs) (c) For patients in the maintenance stage: Provide brief effective relapse prevention advice Relevance (What is important to him? How is smoking related to this?) Risk (What are the risks to his present medical condition if he continues to smoke?) Rewards (What benefits can he expect when he stops smoking?) Roadblocks (What is stopping him from quitting?) Repetition (Repeat every time an unmotivated patient visits you. Tell smokers who have failed previously that most people make repeated quit attempts before they are successful.) Reinforce patient s decision to quit Review benefits of quitting Assist patient in anticipating temptations and planning coping strategies Assist patient in resolving any residual problems arising from quitting (b) For patients in the action stage: Provide options for them to stop Patient stops on his own with minimal assistance (give him self-help booklet) Patient stops with your assistance and follow-up (provide counselling) Patient is referred to a dedicated smoking cessation programme (there are several smoking cessation service providers in Singapore) 83 nhg_guideline_14102010_1112.indd 83
Pharmacotherapy Suggested Guidelines: DRUG DOSAGE DURATION ADVERSE EFFECTS CONTRAINDICATIONS Nicotine patch (Nicotinell) 21 mg/24h (TTS 30) 14 mg/24h (TTS 20) 7 mg/24h (TTS 10) 4-12 weeks then 2-4 weeks then 2-4 weeks Local skin reaction, insomnia Headache, nausea - Allergy to nicotine or any of the other components / ingredients of the NRT Nicotine patch (Nicorette) Nicotine inhaler (Nicorette) Nicotine gum (Nicorette) 15 mg/16h 10 mg/16h 5 mg/16h 6-12 cartridges/day (Maximum 15 cartridges/day) 3-6 cartridges/day 3 cartridges/day to 0 2 mg gum (for low to medium dependence < 20 cig/day) 4 mg gum (for high dependence > 20 cig/day) 8-12 weeks 8 weeks Local mouth and throat irritation, headache, nausea, heartburn Sore mouth and throat, jaw-muscle ache, dizziness, headache, stomach discomfort, nausea, hiccups, vomiting - Children below 18 years old, pregnant and breastfeeding women - Recent heart attack or stroke, unstable angina, severe cardiac arrhythmia - Use with caution on patients with severe hypertension, cardiovascular disease, diabetes, kidney, liver, thyroid, peptic ulcer diseases - Generalised skin disorder (for patch) 8-12 pieces/day (Maximum 24 pieces/day) 4-6 pieces/day 1-3 pieces/day to 0 12 weeks Nicotine lozenges (Nicotinell) 1 mg per lozenge Average 8-12/day (Maximum 25/day) Every 1-2 hours when urge is present 3-6 months After 3 months, must cut down. Stop when dose reduced to 1-2 Slight throat irritation and increased salivation, indigestion or heartburn Note Weaning/tailing down recommendations above serve as a guide only please exercise your professional judgment to adjust the dose or duration of the dosing. 84 nhg_guideline_14102010_1112.indd 84
DRUG DOSAGE DURATION ADVERSE EFFECTS CONTRAINDICATIONS Bupropion Hydrochloride SR (Zyban) (start 2 weeks before quit date) 150 mg om Then 150 mg bd 6 days 7-12 weeks Stop if no help After 7 weeks Insomnia, dry mouth, seizures, nausea - Allergy to any of the components of the preparation - Children below 18 years old, pregnant and breastfeeding women - Current or past history of seizure disorders - Current or past history of bulimia or anorexia nervosa - On medication that contains bupropion - On MAOIs - Use with caution on patients with past history of head trauma, CNS tumour, alcohol abuse, diabetics, on concomitant medications that lower seizure threshold Varenicline Tartrate (Champix) (start 1 week before quit date) 0.5mg once daily 0.5mg BD 1mg BD Day 1-3 Day 4-7 Day 8 to end of treatment (12 weeks) Nausea, insomnia, vivid dreams, changes in mood/ behaviors, suicidal ideation - Children below 18 years old - Use with caution on patients with history of psychiatric illness, pregnant and breastfeeding women, elderly References 1. MOH Clinical Practice Guidelines on 4/2002. 2. Talk to Your Patients About Smoking A Guide For The Busy Health Professional, Health Promotion Board 3. MIMS Annual Singapore 2008/2009 85 nhg_guideline_14102010_1112.indd 85