Management of nicotine dependent inpatients

An evidence-based treatment model

Tobacco and Health BranchNSW Centre for Health Promotion

July 2002

The purpose of this presentation is for

use in training clinicians working with inpatients who smoke,

in the context of the NSW Health Smoke Free Workplace Policy (1999)

(please note: all references for the content of this presentation are included in the ‘Guide for the management of nicotine dependent inpatients’ (page 19) except for lozenge study)

In this presentation we will cover:

Tobacco use in the community

Health policy

Assessment of nicotine dependence

Nicotine withdrawal

Nicotine replacement therapy (NRT)

Frequently asked questions

Brief intervention

Discharge & referral

Background to tobacco use in the community

The World Health Organisation describes smoking as an:

epidemic

that will cause 1/3 of all adult deaths world-wide by 2020

(WHO 1999)

• Overall in 2001 – daily smoking prevalence was 19.5%

• males – 21%

• females - 18%

• Prevalence was higher among younger people, daily smoking rates peaked in the 20-29 year age group

• The mean number of cigarettes smoked per week increased with age peaking at 140 cigarettes by age 50-59

Prevalence of smoking in Australian population

0

5

10

15

20

25

30

14-19 20-29 30-39 40-49 50-59 60+

Males

Females

Prevalence of smoking in Australian population in 2001

Age groups

% of age group

(Adapted from AIHW 2002 report)

Prevalence of inpatient smoking in NSW

• Between 18% - 23% of patients admitted to NSW hospitals are current smokers (self-reported)

• The actual figure may be higher than this……….

• In one study, a further 18% self-reported ‘non-smokers’ tested positive for salivary cotinine, suggests they’re current smokers

• A Central Sydney study found that 1 in 5 inpatients were highly dependent on nicotine (using Fagerstrom Test)

Burden of disease caused by tobacco - NSW

• Tobacco is the major cause of drug-related death & the single greatest preventable cause of premature death &disease

• In 2000, smoking caused 4,316 male deaths & 2,255 female deaths (18.5% & 10.3% of all male & female deaths respectively)

• In 1998/99 smoking caused 50,023 hospitalisations among males and 30,045 hospitalisations among females (5.7% & 3% of all male & female hospitalisations respectively).

Health Policy

Recommends that:- all health care facilities and their immediate surroundings

should be smoke free.

- and that hospital staff should:- ask about smoking status prior to or on admission;- offer brief advice & pharmacotherapy to those who need it;

and: - provide assistance to those interested in stopping.

The World Health Organisation

WHO (2001)

Goal: To prohibit smoking throughout all buildings, vehicles and property controlled by NSW Health

Rationale:• To reduce the harm associated with smoking among staff,

patients, visitors, especially exposure to passive smoking• To provide a clear message to staff, patients, visitors, community

about the health risks of smoking• To provide leadership in the community about reducing harm

associated with smoking

NSW Health Smoke Free Workplace Policy 1999

The guide for the management of nicotine dependent inpatients

• Developed within the context of the NSW Health Smoke Free Workplace Policy (1999)

• Aim: to assist clinicians in the management of nicotine dependence in inpatients confined to smoke-free environment

• Two parts: • a laminated flowchart for use on the ward• a booklet summarising the international evidence

• Is not about smoking cessation, although some patients may use the opportunity of hospitalisation to attempt to quit smoking

Managing nicotine dependenceThe NSW Health Smoke Free Workplace Policy provides a supportive environment for abstinence during hospitalisation

The guide proposes that hospital staff:

• identify nicotine dependent patients

• give patients information about the smoke free policy

• provide prompt and appropriate treatment to patients experiencing nicotine withdrawal

• provide brief intervention for smoking cessation

• advise patients at discharge on options for permanent cessation

• Early identification of smoking status and swift provision of an adequate level of NRT may reduce the potential for a highly dependent smoker to become irritable or aggressive due to nicotine withdrawal

• Reduction of withdrawal symptoms may in turn reduce the amount of work and time required to manage the patient

• NSW Health recommends that AHSs develop specific protocols appropriate for local settings to clarify role delineation & ensure prompt delivery of treatment to patients

Managing nicotine dependence

Recognising and AssessingNicotine Dependence

Tobacco dependence is:

‘a chronic disease with remission and relapse’*

“Nicotine dependence warrants medical treatment as does any drug dependence disorder or chronic disease”

