Module 9 SMOKING Quitting€¦ · track their progress. Time Period Positive Effect4 20 minutes Pulse rate returns to normal 8 hours Nicotine and carbon monoxide levels in blood reduce

Module 9

Quitting Smoking

Contents Smoking 63

Risks of smoking 64

Benefits of quitting 65

Withdrawal 66

Treatments to help quit smoking 70

Supporting patients who want to quit 71

Case study 72

Case study 76

Test your knowledge 80

of chronic respiratory disease

±42%

of lung cancer deaths

±71%

of cardiovascular disease

±10%

SMOKINGAcross the globe, the use of tobacco is the second leading risk factor for death, after high blood pressure1a, while smoking cigarettes is the most harmful form of tobacco use2a.

Globally, tobacco smoking is

responsible for1b

63

Module 9 Quitting Smoking

RISKS OF SMOKING

BENEFITS OF QUITTING

Smoking tobacco is harmful to almost every organ in the human body2a. Nicotine may be the main addictive component of tobacco products, but it is the other toxins and carcinogens in tobacco smoke that are responsible for the negative effects on health2b.

There are plenty of practical advantages when it comes to quitting, including physical, mental and financial benefits. Motivate your patients by discussing the health benefits and encouraging them to track their progress.

Time Period Positive Effect4

20 minutes Pulse rate returns to normal

8 hoursNicotine and carbon monoxide levels in blood reduce by half

Oxygen levels return to normal

48 hours

Carbon monoxide and nicotine are eliminated from the body

Lungs start to clear mucus and other smoking debris

Sense of taste and smell improve

72 hoursBreathing becomes easier

Energy levels increase

2 – 12 weeks Circulation improves

3 – 9 monthsLung function increases by up to 10% – as a result coughs, wheezing and breathing problems improve

1 yearRisk of heart disease falls by approximately 50% compared to a person who continues smoking

10 yearsRisk of lung cancer falls by approximately 50% compared to a person who continues smoking

15 yearsHeart attack risk is reduced to the same as a person who has never smoked

SMOKING ADDICTION Nicotine, the key ingredient in commercial tobacco products, causes smoking dependency2c.

Cravings can begin within days of the first cigarette2d. Nicotine stimulates the brain’s dopamine reward system2e. Dopamine is a chemical or neurotransmitter which is associated with feelings of pleasure3. It is a need for this enjoyment that keeps smokers addicted.

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Abstinence in the first week is key to long-term quitting

success5

COMMON WITHDRAWAL

SYMPTOMS6

REDUCED CONCENTRATION

A reduction in concentration

DEPRESSION

Usually mild, but can be major

RESTLESSNESS

Inability to rest or relax

ANXIETY

Feeling frightened, nervous, or panicky

STRONG CRAVINGS

Strong cravings for cigarettes

GI DISTURBANCES

Gastrointestinal disturbances

SLEEP DISTURBANCES

Initiating & maintaining sleep

WEIGHT GAIN

Weight gain as a result of increased appetite

INSOMNIA

Inability to sleep

IRRITABILITY

Irritability, anger or frustration

HUNGER

Food cravings

HEADACHES

Usually mild headaches & dizziness

First week abstainers are to still be abstinent at week 52 than those who smoke during the first week (<0.001)5

9x more likely

VS

Disclaimer: As per the Medicines and Related Substances Act, 1965, Section 22A(4) and (5), S1 and S2 product recommendations can only be made by a pharmacist, pharmacist intern or a pharmacist’s assistant acting under the personal supervision of a pharmacist.

First week abstainers are 9x more likely to still be abstinent at week 52 than those who smoke during the first week (<0.001). At week 1, the new NICORETTE® Invisi 25mg Patch significantly reduced nicotine adverse mood withdrawal symptom score by 79% vs. placebo (0.26 patch vs.1.23 placebo; p<0.001).5

WITHDRAWAL

DID YOU KNOW? The first few days are the hardest.

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• Relapse most frequently occurs within the first few days of a quit attempt when withdrawal symptoms are the greatest7. Over 75% of unaided quitters relapse within the first week8.

• Evidence suggests that smoking cessation interventions should focus on early relapse prevention7.

