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School of Public Health and Community Medicine The University of New South Wales, Sydney

School of Public Health and Community Medicine The University of New South Wales, Sydney Associate Professor Colin Mendelsohn. Smoking cessation for people living with HIV. HIV Education Qld 15 March 2018. Disclosure. Payments for teaching, consulting and conference expenses from

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School of Public Health and Community Medicine The University of New South Wales, Sydney

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  1. School of Public Health and Community MedicineThe University of New South Wales, Sydney • Associate Professor Colin Mendelsohn Smoking cessation for people living with HIV HIV Education Qld 15 March 2018

  2. Disclosure Payments for teaching, consulting and conference expenses from • Pfizer Australia • GlaxoSmithKline • Johnson & Johnson Pacific • Perrigo Australia

  3. Outline • Nicotine dependence • Overview of management • 2 case studies • Nicotine replacement therapy • Counselling issues • Electronic cigarettes

  4. Why is it so hard to quit? • Half of the smokers with HIV interested in quitting, especially if HIV care provider 1 • Encourages quitting • Discusses cessation • Smokers in general • 40% try to quit at least once each year 2 • Unaided quit rate is 3-5% at 6-12 months 3 • 30% of quitters will relapse after 12 months 4 • Smoking is an addiction, not a lifestyle choice 5 • 1. Pacek LR. AIDS Care 2017 2. Cooper J. ANZJPH 2011. 3. Hughes JR. Addiction 2004. 4. Etter J-F. Tobacco Control 2006 5. American Psychiatric Association. DSM-V. 2013

  5. Smoking cessation for pharmacists Nicotine withdrawal • 80% of smokers • Starts within 6 hours • Peak over 2-3d, settles in 10-14d • Symptoms • Irritability, frustration, anger • Anxiety • Difficulty concentrating • Increased appetite • Restlessness • Depressed mood • Insomnia • + cravings • American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-V. 2013

  6. 3As ASK Ask all patients if they smoke ‘Do you smoke? Do you vape’ ‘Are you still smoking?” ACT • ‘The best way to quit is with support and stop-smoking medication. • Can I give you a referral to see or speak to… • Quitline 137 848 • GP • Pharmacist • Tobacco Treatment Specialist www.aascp.org.au • OR ‘Can we make an appointment to discuss further?’ ADVISE • ‘its not easy, but the best thing you can do for your health is to quit smoking. It will reduce your risk of infection and respond better to treatment’ ASSIST • Psycho-education • Coping strategies • Barriers to quitting • Pharmacotherapy • Set a Quit Date ASSESS • Readiness to quit • Nicotine dependence ARRANGE Arrange follow up visits 5As

  7. 2 components of treatment • 2. Pharmacotherapy for nicotine dependence 1. Behavioural counselling and education for habit

  8. Assessing nicotine dependence • Time To First cigarette (TTFC) 1,2 1. Fagerström K. Time to first cigarette; the best single indicator of tobacco dependence? Monaldi Arch Chest Dis 2003 2. Heatherton T. Measuring the heaviness of smoking. British Journal of Addiction 1989

  9. 1) Behavioural counselling

  10. Smoking triggers distract delay avoid change escape

  11. Barriers to quitting Nicotine withdrawal Fearof failure Weightgain Peerpressure Stress

  12. 2) Pharmacotherapy • All work by relieving cravings and withdrawal symptoms • Supporting smoking cessation. A guide for health professionals. RACGP 2014

  13. Effectiveness in general population PLHIV 2 More research neededAll should be offered intervention 1. Cahill K. Cochrane review 2013 2. Pool EAR. Cochrane Review 2016

  14. All NRTs are not the same

  15. Use an adequate dose • Dose should be sufficient to control withdrawal symptoms and cravings • If in doubt, use more – higher doses are safe • Heavier smokers and faster nicotine metabolisers (women) need larger doses eg 2 patches + oral NRT • 4mg gum and lozenges if TTFC <30mins

  16. Nicotine patch • Full strength patch if ≥ 10 cigs per day • Apply to clean, dry, hairless skin on upper back, chest or arm • Rotate site daily • Side effects: • skin rash • disturbed sleep and vivid dreams • Stead LF. NRT for smoking cessation. Cochrane 2012

  17. Optimal use of oral agents • Correct use instructions vital • Absorbed through oral mucosa • Don’t chew or swallow • Don’t eat or drink while using • Use sufficient to control cravings • Too much nicotine causes nausea • At least 8-12 weeks

