Behaviour | May 23, 2014 | Author: The Super Pharmacist
A study in recent years found that 16% of Australians over the age of 15 are habitual smokers. Another 2% are occasional smokers and about 30% of Australians are former smokers. Reports also indicate that one out of four Australian smokers have a desire to quit. Some want to quit because of a health scare, some have family members suffering from smoking-related health issues and others want to quit simply to save money. In Victoria, smoking is responsible for more deaths than alcohol, drugs and auto accidents combined. Torres Strait Islanders and Aborigines have a higher rate of deaths due to tobacco-related disease, with many dying at a young age.
Smoking should not be viewed as a personal lifestyle choice. To do so would ignore the apparent nature of smokers’ comprehension of the related health risks, the actuality of dependence and the fact that most smokers become nicotine dependent because usage begins at a very early age. In addition to incessant cravings, cessation attempts can have a number of discouraging side effects depending on the severity of the addiction, such as:
More recently, nicotine addiction is becoming recognised as a medical condition, requiring both physiological and psychological treatment. This has become more apparent due to the progression of pharmacotherapies. Recognising smoking as an addiction is paramount to successful cessation. A combination of pharmacotherapy and advice-based assistance from health professionals has been known to increase the success rate of cessation attempts with cumulative benefits. Personalised counselling techniques and medication use tailored to the situation of the smoker has achieved a high rate of success.
The Fagerström Test for Nicotine Dependence was developed to be an evaluation tool to determine the intensity of nicotine addiction. The higher the score the greater the dependence, which can indicate the severity of withdrawal symptoms when cessation is attempted. While those with a low to moderate dependence to nicotine have a greater chance at cessation success, they are at risk of becoming increasingly dependent if treatment is delayed. Those with high level nicotine dependence, nicotine replacement therapy and/or medications are commonly required in order to break the addiction. Addiction to nicotine is a chronic condition that requires recurrent treatments and continuing care. Although there are some who have quit successfully with their first attempt, most smokers will go through up to eight to fourteen attempts at cessation and a number of years before they are able to stop completely.
The primary goal of NRT is to reduce symptoms through the substitution of tobacco products with a safer form of low-dose nicotine. Additionally, no current form of NRT have been shown to provide the same rapidness of delivery that you get from smoking a cigarette. Some evidence suggest that cessation rates increase with nicotine replacement therapy, regardless of the inclusion of counselling. In Australia, there are several brands of NRT brands available, such as QuitX®, Nicontinell®, Nicorette® and Nicabate®. Available forms of NRT include gums, lozenges, mini-lozenges, inhalers, sublingual tablets and transdermal patches.
Gum and Lozenges Oral NRT is available in 2mg and 4mg gum and lozenges, as well as 1.5mg and 4mg mini-lozenges. The stronger versions are recommended for those with a greater level of nicotine dependence, such as smoking one or more packs of tobacco cigarettes per day.
Transdermal Patches Nicotine patches are available through the Pharmaceutical Benefits Scheme (PBS) and are subsidised following a GP consultation. Evidence indicates that starting nicotine patches two weeks prior to quitting and then continuing with the addition of an oral NRT if necessary has improved success rates in comparison to commencing patches at the same time as quitting. This practice has been approved by the Therapeutic Goods Administration.
Combination NRT Combining transdermal patches with oral NRT has been shown to be more effective that either used alone. The reason for this is because the patch provides a steady level of nicotine while the oral treatment helps to curb cravings when used as needed. It is recommended that Australians who have relapsed or experience intense cravings combine using a patch with the 1.5mg mini-lozenge, 2mg lozenge or 2mg gum. However, some experts believe that anyone attempting cessation should use combination NRT. In instances where smokers find it difficult to stop smoking abruptly, it is easier to use NRT for six months as they gradually cut down and eventually stop smoking. Studies have found that there is little difference in success rates for those who stop abruptly and those who reduce the number of cigarettes they smoke gradually before stopping. Generally, the use of nicotine replacement therapy is not recommended for more than one year of continual use. However, there have been some cases were long-term use led to permanent abstinence without any reported negative effects on the person’s health.
There are two different types of cessation assistance medications available in Australia, which are bupropion and varenicline. These have proven to be successful in clinical trials. However, it is important to note the cessation medications have a higher success rate when used in combination with support and counselling.
Varenicline Varenicline is best known by the brand name Champix®. This medication has proven to be the most effective in comparison studies. One study showed it to be more effective than 21mg/day NRT for the first six months after quitting. A reduction of relapse has been accredited to prolonged use of this medication in the first year after quitting. This medication targets the nicotinic acetylcholine receptor that is located in the reward centres of the brain. While helping to alleviate cravings and withdrawal symptoms, the Varenicline prevents any inhaled nicotine from smoked cigarettes to activate the receptor that causes the response of reward and pleasure.
Bupropion Time-release versions of bupropion hydrochloride are available in Australia under the brand name Zyban SR® and a multitude of generic brands. Bupropion was first created to be an anti-depressant. It is a form of non-nicotine oral therapy that is used to lower the desire to smoke as well as reduce the symptoms of withdrawal. Bupropion has proven to be especially helpful in aiding smokers that suffer from cardiac disease, depression and respiratory conditions, such as COPD. It has also proven effective in treating schizophrenic patients with a desire to stop smoking. While not as effective as varenicline, it is an acceptable alternative depending on patient preference and the presence of side effects. This medication is often considered to be a better option for those who suffer from schizophrenia or depression. There is insufficient evidence to support the use of bupropion in combination with NRT for additional long-term cessation benefits.
Additional pharmacotherapy options have proven advantageous for some. Nortriptyline is an anti-depressant that has shown to double the rate of cessations success. However, Nortriptyline is not a registered cessation aid in Australia. Studies are underway to test the cessation effectiveness of Cytisine. It is a naturally-occurring substance that is similar to the chemical makeup of Varenicline. There has been some research done on the development of anti-nicotine vaccines. However, the study results have proven to be inconsistent and require further evaluation.
The Royal Australian College of General Practitioners Supporting Smoking Cessation: A Guide for Health Professionals
Heatherton TF, Kozlowski LT, Frecker RC, Fagerström KO. The Fagerström Test for Nicotine Dependence
Terry A. Rustin, M.D, University of Texas Health Science Center, Houston, Texas American Family Physician. 2000 Aug 1;62(3):579-584 Assessing Nicotine Dependence