Fiore et al, U.S. Dept of Health and Human Services, June 2000

“Indeed, it is difficult to identify any other condition that presents such a mix of lethality, prevalence, and neglect,

despite effective and readily available interventions”

Fiore et al, U.S. Dept of Health and Human Services, June 2000

Identification of smoking status

• Swift identification of smokers on admission increases rates of intervention and guides appropriate treatment

• The Alcohol and Other Drugs Policy for Nursing Practice in NSW: Clinical Guidelines recommends recording a patient’s substance use history (including tobacco) upon admission

• Moderate to heavily dependent smokers should also be screened for depression

• Patients with depressed mood and a history of problem drinking are more likely to be nicotine dependent and may have greater difficulty in abstaining during hospitalisation

Nicotine

• A psychoactive drug affecting mood and performance

• The source of addiction to tobacco

• More addictive than heroin or cocaine (WHO)

• Binds to nicotinic cholinergic receptors found on cell bodies and at nerve terminals in the brain and autonomic ganglia

• Activation (smoking) facilitates release of neurotransmitters- acetylcholine, norephinephrine, dopamine, serotonin, B-

endorphin and glutamate

Manipulation of dose • Arterial blood nicotine concentrations may be up to 100ng/mL - venous concentrations typically 20%-30% of this

• Concentrations in the heart and brain may be up to 200-300 ng/mL immediately after a cigarette

• Regular cigarette smoking plateaus at daily plasma concentrations of 20-35 ng/mL (& 5 -10% carboxyhemoglobin)

• Smoker can titrate the dose of nicotine to regulate a particular level

• Intake of nicotine from a given product depends on puff volume, depth of inhalation, rate and intensity of puffing

• Smokers titrate higher levels of nicotine from ‘light’ cigarettes or reduced number by breathing in deeper & holding smoke in lungs longer

 (Ng/mL = nannograms per millilitre)

Nicotine dependence

• Tobacco use produces tolerance to nicotine, withdrawal symptoms and difficulty in controlling future use

• The bolus of nicotine to the brain achieved by smoking is one of the key reinforcers of dependence

• Nicotine in blood in 4 seconds, in brain in 7 seconds

• Nicotine dependence and withdrawal can develop with use of all forms of tobacco

• Neuro-adaptation (tolerance) can occur within a few doses of the drug, depending on rate and route of dosing

Nicotine dependence (DSM-IV)

Features of nicotine dependence include:

• smoking soon after waking

• smoking when ill

• difficulty refraining from smoking

• reporting the first cigarette of the day to be the one most difficult to give up

• smoking more in the morning than in the afternoon

Assessment of nicotine dependence

• The Fagerstrom Test for Nicotine Dependence (FTND) is based on criteria in DSM-IV (6 questions)

(for questions &scoring see page 9 of Guide)

• 2 questions consistently match valid biochemical indicators of dependence:

• how soon after waking up do you smoke?• how many cigarettes per day do you smoke?

(for scoring see page 10 of Guide)

Time to first cigarette (TTFC)• Due to widespread smoking restrictions, many highly dependent

smokers may not be able to smoke as many cigarettes per day as they need to get adequate nicotine

• Smoke fewer cigarettes – but smoke them more ‘thoroughly’ ie: suck harder, deeper, down to filter etc.

• Wake up extremely nicotine deprived

• 1 question may suffice to determine level of dependence:

how soon after waking up do you smoke?

First cigarette within or =30 minutes after waking – high dependence

More than 30 minutes after waking – low dependence

Time to first cigarette (TTFC)

TTFC

Less than or equal to

30 minutes after waking

= HIGH

DEPENDENCE

TTFC

More than

30 minutes after waking

= LOW

DEPENDENCE

Wake up 0

30 minutes

(Adapted from presentation by Saul Shiffman)

Nicotine Withdrawal Usually worst in the first 24 - 48 hours, then decline in intensity gradually over next 2 weeks.