  18. Nicotine gum

  19. Nicotine gum • ‘Chew and park’ • Chew slowly until peppery, bitter taste then rest between gum and cheek • Chew again several times slowly when taste fades • Repeat for 30 min or till the taste fades • Try not to swallow excessively 2mg and 4mg available

  20. Nicotine lozenges • Allow to dissolve in mouth (about 20 min) moving from side to side from time to time • Use 4mg if TTFC <30 mins Lozenges 1.5/2mg, 4mg

  21. Nicotine mouth spray • Pump spray (150 doses) • Spray under tongue or inside cheek • Delay swallowing for as long as possible to allow absorption • Rapid onset • Starts to relieve cravings after 60 sec 1 • Peak effect in 10 mins 2 • 1. Tonnesen P. EurResp J 2012 2. Kraiczi H. Nicotine Tob Res 2011

  22. Inhalator • Plastic pipe with replaceable nicotine cartridge • About 400 puffs per cartridge • Deep or shallow puffs? • Shallow, frequent puffs for 20 minutes hourly (10 puffs p minute)

  23. Varenicline • Single most effective monotherapy 1 • 1 tablet twice daily for 12-24 weeks (PBS) • Delayed onset: takes 1-2 weeks to work • No drug interactions • Nausea; disturbed sleep, vivid dreams • No significant increase in neuropsychiatric events compared to nicotine patch, bupropion or placebo 2 • Safe and effective for people living with HIV 3 • 1. Cahill K. Cochrane Review 2016 2. Anthenelli RM. Lancet 2016 3. Mercie P. Lancet 2018

  24. Bruce • 35 year old, smokes 20 cigarettes per day • ‘First ciggie with a cup of coffee as soon as I get up’ • Barista, lives with partner James (also smoker) • Drinks 8 cups of coffee daily, 2 cans of coke • HIV 5 years; reflux; oesophagitis; anxiety • Smokes to relax: coffee breaks, in evening after work • Wants to quit: health reasons • Past treatment • Tried nicotine patch but still got strong urges • Nicotine gum made me nauseous • Champix gave him wild dreams

  25. Combination NRT Craving intensity Cue-induced cravings Baseline 7am 1pm 6pm Backgroundcravingsduetolownicotine

  26. Combination NRT for most users • Much more effective than monotherapy 1 • As effective as varenicline 1 • Relieves both types of cravings 2 • Consider for all nicotine-dependent smokers on NRT, esp. more dependent 1. Cahill K. Cochrane Review 2013 2. Ferguson SG. J Subs Abuse Treatment 2009

  27. When should Bruce start the patch? • 2 weeksbeforeQuit Day • 34% more effective 1 • Smoking while using NRT is safe and causes no additional adverse effects 1 • 1. Stead. NRT for smoking cessation. Cochrane Review 2012

  28. Does smoking relieve stress? • Smoking appears to benefit stress but actually increases it1,2 • Smokers feel happier and more relaxed after quitting 3 • Relief of withdrawal symptoms confused with relaxation • 1. Prochaska J. Drug AlcDep 2010 2. Parrott A. Hum PsychpharmClinExp 2012 3. Taylor G. BMJ 2014

  29. The ‘stress paradox’

  30. Should Bruce reduce coffee? • Caffeine levels rise after quitting 1 • Caffeine toxicity confused with nicotine withdrawal • Reduce caffeine by half when quitting • 1. Faber MS. Clinical Pharmacology and Therapeutics 2004 2. Swanson JA. Caffeine and nicotine. A review of joint use and interaction in withdrawal. Addictive Behaviors 1994

  31. ‘I always smoke when I drink coffee’ • Reduce coffee intake • Change to tea, herbal tea, orange juice or water • Have in a different place, where you usually don’t or can’t smoke • Do something else while drinking • Try a different brand of coffee or use a different cup • Use oral NRT before coffee break

  32. Fernando • 48yo single, unemployed on Newstart • Smokes 30cpd, first within 5min of rising • Smokes when he drinks, 8 beers each night • Overweight, BMI 29.5 • HIV 17 years • COPD 2y: ‘the lung specialist said I have to stop’ • ‘I’ve tried everything and nothing works. I miss the hand-to-mouth action and the time out. I really don’t want to quit’ • ‘But I can’t afford it any more’ • ‘A friend used an e-cig. Are they safe?’ • ‘Anyway, doesn’t nicotine cause cancer?’

