In this episode of Cracking Addiction we discuss various smoking cessation interventions including behavioural interventions, nicotine replacement therapy, varenicline, bupropion and nortriptyline to aid patients in stopping smoking.
Hello and welcome to another episode of cracking addiction with philippe naren and thurgle armstrong in the episode of cracking addiction today we’re going to talk a bit more about smoking cessation interventions and in particular the role of counselling and behavioral therapies in smoking cessation so fergal can you tell us a bit more about some of the counseling
Options available for smoking cessation and how effective some of these therapies may be yeah it’s there’s a lot of there’s a lot said about counseling and i think um the danger is that people over complicate it and as a result they may feel that they’re not qualified to deliver smoking cessation counseling so i think you go back to basic principles and you
Talk about motivational interviewing in the cycle of change so if you go back to motivational interviewing you’re asking patients about how they feel in in terms of the importance of smoking cessation how confident they feel in terms of smoking cessation you’re asking them about the impediments that they’ve got to smoking cessation you’re asking them if they’re
Pre-contemplated or contemplative and you’re trying to elicit change talk and then once they’re preparing for smoking cessation then you’re going into more cbt rather than motivational interviewing and you’re talking about anti-antecedents behaviors and consequences and you’re talking about the challenges that they might face in your problem solving with them and
So really the cycle of change early phases motivational interviewing the latter phase of cbt it doesn’t have to be more complicated than that and anyone can do it and there is evidence that actually this does work i mean so the cochrane review uh find that individual counseling could improve the chance of someone quitting beyond the unassisted could rate by up
To 40 to 80 compared to minimal support so we’ve got a huge treatment effect here absolutely yeah so taking the time to actually give people counseling and talk to them a little bit more than just a bit of a brief intervention but talking to them talking them around that cycle of change really does have health benefits absolutely now moving on from some of those
Counseling techniques that you’ve just mentioned fergal onto some of the pharmacotherapies that we sometimes use for smoking cessation i guess we could probably branch them into two separate headings which would be nicotine replacement therapy and then varenicline and bupropion i guess you could do three in if you really wanted to go down the vaping pathway but
That’s an episode or a few episodes in and of itself which we will probably discuss later on but the ease of purpose for this episode we’ll just be talking about nicotine replacement therapy and varenicline and bupropion with regards to nicotine replacement therapy there’s long-acting and short-acting nicotine replacement therapy long-acting being the transdermal
Patches and short acting being the various oral preparations whether it be gum or lozenge what’s your approach to nicotine replacement therapy or initiating nicotine replacement therapy for a patient so i say to patients i’ll give them whatever it takes to get them off the flags and i always start with offering them you know nicotine replacement therapy and
I offer nicotine replacement therapy because we know that again from cochrane reviews we know that cochrane reviews validate the use of nicotine replacement therapy and in particular they validate the use of combination nicotine replacement therapy and that was a big shift for me because when i was younger and starting out in my medical career i used to say oh
Once you’re on the patch account of anything else well that’s just not true we know that people who are on patches do benefit from augmentation with short acting nicotine replacement therapy as well as the long-acting nicotine so if we’re talking about nrt i think the first thing to do is to work out what kind of dose they want and really you know there’s this
Idea that you can use high-dose nicotine replacement therapy for people on more than 20 cigarettes a day and i i actually feel that anyone who’s dependent on cigarettes anyone who’s smoking more than 10 a day and you know smoking within an hour waking up really probably just needs to go straight on high dose cigarettes uh sorry high dose nicotine replacement
Therapy patches and i encourage the use of short acting to help with cravings and i’m happy for them to have whatever they want there are there are theoretical maximums in terms of prescribing short-acting nicotine replacement therapy but like like for instance i mean you know the the lozenges theoretically the maximum dose of a lozenge is 80 milligrams a day
But quite frankly i take this view if it’s the difference between someone smoking and not smoking i don’t care how much nicotine replacement therapy they take if it keeps them off the cigarettes and i think it’s really important for them to have multiple types of nicotine replacement therapy so they can short acting so they can try the gums they can try the
Tablets the lozenges they can try the inhalators they can try the sprays as well as having the patches so they can have a wide range of short acting plus on top of their their topical nrt absolutely and just to add on to what you’ve just said i also tell my patients especially with the short acting oral preparations and that’s whether it’s the gum the lozenge or
The inhalator or spray all of the oral stuff is mainly buccally absorbed so especially when it’s the gum i tell them to use that chew and park technique which is chew it keep it in your mouth do not swallow it because once you swallow it the effect of nrt is not going to be available so just to make sure that the patient knows how these medications work and that