Symptoms may include four (or more) of the following within 24 hours of cessation, often causing significant distress :

• Dizziness

• Coughing

• Tingling sensations in extremities

• Appetite changes

• Constipation

• Decreased heart rate

• Insomnia

• Craving for tobacco

• Depressed mood

• Increased appetite or weight gain

• Irritability, frustration or anger

• Anxiety

• Difficulty in concentrating

• Restlessness

Pharmacotherapy

Nicotine Replacement Therapy (NRT)

Available in gum, lozenge, patch and inhaler

Aims to replace the nicotine obtained from cigarettes, reducing withdrawal symptoms when stopping smoking

Use of NRT is preferable to smoking, because it does not:

• contain non-nicotine toxic substances such as carbon monoxide and 'tar'

• produce dramatic surges in blood nicotine levels

• produce strong dependence

Nicotine Replacement Therapy (NRT) (cont.)

• Odds ratio for abstinence with NRT compared to control is 1.73 (patch 1.76, gum 1.66, inhaler 2.08)† (4mg lozenge 3.69)*

• Odds are independent of intensity of additional support provided to smoker or setting in which NRT offered

• In highly dependent smokers there is significant benefit of 4mg gum over 2mg gum (odds ratio 2.67) (NB:lozenge also)

• Increases quit rates 1.5 - 2 fold, regardless of setting

• NRT is safe, should be routinely recommended to smokers, product choice depends on practical & personal considerations

(†Cochrane review)

( * large RCT)

Level of nicotine dependence and NRT dosage

As a general rule, smokers who are nicotine dependent will have less intense withdrawal symptoms if provided with an adequate dosage of NRT

For example:

The trial for the nicotine lozenge used the ‘TTFC’ (time to first cigarette) measure of dependence to allocate dosage:

• those who smoke within 30 mins of waking - 4mg lozenge• those who wait longer than 30 mins - 2mg lozenge

(Note: the lozenge provides 25% more nicotine than the gum as it dissolves completely)

Nicotine Toxicity

• Recent quitters using NRT often confuse withdrawal with nicotine toxicity

• Nicotine withdrawal symptoms similar to toxic effects of nicotine

• Extremely rare in smokers – more likely not enough nicotine

• Rapid tolerance to nicotine (within several cigarettes or few days of smoking) toxicity symptoms would not occur in smoker

• NRT only provides the body with nicotine levels close to the low ‘trough’ level reached between cigarettes when smoking

Minutes

Incr

ease

in n

icot

ine

conc

entr

atio

n (

ng/

ml )

CigaretteGum 4 mg

Gum 2 mg

Inhaler

Patch

5 10 15 20 25 30 0

2

4

6

8

10

12

14 Smoking produces much higher

nicotine levels than NRT

Source: Balfour DJ & Fagerström KO. Pharmacol Ther 1996 72:51-81.

NRT Dosage Plasma nicotine levels significantly lower from NRT than smoking

MIMS recommended dosages:

• Gum: maximum 40 per day

• Lozenge: maximum 15 per day

• Patch: healthy people > 10 cigs/day >45 kgs: one patch daily 21mg/24 hr or 15mg/16hr

       cardiovascular disease <10 cigs/day, <45 kgs: one patch daily 14mg/24hr or 10mg/16hr

• Inhaler: Self-titrate dose, according to withdrawal symptoms. 6-12 cartridges/day.

Directions for use of NRT products Gum: nicotine absorbed through oral mucosa, chew till a

peppery/tingling feeling, flatten gum and ‘park’ between gum & cheek, or under tongue

Lozenge: nicotine absorbed through oral mucosa, move around mouth from time to time and suck until dissolved (takes

20-30 minutes)

Patch: nicotine absorbed through skin, place on clean, non-hairy site on chest or upper arm on waking, place

new patch on new site each day to prevent skin reaction

Inhaler: nicotine absorbed through oral mucosa, inhale air through cartridge for 20 minutes

Bupropion (Zyban)• First non-nicotine medication shown effective for cessation

• Blocks neural re-uptake of dopamine and/or noradrenaline

• Start one week prior to quit day, limited application for inpatients

• An option for patients after discharge and patients can be referred to their GP to discuss their options

• The only pharmacotherapy available on PBS

• Contraindications include patients with seizure disorder, current or prior bulimia or anorexia nervosa, use of a MAO inhibitor

within the previous 14 days

Combination therapy• Highly dependent smokers may benefit from combining patch with self- administered form of NRT (lozenge/gum/inhaler)

• More effective than single form of NRT

• Use combined treatments if unable to remain abstinent or if still experiencing withdrawal symptoms using single therapy

• Increased success depends on the use of two distinct delivery systems: one passive (ie: patch) + one active or ‘at liberty’ (ie: gum/lozenge/inhaler)

