Current Approaches in Smoking Cessation

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Current Approaches in Smoking Cessation
The importance of developing and continuing anti-smoking programs has been demonstrated by the
discontinuation of declines in smoking practice, and the associated upward trends in smoking amongst
young people. Encouragement of smoking cessation interventions by the media, and the impact of taxation,
establishment of smoke-free public places and health education are all relevant to tobacco control policy.
GPs have a significant opportunity to influence smoking behaviours. This bulletin summarises options which
are currently available.

Brief intervention
The credibility and scope of opportunity available to GPs provides for intervention in a cost-effective
manner. Available data suggest that advice on smoking cessation is welcomed by most patients and,
accordingly, brief intervention is demonstrably effective. However the more time taken in consultation, and
frequency of follow-up, the greater the likelihood of cessation. Brief intervention involves six steps below
and can take less than 10 minutes.

             • Amongst all patients, including adolescents, systematically identify smokers
                and document their status
             • Strongly urge all smokers to quit
             • Identify smokers willing to make a quit attempt; motivate those who are
                not ready to quit; reinforce their intentions.
             • Provide supplementary information; offer practical advice on how to deal
                with life as a non-smoker.
             • Advise a course of action: Help set a quit date and plan; offer nicotine
                replacement or other kinds of pharmaceutical therapy; schedule follow-up

Nicotine re p l a c e m e n t
Nicotine replacement therapy is available as patches, gum, nasal spray or inhaler, and may increase the
smoking cessation success rates up to 30%. Studies comparing the efficacy of each available option have
shown that compliance is associated with using the therapy as prescribed, not with the type of therapy
used. Encouragement of patients to use the product as directed will increase ability to cease smoking.

Smoking and co-morbidity: A recent development
A US study has established that persons with mental illness, such as depression, are about twice as likely
to smoke as other persons. Nicotine may be used to self-medicate due to its properties as an anti-
depressant. Smoking cessation programs based on brief intervention or nicotine replacement may be
insufficient for this group of people, as there may be other concerns. Smoking cessation efforts for persons
in this risk category will begin with identifying and treating the mental illness.

Bupropion hydrochloride, an oral antidepressant, is believed to eliminate nicotine cravings and decrease
the physiological symptoms associated with nicotine withdrawal. Patients who have otherwise not been
successful in smoking cessation may benefit from this therapy, with associated cessation rates ranging from
10.5 to 24.4%. The reduced potential for weight gain, and the ability to use Bupropion in combination
with nicotine replacement therapy, make this drug a useful treatment option. Bupropion use in Australia has
been recently approved, and can be prescribed as Zyban at a cost of $280 for a seven-week course.

                                                                 Cancer Control Bulletin
                       Information for GPs
             Current Approaches in Smoking Cessation
A c u p u n c t u re                                                        adverse pregnancy outcome, including low birth weight.
Evidence on the benefits of acupuncture is currently                        Paternal smoking also increases the risk of infant
conflicting. There is some evidence suggesting that                         respiratory infections and sudden infant death syndrome,
acupuncture may assist the motivated individual going                       irrespective of maternal smoking status. Furthermore,
through nicotine withdrawal.                                                men’s smoking habits are probably one of the strongest
                                                                            influences on the extent to which women are able to quit
Hypnotherapy                                                                smoking in pregnancy and maintain cessation after birth.
Hypnotherapy is proposed to act on underlying impulses,                     Thus her partner should be involved in a woman’s attempt
and thereby weaken the desire to smoke or strengthen the                    to cease smoking during pregnancy.
will to stop. However research has not confirmed an effect of               Weight gain concern s
hypnotherapy when compared to other cessation interventions.
                                                                            Although weight gain does not offset the health benefits of
                                                                            smoking cessation, it is frequently a source of concern for
Aversive smoking
                                                                            smokers planning to quit. A recent meta analysis found
Aversion therapy or “rapid smoking” pairs the pleasurable                   that risk of weight gain is highest 2 years after smoking
stimulus of smoking with some unpleasant stimulus and                       cessation, and declines thereafter. Average sustained
thereby suppresses craving. Recent research in the United                   quitters gain about 5 to 6 kg in weight. Evidence
States confirms that aversive smoking did suppress                          regarding the permanence of the weight gain is
craving, but it did not lead to cessation. Accordingly,                     conflicting. Research has recently shown that weight gain
aversive therapy does not currently have a position in                      does not lead to recommencement of smoking. Written
smoking cessation.                                                          information on physical exercise and healthy eating may
                                                                            be provided. However treatment efforts should focus
Nortriptyline hydro c h l o r i d e                                         smoking cessation alone to avoid unrealistic goals of
Nortriptyline hydrochloride was recently found to lead to                   behaviour change.
an increased short-term cessation rate (6mths). There were
also significant but relatively small reductions in                         Further Reading:
withdrawal symptoms such as anxiety irritability, difficulty                Britton J and Jarvis M, 2000. Bupropion: a new treatment
concentrating, restlessness, and impatience. Nortriptyline may              for smokers. BMJ 321: 65-66.
present a new therapeutic approach to smoking cessation.
                                                                            Hajek P et al, 1999. Randomized comparative trial of
                                                                            nicotine polacrilex, a transdermal patch, nasal spray, and
Other medications
                                                                            an inhaler. Arch Intern Med 159:17 2033-2038.
There is no evidence of efficacy of the use of clonidine and
tricyclic antidepressants or benzodiazepines, for which                     Lasser K et al, 2000. Smoking and mental illness: JAMA
side effects outweigh possible benefits.                                    284:20 2606-2610.
                                                                            Raw M et al, 1999. Smoking cessation: evidence based
Smoking and pre g n a n c y                                                 recommendations for the healthcare system. BMJ 318: 182.
Research in Spain found that one out of five women give
up smoking spontaneously during pregnancy. Cessation                        Websites:
 ypically occurred in the period from awareness of                          Tobacco Control Supersite:
pregnancy to the first antenatal visit. Women are less likely     
to stop smoking during pregnancy if they smoke heavily
                                                                            Quitnet - Quit all together:
and/or have partners who smoke. Increasing awareness
of adverse effects may encourage cessation. South
Australian research established that smoking among                          World Health Organization:
partners of non-smoking pregnant women is linked to               

    This bulletin (number 11 of a series) is produced as an activity of the Cancer Control Program (Head, Prof BW Stewart),with support from the
    Health Outcomes Council and the General Practice Advisory Committee. Bulletins are distributed with the active support of the four Divisions
    of General Practice. The assistance of Dr Renee Bittoun in the preparation of this bulletin is gratefully acknowledged.

                       For further information on the Bulletin program, contact Ms Kelly-Anne Ressler, 9382 8333.

                                                        - Public Health Unit

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