Smoking

Question 1

Epidemiology

Answer 1

14.7% in the UK smoke

Question 2

Investigation

Answer 2

CO level of ≤10ppm indicates abstinence from smoking

Question 3

Management

Answer 3

Very Brief Advice (VBA) – offer at ANY interaction in ANY healthcare setting:

• Ask about current and past smoking behaviour
• Provide verbal and written information on risks of smoking and benefits of stopping smoking

· Risks – cancer, bronchitis, COPD and hospital admissions

· Benefits of stopping – cost savings, better health

• Advise options for quitting smoking including behavioural support and medication
• Refer the person to their local stop smoking service (if they wish to stop smoking)
• If they don’t want to quit, enquire to a harm reduction policy (i.e. stop smoking, but use NRT)

o 1st: Advice:

• Stopping is best done through behavioural support + medication
• Set a quit date, and commit to it
• The first few days are often the most difficult (may experience withdrawal), but passes by 3-4 days

o 2nd: Medications – depends on individual preference – cannot prescribe NRT in combination with medications:

• Nicotine Replacement Therapy (i.e. lozenges, mouth spray, patches)
• Start on the agreed quit date

Patches (24hr) useful if:

o Smoking shortly after waking

o On combination NRT (as patch is for ‘background’ cravings)

Varenicline:
- Mechanism: partial nicotine receptor agonist
- Dose: 1mg BD, titrated up from 500mcg OD over 1 week

o Started 7-14 days before quit date, whilst they are still smoking

• Contraindications: <18yo, renal disease

Bupropion:
- Mechanism: selective DA and NA re-uptake inhibitor (weak)
- Dose: 150mg BD, titrated up from 150mg OD over 1 week
- Maximum use for 7-9 weeks, then discontinue use
- Started 7-14 days before quit date, whilst they are still smoking
- Contraindications: <18yo, seizures, CNS disorder, eating disorder, BPAD, cirrhosis

Do not recommend e-cigarettes (unclear health impacts)

3rd: Follow-up:

• 2 weeks if on NRT; 3-4 weeks if on medications
• Measure CO levels 4 weeks after quitting
• Check progress, withdrawal symptoms
• Of relapse, or partial relapse, provide encouragement and set a new quit date