They’re not just popping a lot of nrt and then quickly swallowing them because it will have no effect if that occurs yeah i think there’s there’s some concern still among some of our colleagues about the the the risks of nrt and people allude to the safety profile of nrt especially in people with unstable cardiovascular disease um i mean there are you know
If you look at the side effects of nrt they will state that you know you do have the risk of insulin resistance you do have a risk of accelerated arthrogenesis and you do have the risks of vasoconstriction vasoconstriction but at the end of the day there has been there were there were randomized controlled trials trials we’re looking at this issue and there’s
Been no evidence of an increased elevation in the risk of any coronary cardiac or vascular event i think it’s really important again it goes back to harm minimization would you rather have someone taking high-dose nrt albeit that they also have unstable heart disease or would you rather have them smoke and any day of the week i’d rather have them have the nrt
Even when they’ve got unstable heart disease because the risks of smoking and the dangers associated with smoking are so vast i i totally agree fergal and we do know that in say stable ischemic heart disease nrt is safe and you’re alluding to unstable heart disease there and usually the guidelines i’ve seen vary from uh nrt is not recommended between two to six
Weeks post a cardio cardiovascular event however like you mentioned i would much rather a patient be on nrt then resume smoking with all the carcinogens and all the pathology associated with cigarettes so if we’re talking about harm reduction here i agree with you fergal a total no-brainer for me i would much rather a patient be on nrt and and as long as it’s
Consent provided um i think uh it’s certainly the lesser of two evils in in many respects in all respects i would argue now going on to varenicline um so varenicline is one of the uh tablet medications we use to aid in smoking cessation it’s a partial agonist of the alpha-4 beta2 nicotine receptor and it helps to reduce cravings for for cigarettes and reduce the
Rewarding effects of smoking what’s your approach with varenicline fertile well i actually use it uh first line uh if if if people are are happy to accept the the side effect profile that’s the the one drug that i will say look let’s start off with champix what i say is that it doesn’t stop people from smoking what it does is it changes people from being smokers
To non-smokers and that takes time i mean you’ve you’ve got basically talking about a 12-week course and you have you know the first few days you’ve got an escalating dose but fundamentally you’re on one milligram twice a day for about 12 weeks the biggest problem i have with people on varenicline is that they don’t finish the course so i have to emphasize you
Have to finish the course and then you can consider yourself as treated and actually some people especially very heavy heavily dependent smokers they actually need two courses so they might need six months worth of shampoos to to you know to really you know get them away from the cigarettes the other thing is that people worry about having to set a quit date and
I say actually with sean picks yes you know the recommendation is that you set a quick date two weeks into the into the course but you know if you don’t want to set that quit date that’s fine i mean i’ve had a couple of cases of people who who have not been able to set quick dates until they’ve hit the second full course of shampix so basically 13 14 weeks
Yes they’ve reduced but they haven’t actually managed to cut to quit completely so again what i’m saying is there needs to be a certain amount of flexibility in prescribing varenicline you need to be aware of the guidelines you need to be aware of the risk factors and the side effects and in particular the nausea and the loss of appetite and the vivid dreams
These can be quite off-putting what’s your take on varana clean i find it quite useful it’s certainly the medication i use more than say bupropion for example the thing that i struggled with initially when i was a general practitioner was the warnings or the concerns about the neuropsychiatric side effects of varenicline and if someone had unstable depression
Anxiety or unstable mental health diagnoses it was when i was training it was viewed as an absolute contraindication for convincing varenicline however there have been more recent studies which have shown that this is not necessarily accurate so nowadays i counsel my patients i still offer it to to patients i do state that sometimes there can be a bit of mood
Disturbance but that requires just closer monitoring and review rather than not offering it to patients is that similar to your practice verbal yeah yeah yeah absolutely i i too remember the days when i would refuse to give varenicline to someone with a history of depression or suicidal ideation or schizophrenia there’s a couple of things to say about that i
Mean the key landmark trial that basically exonerated varenicline in this regard was the eagles study and it demonstrated there was no increase uh and then psychiatric events due to that could be attributed to varenicline so really what i think of this as it’s the act of smoking cessation and it’s the stress associated with smoking cessation that causes all of
This decompensation so i think it and i think it’s safe to use varenicline in people with mental health disorders but that doesn’t mean you you are absolved from the clinical duty of care to actually watch your patient monitor their mental state you still have to watch them and you know there have been there have been documented reports of patients being told to
