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Helping people to stop smoking: The role of treatment products.

VOL: 101, ISSUE: 48, PAGE NO: 52

Jennifer Percival, RN, RM, RHV, Cert Health Ed, Dip Counselling, is Royal College of Nursing tobacco policy manager

Percival, J. (2005) Helping people to stop smoking: the role of treatment products. Nursing Times; 101: 48, 52-54. Advising patients to stop smoking is an important intervention that will have an effect on their immediate and future health. Nurses need to be familiar with the numerous products that are available to assist smokers to give up cigarettes. Jennifer Percival describes how nicotine replacement therapy and bupropion can help smokers achieve success.

Percival, J. (2005) Helping people to stop smoking: the role of treatment products. Nursing Times; 101: 48, 52-54. Advising patients to stop smoking is an important intervention that will have an effect on their immediate and future health. Nurses need to be familiar with the numerous products that are available to assist smokers to give up cigarettes. Jennifer Percival describes how nicotine replacement therapy and bupropion can help smokers achieve success.


The government has set a number of new targets to reduce smoking in the population that focus on people in disadvantaged groups. The new Public Service Agreement target (Her Majesty's Treasury, 2004) is to reduce adult smoking rates to 21 per cent or less by 2010, with a reduction in prevalence among routine and manual groups to 26 per cent or less.

Smoking cessation guidelines for health professionals (Raw et al, 1998) state that they should, where appropriate:

  • Ask patients at every opportunity whether they smoke;
  • Advise all smokers to stop;
  • Assess the smoker's motivation to stop;
  • Assist those interested in stopping smoking;
  • Arrange follow-up visits or referral to a specialist cessation service and recommend smokers who want to stop to use nicotine replacement therapy (NRT) or bupropion (Zyban), and provide accurate information and advice on both.

Community nurses need to give up-to-date advice on treatments for nicotine dependence when they discuss smoking with a client.

Addiction to nicotine

Many nurses say that they feel disillusioned when they see their clients return to smoking. However, smokers who attempt to give up smoking without help have only a 1-3 per cent chance of success (Fowler, 2004). Cigarettes are as addictive as heroin or cocaine (Royal College of Physicians Tobacco Advisory Group, 2000), and relapse is part of the normal cycle of smoking cessation.

Withdrawal symptoms

Smokers may get withdrawal symptoms when they stop smoking, and it is often these that make them start again. Some of the symptoms of withdrawal are shown in Box 1.

It is important to reassure clients that these are normal signs of withdrawal and to advise them that using pharmacotherapy products will greatly reduce many of the symptoms.

NRT and bupropion

Guidance on the use of NRT products and bupropion for smoking cessation has been produced by the National Institute for Clinical Excellence (2002), which positions these treatments at the centre of any successful smoking cessation strategy. Both NRT and bupropion help people stop smoking, and although they do not provide a complete replacement for cigarettes or eradicate the need for willpower, they do help to reduce withdrawal symptoms. Clinical trials (Silagy et al, 2004) have shown that both of these types of products double the chance of smokers successfully giving up the habit.

Nicotine replacement products and bupropion are available on prescription. All NRT products can also be bought over the counter from pharmacies, and some are on general sale. Unfortunately, there are many misconceptions about the safety of nicotine, and its use as a pharmacological treatment is misunderstood by many smokers.

A survey carried out by one pharmaceutical company found that 82 per cent of people think (incorrectly) that nicotine causes cancer, and one-third believe that NRT is unsafe because it contains nicotine (see www.responsesource.com/releases/rel_display.php?relid=QXEAi).

However, the risks associated with smoking are significantly greater than the risks of using NRT, so clients who are reluctant to use a treatment should be asked the reasons for their reluctance.

UK Committee on Safety of Medicines (CSM) and MHRA have stated that :

  • All forms of NRT can be used by patients with heart and circulatory disease.
  • All forms of NRT can be used by regular smokers aged 12 and over.
  • NRT can be used by pregnant smokers under medical supervision.
  • More than one form of NRT can be used together.
  • NRT can be prescribed for up to 9 months if there is evidence of a continued need for treatment beyond the 8 to 12 week treatment period.
  • NRT can be used while still smoking, to help a smoker reduce the amount they smoke before their planned quit date CSM and MHRA 2006)

Other changes include combinations of two types of NRT and NRT to enable patients to cut down whilst still smoking. Nicotine Assisted Reduction or Cut Down to Quit allow patients much more freedom to tailor treatment regimes to suit their own requirements (ASH 2005)

Which product for which smoker?

It is important that smokers know how to use the product that they have chosen. One of the most common problems with NRT is that people fail to use their chosen product often enough and for long enough to enable them to quit. A full course lasts from 10-12 weeks.

The product range

The nicotine skin patch - This is put on each morning, and is designed to be worn for 16 or 24 hours. It is available in three strengths. The recommended time for using a patch is 12 weeks. Unless people smoke fewer than 10 cigarettes a day they should normally start on the highest dose patch.

Occasionally, patients find that the adhesive in the patches irritates their skin, although this can pass after a few days.

Nicotine chewing gum

This is supplied in 2mg or 4mg doses and in a variety of flavours. The taste may be unpleasant at first. The gum should be chewed slowly to release the nicotine and then rested at the side of the mouth to allow the nicotine to be absorbed by the mucous membrane. The procedure should be repeated for around 30 minutes for each piece. Nicotine that is swallowed is inactive.