67% 76% 78% 81%

33% 24% 22% 19%

Relapse

Complete abstinence

Relapse pattern in smokers who quit unaided (n=630)8

Time post-cessation

% S

mo

kers

wh

o m

ake

an u

nai

ded

q

uit

att

emp

t o

n d

ay 0

0

20

40

60

80

100

2 days 7 days 14 days 1 month

Smokers need the most support in the initial stages

of their quit attempt

Comparative levels of efficacy in treatments for controlling

withdrawal symptoms

423 (p<0.001)

393 (p<0.001)

317 (p=0.02)

249 (p=0.022)

Adverse mood withdrawal symptoms in abstinent subjects5

Weeks after start of treatment

Ad

vers

e m

oo

d s

core

Placebo

15mg

25mg

0.5

0.5

1.0

1.5

0

01 23 43 67 8

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TREATMENTS TO HELP QUIT SMOKING

Tips for patients who want to stop smoking

Effective treatments for quitting smoking include:

People who recognise or are aware of their smoking cues can modify their behaviour.

Some tips for kicking the habit include:

• Hide matches, lighters and ashtrays12

• Designating the home a non-smoking area12

• Asking friends and colleagues who smoke to avoid smoking around you12

• Avoiding places where people smoke12

• Taking a walk instead of having a coffee break10c

• Eating candy or chewing a toothpick or gum instead of smoking10c

• Avoiding alcohol, which can temporarily reduce a person’s resolve10c

People can change the habits that encourage smoking during everyday activities.

Common triggers include10c:

• Telephone conversations

• Coffee breaks

• Meals

• Sexual activity

• Boredom

• Traffic problems

SUPPORTING PATIENTS WHO WANT TO QUIT

Even when smokers know the health risks, it is hard to overcome the powerful withdrawal symptoms6b. It can be beneficial to warn your customers about these withdrawal symptoms, but to also assure them that6a:

• Symptoms are worst in the first week – the time when most people relapse

• The majority of the withdrawal symptoms subside within 2 weeks

Remedy Availability Effect

Nicotine replacement therapy (NRT) products, such as Nicorette®10a

NRTs are available over the counter in a variety of forms, including chewing gum, lozenge, patch, nasal spray and inhaler

Nicotine replacement therapy (NRT) supplies the body with lower levels of nicotine than in cigarettes, but enough to help relieve cravings and withdrawal symptoms. The aim is to gradually reduce the level of nicotine until the smoker no longer needs it

Supportive counselling10b

Take up therapy or join a counselling group

Counselling helps modify behaviour and emotional reactions


DID YOU KNOW? Quitting cold turkey (completely) is better than gradually cutting down, as people who smoke fewer cigarettes may unconsciously inhale more deeply to attain the same nicotine levels10c.

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Ask the following questions

• How much do you smoke?

• Have you tried to stop smoking before?

• How did you go about quitting?

• Did you experience any symptoms when you tried to quit?

• How serious are your cravings when you don’t smoke?

CASE STUDYDebbie, 50, Landscape Designer

• Debbie has come to the pharmacy to ask for advice.

• She tells you that she smokes and finds that she is getting sick more often than she used to.

• She would like to know which OTC product she can use to help her quit.

Debbie tells you that she smokes 5 cigarettes a day. She used to smoke 10. She has tried to stop smoking before on her own without any help, but she could not manage to stop for longer than 48 hours. She has, however, cut down on her smoking over time. When she tried to stop completely she was very irritable and suffered from headaches.

TOP TIPS TO HELP YOUR PATIENTS QUIT • Set a quit date:

Suggest that your patient set a quit date to focus on. It’s not recommended to quit during a stressful time10e.

• Start an exercise programme: Weight gain is a major concern when trying to quit smoking – especially for women. An exercise regime will help prevent weight gain and can reduce the craving for nicotine10f.

• Keep healthy snacks at hand: Suggest that your patient keep wholesome snacks, like fruit, nuts and vegetable sticks within easy reach, and avoid processed foods that are high in fat or sugar13.



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Dosage: Nicorette® Gum• Chew 1 gum at a time.

• Stop smoking completely to increase the chances of success.

• Number of pieces chewed per day will depend on cravings.

• Use 10 – 12 pieces, but not more than 15 pieces in a 24 hour period.

• As the urge to smoke becomes infrequent reduce the number of pieces of gum chewed to 3 – 6 pieces per day.

• Smoking cessation may be achieved within 2 – 3 months.

• Treatment should not exceed 3 months.

• Starts to work from the 1st chew14 and fights cravings for up to 2 hours.