Go back on the cigarettes because of such a deterioration in their mental state but remember it’s not due to the varenicline as due to the stress of smoking cessation that would have happened with any medication but really the eagles trial exonerated varenicline and zyburn for that matter from being guilty of any decompensation of mental state and really that’s
A great outcome for us because remember let’s not forget varenicline is the most effective smoking cessation intervention that we have it it it is associated with a 30 quid rate and remember that the unassisted quit rate’s about five percent the nrt quit rates doubles by about 10 percent but really for anaclean you’re looking at a 30 quid rate which is the best
We’ve got and that also alludes to the fact that really not everyone will will quit with varenicline and not everyone will quit with varenicline on the first time so it’s always worth a second ago absolutely what’s your view on varenicline and nrt yeah i give it i i’ll happily combine the two i mean it’s not uh it’s not specifically recommended i don’t think
The guidelines recommended but i don’t see a reason why not and i am aware that there’s there’s evidence uh studies have been published that actually combination of nrt and varenicline actually increases the successful quick rate so yeah it’s it’s i’m happy to to prescribe both excellent that’s similar to my practice as well to be honest the last medication i
Think we were going to talk about is bupropion which is the other tablet medication that we uh prescribe for smoking cessation commonly known as xyban in australia it’s an antidepressant that is thought to to work by affecting the re-uptake of noradrenaline and dopamine what’s your thoughts and experiences with bupropion verbal i haven’t really used it that much
I’ve used in a couple of patients more recently because actually in uh currently in australia there’s a shortage of uh of uh champigs but you know it it is validated as an intervention it’s got a good evidence base it’s supported by the cochrane review and it’s also supported by the eagle studies so it’s safe and effective it’s not as effective as shampix but
It’s better than um it does have benefits above the unassisted quit rate um there’s a couple of concerns that i’ve had people mention some people are worried about the risk of hypertension some people are worried about the risk of seizures so you know i don’t believe that hypertension is a reason to exclude someone from smoking cessation so if you’re worried
About their blood pressure we’ll treat their blood pressure you know check it and treat it and you know be it is an antidepressant it’s an ndri it does have a seizure risk but it’s no worse than the seizure risk associated with uh citalopram so for instance which one the citalopram has a seizure risk of one in a thousand so two is champix and actually there
Is evidence that most ssris at therapeutic doses are actually uh anti-seizure in that they increase the seizure threshold so you know you know every tablet you have has a risk so there is a risk of seizures with bupropion but it’s manageable like any other risk or using any other antidepressant at the end of the day it is an antidepressant and it does have a
Good safety profile and it is used extensively certainly in other countries for uh the for its antidepressant effect i haven’t used xyban as an antidepressant in australia have you not as an antidepressant no no so the strange side isn’t it it’s licensed for smoking cessation but it’s mechanism of actions basically as an antidepressant it is interesting yeah we
Don’t we don’t use it it is interesting but as as good and rational prescribers we follow our relevant state and government regulations in terms of the indications we use our medications and we and we never actually deviate from those guidelines ever now before we before we close i do think it’s important actually to mention one other drug that can be used uh in
Smoking cessation that is an antidepressant that is licensed for depression in australia and that is nortriptyline have you ever used nortriptyline for smoking cessation i can’t say that i have i’ve heard of some other prescribers using it um too good effect actually i must admit but personally i haven’t delved into it myself have you had much experience with
Nortriptyline fergal i’ve never used it but you know i i like you i’ve heard good stories about it and the evidence suggests that it does have a role in smoking cessation it’s very much second line so you know you’ve tried the nrt you tried the champ xp program that’s trianotriptyline and i think it’s important to emphasize that it’s smoking cessation effect
Is actually separate from its antidepressant effects so yes we use more tryptophan well i actually use more tripling nor triptyline for chronic pain rather than depression because of the the the risk of overdose and death with nortriptyline so you wouldn’t want to give someone who’s really suicidal nor tryptolin so i tend to use it more for pain but yes it it
Has an independent smoking cessation action and again you know you want to get up to about 75 milligrams and you want to give it for about uh you know 10 to 12 weeks and it does actually increase the abstinence rate from uh from from unassisted by 10 so you know it it is it has got a a evidence base for it and it is efficacious in this regard but i’ve never
Used it excellent so in the episode of cracking addiction today we’ve covered quite a bit of information we’ve talked about behavioral interventions in smoking cessation we’ve talked about nicotine replacement therapy varenicline bupropion and nortriptyline to aid our patients in smoking cessation thanks for your attention in joining us for this episode of
Cracking addiction and bye for now
Transcribed from video
Smoking cessation interventions By MedHeads