Contraindications (*MIMS 2001) NRT is currently contraindicated for some patient groups and use by

these patients requires special consideration

Gum* non-tobacco users, pregnancy, lactation, children (< 12 yrs)

Patch* non-tobacco users, acute MI, unstable angina, severe arrhythmias, recent CVA, skin disease, children (< 12 years) pregnancy, lactation

Inhaler* non-tobacco users, hypersensitivity to menthol, pregnancy, children (< 12 years)

Lozenge non-tobacco users, phenylketonurics, pregnancy, lactation, recent heart attack or stroke, severe irregular heartbeat unstable or resting angina, (from pack info)

(NB: while NRT is contraindicated during pregnancy, if patient unable to abstain, then gum, lozenge or inhaler are preferable to smoking)

Frequently asked questions

Is NRT suitable for cardiovascular patients?

• No evidence of increased cardiovascular risk with NRT

• NRT delivers plasma nicotine concentrations below those produced by smoking and does not expose the smoker to carbon monoxide or other harmful substances

• Clinical trials of NRT in patients with underlying, stable coronary disease suggest that nicotine does not increase cardiovascular risk

• The health risks of using NRT to assist such patients to stop, or significantly reduce, smoking far outweigh any treatment-related risks

Is NRT safe for pregnant or lactating women?

• NRT should be considered when a pregnant woman is otherwise unable to quit

• Potential benefits of quitting outweigh the risks of the NRT & potential continued smoking

• NRT less harmful than smoking during pregnancy - lower total nicotine dose and no exposure to carbon monoxide & other toxic substances

• NRT clearly beneficial to highly dependent smokers, more at risk of adverse reproductive outcome & less likely to quit when

pregnant

 

Is NRT safe for pregnant or lactating women? (cont.)

• A maternal 10% blood carboxyhemoglobin level (40 cigs per day) can cause 10 -15% higher carboxyhemoglobin level in the foetus than in the mother (= 60% reduction in foetal blood flow)

• If clinician and patient decide to use NRT, consider forms that yield intermittent nicotine (lozenge/inhaler/gum) rather than continuous drug exposure (patch) due to potential neurotoxicity in the foetus of continuous exposure to nicotine   

• A pregnant smoker should receive encouragement and assistance in quitting throughout her pregnancy

Is pharmacotherapy safe for patients with psychiatric comorbidity?

• Always in patients’ best interests to quit smoking

• Tobacco use is associated with affective disorders and depressive symptoms

• Depression decreases likelihood that abstinence will be successful and depressed mood is a common symptom of nicotine withdrawal

• Antidepressants may aid abstinence in those with symptoms of depression

• Possible that smoking increases risk of depression perhaps by affecting neuro-transmitter systems

 

Is pharmacotherapy safe for patients with psychiatric comorbidity? (cont)

• Patients with a history of major depression who quit may be 7 times more likely to have a recurrence of major depression than people who continue to smoke  

• Current smokers have higher rates of anxiety disorders & may find it more difficult to remain abstinent. Evidence suggests that anxiolytics are not effective smoking cessation aids  

• Quitting may affect the pharmacokinetics of psychiatric medications (eg anti-psychotic medications)

• Monitor actions or side effects of psychiatric medications in smokers attempting abstinence

• Mental health patients demonstrate a preference for nicotine inhaler over the transdermal patch

Is NRT safe for adolescents?• Young people can become addicted to tobacco very quickly

• NRT provides lower dose of nicotine than smoking, no carbon monoxide and other toxins

• While there are no LEGAL restrictions, the info on the NRT pack states: ‘Do not use if you are under 18 years of age’ – a condition of registration of product by Commonwealth

•  When treating adolescents, clinicians may consider pharmacotherapy when there is evidence of nicotine dependence

• Factors such as: degree of dependence, number of cigarettes per day and body weight should be considered  

• Prescription guidelines from pharmaceutical companies recommend 21 mg patch if >45 kilos, 14 mg patch if <45 kilos

How long should NRT be used for?