• 10 – 12 pieces of gum daily for up to 3 months. (Depends on smoking patterns.)


Treatment Since Debbie is struggling to stop smoking you can recommend the following Nicorette® products:

Please note: Nicorette® Gum is available in 2 flavours: freshfruit and freshmint.

Advise Debbie to choose between the two products depending on her cravings.

Nicorette® 2 mg (low dependency)For the active control over nicotine cravings, and flexible, on-demand dosing when needed.

Nicorette® 4 mg (high dependency)For the active control over nicotine cravings, and flexible, on-demand dosing when needed.

2

1

1

DID YOU

KNOW? Most smokers would like to stop smoking, and while each year

about half try to quit only about 6% manage

to. Medications, such as NRT, can,

however, help in many cases.11

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Ask the following questions

• How much do you smoke?

• How long have you been smoking?

• Have you tried to stop smoking before?

• How did you go about quitting?

• How serious are your cravings when you don’t smoke?

CASE STUDYBlake, 31, Head of Strategy

• Blake has come to the pharmacy to ask for advice.

• He would like to know which OTC product he can use to help him quit.

Blake tells you that he smokes at least a pack of cigarettes a day - and has been doing so for years. He has tried to stop smoking before on his own without any help.

When he tried to stop completely he struggled with nicotine cravings.



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12-WEEK PROGRAMME

For patients who smoke 10 or more cigarettes a day start with 25 mg

12-WEEK PROGRAMME

For patients who smoke less than 10 cigarettes a day start with 15 mg



Treatment Since Blake is struggling to stop smoking you can recommend the following Nicorette® product:

Nicorette® Transdermal Patch 25 mg (for 8 weeks)For the active control over nicotine cravings, and flexible, on-demand dosing when needed. In terms of Blake’s working life, the new patches are discreet and convenient. They can be applied and forgotten, allowing him to attend meetings or visit clients without having to chew gum to offset his cravings.

1

Dosage• 1 Nicorette® Transdermal Patch 25 mg lasts

up to 16 hours.

• Wear one patch at a time.

• Stop smoking completely to increase the chances of success.

• One patch a day.

• Applied in the morning.

• A quit attempt should be made as soon as the smoker feels ready.

Support Program

The new Nicorette® Transdermal Patch 25 mg

Nicorette® now offers 3 new Transdermal Patches - available in 3 strengths to successfully complement support programs based on the level of smoker trying to quit.

25 mg 8 weeks

15 mg 2 weeks

15 mg 8 weeks

10 mg 2 weeks

10 mg 4 weeks

1

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Product Portfolio

QUITTING SMOKING

WHY CHOOSE NICORETTE®Nicorette Transdermal Patches is a nicotine replacement therapy (NRT) range that offers a convenient way to make nicotine bio-available. Nicorette is also available in a gum range to relieve cravings and helps you stop smoking.

Nicorette® Transdermal Patch 10 mg



Nicorette® Gum 2 mg

Nicorette® Gum 4 mg


Nicotine addiction Nicotine addiction

30's, 105's 30's, 105's

• Active control over cravings

• Flexible, on-demand dosing when needed

• Gum available in palatable flavours: Freshfruit and Freshmint

• Available in 2 mg and 4 mg formats for low and high dependency smokers

• Smoking cessation may be achieved within 2 – 3 months

Nicotine-resin complex 20 % 20,0 mg equivalent to 4 mg nicotine

Nicotine-resin complex 20 % 10,0 mg equivalent to 2 mg nicotine

Nicotine addiction Nicotine addiction Nicotine addiction

7 patches 7 patches 7 patches

• Active control over cravings

• Flexible, on-demand dosing when needed

• Smoking cessation may be achieved within 2 – 3 months

Transdermal delivery system releasing 25 mg of nicotine respectively over 16 hours



Ind

icat

ion

US

PA

ctiv

e In

gre

die

nts

Siz

e


Nicorette® 25 mg Transdermal Patch

Nicorette® 2 mg Gum


Nicorette® 4 mg Gum


Starts to workfrom the

1st chew14Lasts up to16 hours

S0 Nicorette® Gum Freshmint 4 mg: Reg.No.: A40/34/0523.

NICORETTE® is sugar free.

