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ABC FOR SMOKING CESSATION

QUICK REFERENCE CARD ASK

Ask all people if they smoke and document their smoking status in the clinical record. Use the following descriptions (or similar). • Current smoker • Ex-smoker • Never smoked For anyone who smokes or has recently stopped smoking, check and update their smoking status on a regular basis.

BRIEF ADVICE

Give brief advice at least once each year to all people who smoke and record this information in their file. Brief advice can be structured around the following three points. 1 Personalise your advice to what is important to the person (for example, health, family, or finances). 2 Acknowledge that it can be hard to stop but that it is possible. People successfully quit smoking for good every day. People often need to try a few times before they succeed. The important thing is to keep on trying. 3 Encourage them and offer support to quit. Some people will not want to stop right now, but they should know that you can help them whenever they are ready. You have several options for providing Cessation Support. 1 Write a prescription or Quit Card for NRT (see the next page for details). 2 Provide a prescription for varenicline, nortriptyline or bupropion (see pages 44-48 of the 2007 Smoking Cessation Guidelines). 3 Recommend that the best results are achieved with a combination of one of the above medications and behavioural support. The options available for support are: • Quitline (0800 778 778 or www.quit.org.nz) • Aukati Kai Paipa (www.aukatikaipaipa.co.nz) • local providers (contact your local DHB’s Smokefree Service) • provide the support yourself if you have the time and feel able to do this (multi-session support over at least four weeks is best).

CESSATION SUPPORT

© Ministry of Health August 2009 WL12811

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NICOTINE REPLACEMENT THERAPY (NRT)

NRT patches, gum, and lozenges are available on prescription from September 2009. NRT will also still be available on the Quit Card scheme.1 In general, let people decide which product they would like to use. Combination of patch and gum or lozenge is safe and may increase the likelihood of quitting.

PATCH (24-HOUR) PRODUCT INFORMATION PRODUCT AND DOSAGE 3

Three strengths 2 (21 mg, 14 mg, and 7 mg).

GUM

Two strengths (4 mg and 2 mg).

LOZENGE

Two strengths (2 mg and 1 mg).

A GUIDE TO PRODUCT CHOICE:

• Smokers of 10 or more cigarettes per day: recommend patch 21 mg/24 hr and/or gum or lozenge. • Smokers of fewer than 10 cigarettes per day: recommend gum or lozenge. If an oral product cannot be tolerated then use a 14 mg patch/day.

A GUIDE TO DOSAGE:

Use time to first cigarette 4 to guide dose of gum and lozenge: • if within an hour of waking use 4 mg gum or 2 mg lozenge • if after an hour of waking use 2 mg gum or 1 mg lozenge. The dose of NRT can be increased if the user has inadequate relief of withdrawal symptoms (eg, urges to smoke, irritability, restlessness).5 All products should be used for 8-12 weeks, or longer for some people. NRT can be used in all people who smoke. 6789

INSTRUCTIONS FOR CORRECT USE

PATCH

Apply patch to clean, dry and hairless skin. Remove old and apply new patch daily, alternating sites. Some redness under the patch may occur – this is normal. If sleep disturbance is experienced the patch can be removed overnight.

GUM

Chew to release ‘peppery’ taste and then rest in the side of the mouth (between cheek and gum). Chew again when the taste starts to fade. Do this for 30 minutes and then discard.

LOZENGE

Suck to release ‘peppery’ taste, and then rest in the side of the mouth (between cheek and gum). Suck again when the taste starts to fade. Do this for 30 minutes and then discard.

WHAT TO WRITE ON THE PRESCRIPTION OR QUIT CARD

PATCH

Nicotine Patch 21 mg 8 weeks supply (dispensed 4 weeks at a time)

GUM

Nicotine gum 4mg (or 2mg) 8 weeks supply (dispensed 4 weeks at a time)

LOZENGE

Nicotine lozenge 2mg (or 1mg) 8 weeks supply (dispensed 4 weeks at a time)

Up to 3 different products can be combined on one script or quit card.

Notes about NRT:

1 2 3 4

5 6 7 8 9

Sublingual tablets (Microtabs) and inhalers are available in pharmacies (see page 41 of the Smoking Cessation Guidelines). These medications are not currently subsidised. Lower strength patches are generally used only for weaning. Their use is not strictly necessary. Note that these recommended doses differ from those listed on the product packaging. These recommendations simplify NRT dosage and try to ensure that people are getting enough nicotine replacement. The number of cigarettes smoked per day is not the best indicator of tobacco dependence. People can reduce consumption, but typically compensate by smoking their fewer cigarettes more intensely. A better indication of dependence is time to first cigarette after waking. Those who smoke within 60 minutes of waking show a greater dependence than those who smoke after this length of time. Smoking within 30 minutes of waking can also be used as a cut-off point. Most smokers don’t use enough NRT, but rarely some have too much and then feel nauseated. If someone feels sick using NRT they should reduce the frequency or dose of the product. NRT can be used in pregnancy if the woman would otherwise continue to smoke. Do a risk-benefit assessment: can she quit without NRT? If not, NRT is safer than smoking. (See page 49 of the Smoking Cessation Guidelines for more information.) NRT is safe to use in people with cardiovascular disease. No dosage adjustment is needed. NRT can be used in adolescents (aged 12 and over). Use the product best suited to their needs. There are no drug interactions with NRT. However, the doses of some medicines (eg, some psychiatric medicines) may need a dosage adjustment when people stop smoking (see page 50 of the Smoking Cessation Guidelines).