Clinicians advising clients in smoking cessation should tailor the dosage and duration of therapy to fit the needs of patients

Patch - 8 weeks of continuous use has been shown to be as effective as longer treatment periods (no need to taper)**

Gum – generally should be used for up to 12 weeks** Inhaler – up to 6 months, tapering off during final 3 months** Lozenge –trial suggests 24 weeks of treatment using same product

in diminishing doses (however, similar period of use to gum likely to be effective due to similar absorption method)

(**Fiore et al, 2000)

What is best to prevent weight gain? • Smokers weigh on average 4 kg less than non-smokers**

• When smoker stops, gains average of 2.3kg in next year***

• Brings quitters up to similar weights to sex & age matched never-smokers

• Of great concern to some smokers, especially women and adolescents, can act as motivator to start or continue smoking

•  NRT (particularly gum & lozenge) & bupropion delay, but don't prevent post-cessation weight gain

• Advise that health risks of moderate weight gain are small compared to risks of continued smoking - concentrate on cessation till confident

will not return to smoking

• Recommend regular exercise program & healthy eating to control weight

Brief Intervention

Brief Intervention• The World Health Organisation encourages provision of brief

opportunistic interventions delivered by all health professionals in the course of their routine work

• The purpose of brief intervention for smoking cessation is to increase motivation to quit

• Same technique can be used during provision of information for management of dependence while hospitalised

• Hospitalisation is a time when the adverse consequences of smoking are highlighted for the individual – a window of

opportunity for a ‘teachable moment’

Brief Intervention (cont.)• Brief advice (approx 3 minutes) by doctors, nurses and other health care workers is effective

• More intensive interventions only marginally increase the efficacy of brief advice

• Personalised, non-critical feedback that helps them understand the impact of smoking on their health

• Motivational interventions most likely to succeed when clinician is empathetic, promotes patient autonomy, encourages self-

efficacy & identifies previous successes in behaviour change efforts

Discharge & referral

Discharge and referral Every patient identified as a smoker should be assessed prior to discharge to determine their interest in quitting

• 80% of smokers have made past attempts to quit, 50% of male & female current smokers plan to quit in next 6 months

(NSW Health Surveys)

• Patients planning to quit should receive:• at least 3 days’ supply of NRT• treatment summary in discharge plan• a ‘Quit Kit’• advice to seek support from GP/pharmacist/Quitline 131 848

• Patients not planning to quit should be encouraged to make a future quit attempt

Quit plan For those patients ready to quit, a few key points can increase their chance of success: 

• Set a date to stop and stop completely on that day

• Use pharmacotherapy (whichever product suits best)

• Review past periods of abstinence (what helped -what hindered?)

• Identify future problems and make a plan to deal with them (problem-solving)

• Enlist support (family, friends, colleagues)         

• Avoid alcohol for first 2 weeks

• Reduce caffeine consumption by half (more caffeine is absorbed) 

Relapse • Any smoking within the first 2 weeks is a reliable predictor of failure in the quit attempt (95% probability of returning to smoking)

• Other predictors include:• short periods of abstinence in previous quit attempts • low motivation to quit • low confidence in ability to quit• smokers in subject's environment • high pre-cessation alcohol consumption

• Common triggers for relapse include:• other people smoking• alcohol• stressful or negative events • depression

Prevention of relapse Relapse prevention should include:

• discussion of high-risk situations • developing coping strategies (e.g. using pharmacotherapy,

reducing alcohol consumption)• reinforcing total abstinence (but relapse is not failure, continue quit attempt)• most people make several quit attempts before success

Many smokers cannot stop without more intensive help – (often heavier smokers more at risk of smoking related disease)

• refer to specialist treatment service, such as AHS D&A Services, their GP or the Quitline for telephone counselling• outpatient clinics should be advised of hospital treatment

 

Useful web sitesResources about tobacco for non-English speaking patients:

www.mhcs.health.nsw.gov.au/health-public-affairs/mhcs/publications/5885.html

Tobacco control super site (Sydney University):www.health.usyd.edu.au/tobacco/

US Surgeon General clinical practice guideline:www.surgeongeneral.gov/tobacco/treating_tobacco_use.pdf

UK clinical practice guideline:www.bmj.com/cqi/contents/full/318/7177/182

Tobacco in Australia: Facts and Issues:www.quit.org.qu/quit/FandI/welcome.htm

Encyclopaedia on tobacco:www.tobaccopedia.org/

For more informationIf you have any queries about:

The NSW Smoke Free Workplace Policy (1999)

The guide for the management of nicotine dependent inpatients

This PowerPoint presentation

Please contact:Elayne Mitchell (02) 9391 9466

emitc@doh.health.nsw.gov.au