Nicotine nasal spray

This is a small bottle of nicotine solution that is squirted into the nostrils. Nicotine taken in this way is absorbed faster than from the other products and may suit heavy smokers. It may be difficult to get used to at first because it can irritate the nasal passages.

Nicotine inhalator

This consists of a plastic mouthpiece and a supply of nicotine cartridges that fit on the end of it. Smokers draw on it as they would a cigarette. Despite its name, the nicotine does not reach the lungs but, rather, is absorbed in the mouth and throat.

Microtab

This is a tablet which, when placed under the tongue, slowly dissolves to release 2mg of nicotine. It should not be sucked, chewed or swallowed as this stops the absorption of nicotine.

Lozenges

These are used in a similar way to Microtabs and nicotine gum. They are available in 2mg and 4mg doses and should be sucked to release the nicotine, allowing absorption through the mucous membrane.

Bupropion

This is a two-month tablet treatment that is available only on prescription, which seems to have an impact similar to that of NRT (Jorenby et al, 1999). It works by reducing the desire to smoke and reducing withdrawal symptoms. The smoker becomes ready to stop during the second week of the course. However, bupropion is not suitable for everyone. Before it is prescribed, a full medical history needs to be taken by the patient's doctor to determine whether or not it is suitable for the individual.

The contraindications for using this product are listed in the British National Formulary, No 50, 2005.

Who can use NRT?

All smokers over the age of 18 can use NRT, unless there are specific medical reasons for not doing so. Although most research on NRT has been carried out on people who smoke at least 15 cigarettes a day, the patch and the 2mg chewing gum appear to be just as effective with lighter smokers.

Who should not use NRT?

There are some contraindications and cautions relating to the use of NRT products, but expert opinion suggests that, in most cases, they are much safer than continuing to smoke (McNeill et al, 2001).

A risk-benefit analysis may be needed for some smokers with specific diseases - for example, immediately following a myocardial event - and additional medical supervision while taking these products may be required. Guidance on this will be included in the manufacturer's summary of product characteristics. Nicotine replacement therapy can be used during pregnancy and breastfeeding, and women should seek medical advice.

New developments in NRT prescribing

Many smokers will say that they want to stop smoking at some future point when, clearly, they are not intending to take immediate action. This can be very frustrating for the nurse, especially if it is obvious that the patient's health is deteriorating.

The Nicorette brand of gum and the Nicorette inhalator have recently been licensed for a 'Cut Down Then Stop' strategy (see below). Smokers can now use these forms of NRT to reduce the number of cigarettes they smoke as a step towards eventual cessation. The aim is to get the smokers to set a target for the number of cigarettes that they feel able to cut down by - it is recommended that cutting down by 50 per cent will give them the greatest chance of succeeding.

Smokers need to set a realistic time for being able to reach their target. If they manage to keep to it, they become more confident and are motivated to continue to cut down and to stop smoking completely.

Conclusion

Achieving government targets for smoking reduction will not be easy, but by applying the smoking guidelines, and encouraging clients to use treatment products such as NRT or bupropion, their chances of success will double. The more people who can be helped to stop smoking the sooner the official targets for cancer and heart disease will be achieved, so reducing health inequalities.

Further information on the 'Cut Down Then Stop' strategy is available on the ASH website: www.ash.org.uk/html/cessationdetail.php#reduction

KEY POINTS

  • The government aims to reduce adult smoking rates to 21 per cent or less by 2010
  • Nurses need to be able to give up-to-date advice on treatments for nicotine dependence
  • Nicotine replacement therapy and bupropion can reduce the symptoms of withdrawal
  • A brand of nicotine chewing gum and a nicotine inhalator (Nicorette) have been licensed for a 'Cut Down Then Stop' strategy

ASH (2005) Guidance for health professional on this new indication www.ash.org.uk/html/cessationdetail.php#reduction)

Fowler, G. (2004) Time to confront a major health issue. Update; (suppl), May, 6.

Her Majesty's Treasury (2004) Spending Review: Public service agreements 2005-2008. London: HM Treasury. Available at: www.hmtreasury.gov.uk/spending_review/spend_sr04/psa/spend_sr04_psaindex.cfm

Jorenby, D. E. et al (1999) A controlled trial of sustained-release bupropion, a nicotine patch, or both for smoking cessation. New England Journal of Medicine; 340: 9, 685-691.

McNeill, A. et al (2001) Regulation of nicotine replacement therapies. A critique of current practice. Addiction; 96: 12, 1757-1768.

Committee on Safety of Medicines & Medicines and Healthcare Products Regulatory Agency. (2006) Report of the Committee on Safety of Medicines working group on nicotine replacement therapy. London, CSM and MHRA.

National Institute for Clinical Excellence (2002) Guidance on the use of nicotine replacement therapy (NRT) and bupropion for smoking cessation. Technology Appraisal Guidance No. 38. London: NICE.

Raw, M. et al (1998) Smoking cessation guidelines for health professionals. Thorax; 53: (suppl 5), Part 1, s1-s19.

Royal College of Physicians Tobacco Advisory Group (2000) Nicotine Addiction in Britain. London: Royal College of Physicians.

Silagy, C. et al (2004) Nicotine replacement therapy for smoking. The Cochrane Database of Systematic Reviews, Issue 3.

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