CPD: Key questions on supporting patients to quit tobacco smoking

Smoking cessation specialists Dr Alex Bobak and Louise Ross answer key questions on supporting people to quit tobacco smoking, covering the latest on supply issues with medications, the role of e-cigarettes (vaping), tailoring support according to level of addiction and how to advise patients about the value of stop smoking services

1. How effective is simple opportunistic advice in the consultation in terms of helping people to quit tobacco? And how can we assess a patient’s genuine motivation to progress onto smoking cessation aids and services?

Brief advice to patients who smoke is one of the most cost-effective interventions GPs can give.¹ However, many of us can be reluctant to do this due to time pressures, fear of confrontation and a feeling it won’t work. In reality, most smokers expect to be asked about their smoking and there is now a way of offering brief smoking cessation advice that is quick and easy to deliver, effective and usually well received.

This model recommended by NICE is ‘Very Brief Advice (VBA)’² which was originally designed for time-pressured NHS GPs and is now used in primary care internationally. VBA consists of three sections:

ASK – Establish and record smoking status.
ADVISE – Explain that the best way to stop is with support and pharmacological treatment.
ACT – Signpost where support and treatment can be obtained locally.

Perhaps surprisingly, VBA deliberately avoids many things we frequently say to smokers such as telling them to stop, asking if they want to stop or enquiring what or how many cigarettes they smoke. This not only saves significant time but is also thought to avoid ‘challenging the addiction’ which can make the interaction uncomfortable and distract the smoker from the positive messages about how to stop. A free online module on how to deliver VBA is available for GPs from the National Centre for Smoking Cessation and Training (NCSCT) here.

One systematic review showed a number needed to treat (NNT) of 50 for brief advice from healthcare professionals, including GPs, to achieve long-term smoking cessation.¹ Given that VBA is designed to take no more than 30 seconds to deliver, that equates to less than 25 minutes of GP time per long-term quit.

Key questions on supporting patients to quit tobacco smoking - nicotine replacement therapy products

Opportunistic brief advice in a consultation should not be confused with the delivery of support and treatment that is the gold standard of smoking cessation. The aim of brief advice is not in itself getting a smoker to stop, but to get them to access support and treatment in a series of dedicated appointments.

Assessment of readiness to stop smoking involves exploring patients’ attitudes to their smoking and quitting, past quit attempts, barriers and concerns. It takes time to do properly, so is best left to dedicated smoking cessation appointments (see behavioural support below).

2. What are the current options available for helping patients to quit tobacco, and how effective are they?

It is well established that the most effective way of stopping smoking is by combining an evidence-based stop-smoking aid with behavioural support.

Evidence-based stop smoking aids are outlined in Box 1 below.

Box 1. Summary of recommended stop smoking aids

Nicotine Replacement Therapy (NRT)

Availability: All available on NHS prescription or over the counter.
Mode of action: NRT delivers controlled doses of nicotine without the harmful toxins found in tobacco smoke, reducing withdrawal symptoms and cravings.
Tips for use: Available in various forms such as patches, gum, lozenges, inhalators, oral and nasal sprays. NRT should be used according to package instructions and individual preferences.Cautions: NRT patches may cause skin irritation, and oral preparations can cause gastrointestinal discomfort and hiccups. See formularies.
Relative effectiveness: A single NRT product with support is moderately effective in helping smokers quit, with meta-analyses indicating that it roughly doubles the chances of successful cessation compared to placebo. Combination of two (or more) forms of NRT (usually a patch + other/s) plus support are now recommended as a significantly higher quit rate is achieved on a par with varenicline plus support.³

Varenicline (Champix)

Availability: Prescription only. Currently only available as generic varenicline as Champix is no longer available – see below.
Mode of action: Varenicline is a partial agonist at nicotinic acetylcholine receptors in the brain, reducing cravings and withdrawal symptoms while also blocking the rewarding effects of nicotine if the individual smokes.
Tips for use: Varenicline is typically started one to two weeks before the quit date and taken for a 12-week course. The starting dose is 0.5mg daily for three days, then 0.5mg twice daily for four days followed by the maintenance dose of 1mg twice daily for the rest of the course. Common side effects include nausea and vivid dreams.
Cautions: Epilepsy/low seizure threshold, moderate/severe renal impairment. Lack of data means it is not recommended in under 18s or pregnant women.
Relative effectiveness: Varenicline with support is the most effective treatment regime for smoking cessation (NNT=11).⁴