  33. ‘Will I put on weight after quitting?’ • Average weight gain vs continued smoking 2.6kg (5y) 1 • Strict dieting not recommended 3,4 • Eat sensibly • Exercise regularly (reduces weight gain by 2kg) 4 • Accept some weight gain for now • Focus on quitting • Lose weight later • 1. Tian J. Obes Rev 2015 2. Pisinger C. Prev Med 2007 3. Spring B. Addiction 2009 4. Farley AC. Cochrane review 2012

  34. ‘Why do I have to cut down alcohol?’ • Strong behavioural association • Each reinforces the pleasure from the other 1 • Alcohol is a common causes of relapse to smoking 2 and smoking triggers relapse to alcohol 3 • Concurrent treatment preferred 4 • More intensive treatment recommended • 1. Doyon W. Biochem Pharm 2013 2. Kalman D. 2005 3. Weinberger AH. Alcohol ClinExp Res 2015 4. Prochaska JJ. J Consult Clin Psych 2004

  35. Is nicotine safe? • The main psychoactive agent but causes few significant health effects (except pregnancy, ?adolescence) 1 • Nicotine 1 • does not cause cancer • is not a major cause of cardiovascular disease • does not cause respiratory disease • Accurate information may increase uptake and compliance 2 1. Zwar N. Pharmacist. 2006 2. Ferguson SG. Add Behav 2011

  36. Tobacco harm reduction? • For smokers unable or unwilling to quit with approved treatments • A less harmful alternative • Continue nicotine and habit, without the smoke • ‘Smoke for the nicotine but die from the tar’ 1 • Some will go on to stop vaping • Other harm reduction strategies • Methadone; needle exchange; MSIR • 1. Russell M. Low-tar medium-nicotine cigarettes - a new approach to safer smoking. BMJ 1997

  37. Electronic cigarettes e-liquid Simulates smoking Nicotine Habit Heating element Battery The most popular quitting aid in the UK and US

  38. The evidence • E-cigarettes are helping smokers quit 1-7 • Not risk-free but far safer than combustible cigarettes • ‘unlikely to exceed 5% of the harm from smoking tobacco’1,2 • 44% of PLHIV interested in using ecigs for cessation 8 • Switching leads to • Substantial improvements in health • Substantial reductions in toxins • 1. UK Royal College of Physicians 2016 2. Public Health England 2018 2. Cochrane Review 2016 4. The Schroeder Institute for Tobacco Research and Policy Studies 2017 5. US Centre for Addictions Research of British Columbia, Canada 2017 6. US National Academies of Science Engineering and Technology, 2018 7. UK Centre for Tobacco and Alcohol Studies 2016 8. Pacek L. AIDS Care 2017

  39. Cigalikes and pod models • Rechargeable battery with sealed prefilled cartridges/pods • Simple, easy to use Cigalikes Pod models

  40. Intermediate tank models • Coils • Higher nicotine delivery and quit rates • Buy nicotine e-liquid separately • Refillable chamber • Rechargeable battery • Replacement coils • InnokinEndura T18 • Joyetech AIO

  41. Advanced models • Larger battery and tank • Higher nicotine delivery • Adjustable: power settings, resistance, temperature • Modifiable

  42. Select a device • Basic tank device Advanced device if not satisfied OR Pod model

  43. E-liquid 2-5ml per day Flavourings • Tobacco • Fruit, menthol, foods, beverages… Nicotine 0 - 3.6% (start 1.2-1.8%) + Propylene glycol Flavour, throat hit Vegetable glycerine Mist production PG:VG 50:50, 60:40, 70:30

  44. How to counsel clients

  45. How to counsel clients

  46. Is it legal? No script    • Compounding pharmacy • Personal Importation Scheme Queensland Health have a different interpretation of the law

  47. Legal purchase of nicotine • Australian compounding pharmacy • www.nicopharm.com.au • Nicotine concentrations: 1, 3, 6, 12, 18, 24 mg/ml • Script provided online • International websites • TGA Personal Importation Scheme: Import 3 months’ supply at a time for personal use to quit • Prescription required • www.mixologyvape.co.nz • www.vapoureyes.co.nz • www.nzvapor.co.nz • https://wickandwireco.com

  48. Health promotion charity • Raise awareness of vaping and educate smokers and health professionals • Website, educational campaigns, media, social media, education of stakeholders • Board of Directors: 4 doctors and one consumer • Donations over $2 tax deductible • Web: www.athra.org.au | Twitter: ATHRA_AU

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