NICORETTE® is indicated as a temporary aid to the cigarette smoker seeking to give up his or her smoking habit while participating in a behavioural modification programme under professional supervision. The efficacy of NICORETTE® use without concomitant participation in a behavioural modification programme has not been established. The benefits of NICORETTE® use beyond 3 months have not been demonstrated.

S0 Nicorette® Gum Freshfruit 2 mg: Reg.No.: A40/34/0565.

S0 Nicorette® Gum Freshmint 2 mg: Reg.No.: A40/34/0520.

S0 Nicorette® Gum Freshfruit 4 mg: Reg.No.: A40/34/0566.

S1 Nicorette Transdermal Patch 25 mg – 45/32.16/0954




References 1. World Health Organization. Global Health Risks: Mortality and Burden of Disease Attributable to Selected Major Risks Global Health

Risks. Available at www.who.int/healthinfo/global_burden_disease/GlobalHealthRisks_report_full.pdf. pp. v, 11, 21. Accessed on 17 January 2018.

2. Prochaska, J. (2018). Tobacco. [online] Merck Manual. Available at: https://www.merckmanuals.com Accessed on 6 Aug. 2019.

3. ASH Fact Sheet. Nicotine and addiction. Available at ash.org.uk/files/documents/ASH_114.pdf. Accessed on 18 January 2018.

4. NHS Smokefree (UK). Adapted from ‘What happens when you quit?’ Available at www.nhs.uk/smokefree/why-quit/what-happens-when-you-quit#ow7IKbWJt4XTfImP.97. Accessed on 18 January 2018.

5. Tønnesen P et al. Higher dosage nicotine patches increase one-year smoking cessation rates: results from the European CEASE trial. Eur Resp J 1999;13:238-246

6. Porter RS (Ed). Tobacco Use: Smoking Cessation. The Merck Manual of Diagnosis and Therapy. Available at www.merckmanuals.com/professional/special-subjects/tobacco-use/smoking-cessation. Accessed on 18 January 2018.

7. Hughes JR et al. Shape of the relapse curve and long-term abstinence among untreated smokers. Addiction 2004;99:29–38.

8. Hughes JR et al. Smoking cessation among self-quitters. Health Psychol 1992;11:331–334.

9. Henningfield JE. Nicotine medications for smoking cessation. N Engl J Med 1995;333:1196–1203

10. Porter RS (Ed). Tobacco Use: Smoking Cessation. The Merck Manual Home Health Handbook. Available at www.merckmanuals.com/home/special-subjects/tobacco-use/smoking-cessation. Accessed on 18 January 2018.

11. National Institute of Drug Abuse. Tobacco/Nicotine. Available at www.drugabuse.gov/publications/research-reports/tobacco/nicotine-addictive. Accessed on 18 January 2018.

12. WebMD. Smoking during pregnancy. Available at www.webmd.com/baby/smoking-during-pregnancy. Accessed on 18 January 2018.

13. Better Health Channel. Quitting smoking and managing weight. Available at www.betterhealth.vic.gov.au/health/healthyliving/smoking-and-weight. Accessed on 18 January 2018.

14. Data on file.

1 Which one of the following is the main addictive component of cigarettes?

a Tobacco

b Nicotine

c Dopamine

d Carcinogens

2 Which one of the following statements about Nicorette® is untrue?

a It offers active control over cravings

b It offers a flexible, on-demand dosing of nicotine when needed

c It is available in 6 mg and 8 mg formats for low and high dependency smokers

d With Nicorette® smoking cessation may be achieved within 2 – 3 months

3 Which of the following is not an effective treatment for quitting smoking?

a Nicotine replacement therapy

b Varenicline

c Supportive counselling

d Regular coffee breaks

4 In the first 20 minutes after quitting smoking what benefit can be observed?

a Heart attack risk is reduced

b Nicotine cravings are noticeably less

c Sense of smelling becomes clearer

d Pulse rate returns to normal

TEST YOUR KNOWLEDGE

You’ve reached the end of the module. You can test your knowledge right away while the info is fresh, or you can complete the full Class Test in one go once you reach the end of this Study Pack. See the back page of the booklet for more details on how to complete and submit your test.

Below are the questions from the Class Test that apply to the module you just finished. The full Class Test appears on the fax sheet included separately.



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Documents

Module 9 SMOKING Quitting€¦ · track their progress. Time Period Positive Effect4 20 minutes Pulse rate returns to normal 8 hours Nicotine and carbon monoxide levels in blood reduce