Bupropion (Zyban)

Availability: Prescription only.
Mode of action: Bupropion is a dopamine and noradrenaline re-uptake inhibitor which was originally, and still is, used as an antidepressant in the USA and other countries. It acts by reducing cravings and withdrawal symptoms associated with nicotine addiction.
Tips for use: Bupropion is typically started 1 to 2 weeks before the quit date. The 150mg tablets are taken one per day for six days then one twice a day for the rest of the 7-12 week course. It may cause side effects such as, insomnia, dry mouth or nausea.
Cautions: Similar to SSRIs, bupropion may increase the risk of seizures, especially in individuals with a history of seizure disorders. Caution is advised in those with underlying medical conditions or taking other medications that lower the seizure threshold. Not recommended in under 18s or in pregnancy.
Relative effectiveness: Bupropion with support significantly increases smoking cessation rates (NNT=20), although it is generally less effective than varenicline.⁴

Cytisine

Mode of action: Cytisine (a similar molecule to varenicline) is a partial agonist at nicotinic acetylcholine receptors in the brain. It acts similarly to varenicline, reducing withdrawal symptoms and cravings associated with smoking cessation.4.
Tips for use: Cytisine is typically started no more than five days before the individual’s planned quit date. The usual dosing regimen of the 1.5mg tablets involves gradually decreasing from six daily on day one achieving the final dose on day 21 of one twice a day for the rest of the course. Standard treatment duration is 25 days, but improved outcome can be achieved by extending up to 11 weeks. Detailed information on safety, efficacy and use of cytisine is available from the NCSCT here.
Cautions: Cytisine may cause side effects such as nausea, vomiting, abdominal pain, and insomnia. It should not be used in patients with unstable angina, recent myocardial infarction or stroke, clinically significant cardiac arrhythmia or if pregnant or breastfeeding. Lack of data means it is not recommended with renal or hepatic impairment, over 65 or under 18 years of age.
Relative effectiveness: Quit rates with cytisine are comparable to those seen with varenicline and combination NRT.⁵

E-cigarettes

Mode of action: E-cigarettes, also known as vapes, work by heating a liquid solution (e-liquid) usually containing nicotine, propylene glycol, vegetable glycerine and flavourings to produce an aerosol that is inhaled by the user. The nicotine in e-cigarettes satisfies cravings and withdrawal symptoms, mimicking the effects of smoking traditional cigarettes without the harmful combustion products.⁶
Tips for use: Choose a reputable brand and device type that suits individual preferences and needs. Start with a device that delivers nicotine levels similar to the individual’s current tobacco product to ensure satisfaction. Gradually reduce nicotine concentration over time with the ultimate goal to quit nicotine altogether. Use e-cigarettes as a complete alternative to smoking, replacing all tobacco products rather than using both simultaneously. Regularly maintain and clean the device to ensure proper functioning.
Relative effectiveness: E-cigarettes with nicotine increase quit rates comparable to those of combined nicotine replacement therapy.⁷ Evidence on the effectiveness of e-cigarettes for smoking cessation is evolving. E-cigarettes are more effective for smoking cessation when combined with behavioural support.
Cautions: E-cigarettes are not completely risk-free but are far safer than smoking. Non-smokers, particularly young people and pregnant women should avoid using e-cigarettes.

Behavioural support

Effective behavioural support for smoking cessation typically involves a combination of various strategies tailored to the individual’s needs.⁸ These strategies include:

Assessment and discussion of tobacco dependence and motivation to stop smoking.
Discussing smoking history and past quit attempts.
Setting a Quit Date.
Identifying triggers and developing coping strategies for them.
Discussing all available treatment options and the importance of support.
Providing the chosen treatment/s.
The ‘not a puff rule’- a verbal contract from the patient.
Providing ongoing positive motivational support for 8-12 weeks.
Discussing and advising on lapses.
Encouraging lifestyle changes such as exercise.

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Dr Alex Bobak is a GP Specialist in smoking cessation and Honorary Clinical Senior Lecturer at Imperial College, London. Louise Ross is Clinical consultant for the National Centre for Smoking Cessation and Training