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Brief Interventions - Smoking

Brief Interventions - Smoking. C. Tyreman and K. Durkan. Objectives. Background NICE recommendations Consultation tips Pharmacotherapy Evidence base. Background. Smoking prevalence 20% (similar both sexes); highest in 20-24year olds; Yorkshire and Humber one of worse areas

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Brief Interventions - Smoking

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  1. Brief Interventions - Smoking C. Tyreman and K. Durkan

  2. Objectives • Background • NICE recommendations • Consultation tips • Pharmacotherapy • Evidence base

  3. Background • Smoking prevalence 20% (similar both sexes); highest in 20-24year olds; Yorkshire and Humber one of worse areas • Leading cause of morbidity / mortality; 460,000 hospital admissions related to smoking (5%); 80,000 deaths related to smoking (20%) • 67% want to give up; 75% have tried; £88 million spent on NHS stop smoking services

  4. NICE recommendations • Brief interventions – opportunistic advice, discussion, negotiation and encouragement. • 5-10 min; patient centred; multi-disciplinary May include: • Simple advice to stop • Assessment of patients commitment to quit • Referral to more intensive support e.g. NHS Stop Smoking Services • Offer of pharmacotherapy / behavioural support

  5. 1) Advice to stop: • To all smokers • Have they considered stopping?/ do they know the risks? • QOF – identify smokers / give advice 2) Assess commitment • Advice should be sensitive to this – are they ready to stop?

  6. 3) Referral to intensive support • All who want to stop • NHS Stop Smoking Service, nurse specialist • QOF – offer support / Rx 4) Offer pharmacotherapy / behavioural support • In line with guidance – NRT, varenicline, bupropion; counselling; group support; self help literature • QOF – offer support / Rx

  7. The Initial Consultation Why stop? How long smoked? Why smoke? Why stop now? Tried stopping before and how? When 1st cigarette / when last of the day?

  8. Nicotine Replacement Therapy Prescribe two weeks initially NRT and medication no longer than 12 weeks Options Patches Inhalers Lozengers Gum Mouth / nose spray Microtabs

  9. Varenicline Binds with nicotinic receptors and acts as an agonist. Alleviates symptoms of craving and withdrawal as well as reducing rewarding effect. SEs = GI disturbance, dry mouth, appetitie changes. AGITATION / DEPRESSION / SUICIDAL THOUGHTS. Cost = £163.80 for 12 weeks course

  10. Bupropion Anti-depressant Alleviates crave and withdrawal symptoms but mode of action unclear. SEs = taste disturbance, GI upset, anxiety, CAUTION in previous seizures. Initially 150mg OD 6 days then BD 7-9 weeks. Cost = £71.73

  11. The Evidence NRT v placebo All forms of NRT significantly more effective No significant difference between types Varenicline v placebo At 52 weeks varenicline 3x more effective Average quit 21% v 8% Buproprion v placebo 19% v 10% Varenicline v Bupropion Varenicline significantly more chance of quitting (21% v 14%)

  12. Guidance on Therapies Initial prescription enough for 2 weeks after target stop date. Then re-asses. No repeat for 6 months if unsuccessful, unless special circumstances Can combine NRT therapies No combination of NRT / pharmacological.

  13. So which Rx do I suggest? • NICE recommendations: • Discuss options with patient and decide • CIs and potential SEs • Patient preference • Availability of support and follow up • Likelihood of patient following treatment • Previous experience of smoking cessation

  14. References The NHS Information Centre. Accessed 2013. NICE. Brief interventions and referral for smoking cessation in primary care and other settings. 2006. NICE. Smoking Cessation Services. 2008. NICE. Varenicline for Smoking Cessation. 2007. British National Formulary. 2012. NHS Evidence. Clinical Knowledge Summaries. Smoking Cessation Evidence. Accessed 2013.

  15. Thank you. Any Questions? http://smokefree.nhs.uk 0800 0224332

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