Nicotine Replacement Therapy

“My Quit Plan”

Why NRT?The aim of this training is to increase the understanding of:- The role of community pharmacy in providing NRT - The personal barriers to quitting- The common interventions used to quit smoking - How to use the “My Quit Plan”

Why Pharmacy?- ONE in SIX people visiting your pharmacy will be a smoker.- Less than ONE in TWENTY people who attempt to quit by

themselves will be unsuccessful - The community pharmacist is in an ideal position to AID in

these attempts. - Research shows that smokers appreciate the proactive smoking

cessation advice from the pharmacist and that pharmacist advice can significantly enhance the success of a quit attempt.

- “5 A’s” approach—efficacy has been proven in controlled clinical trials.

- Ask about tobacco, advise patients to quit, assess willingness to quit, assist with quitting, and arrange follow-up counselling.

Benefits of Quitting- Smoking remains the single largest preventable

cause of illness and death in the Australian community.

- Smokers vs. Non- Smokers - Risk of heart disease is 3 times greater - Risk of COPD is 6.3 times greater - Risk of lung cancer is 20 times greater - There are many other health impacts that may

be noticeable early on such as reduced fitness and shortness of breath.

Tip: Remember one or two of these facts for brief educational

interactions with patients

Benefits of QuittingAfter twelve hours almost all of the nicotine is out of your system. Your heart rate slows and blood pressure decreases.

Within two months your lungs will no longer be producing extra phlegm caused by smoking. You will be coughing and wheezing less.

After twenty-four hours the level of carbon monoxide in your blood has dropped dramatically. You now have more oxygen in your bloodstream.

Within Two months your blood is less sticky and blood flow to your hands and feet has improved

Within days your sense of taste and smell improves.

After twelve months your increased risk of dying from heart disease is half that of a continuing smoker.

Within a week your lungs start to recover and their natural cleaning system begins removing tar, dust and mucus.

After ten years of stopping your risk of lung cancer is less than half that of a continuing smoker and continues to decline (provided the disease is not already present).

Within a month your blood pressure returns to its normal level and your immune system begins to show signs of recovery.

After fifteen years your risk of heart attack and stroke is almost the same as that of a person who has never smoked.

“you will feel the benefits of quitting pretty fast, within

a week you will notice your lungs feeling better”

Tip: Practice a way of

saying one of these facts that comes naturally

to you

Smoking addiction= (1) nicotine dependence + (2)

behavioural habits 1. Smokers have 300% more Nicotinic receptors in their

brain compared to non-smokers– When they stop smoking the absence of nicotine results in

abnormally low levels of dopamine (responsible for the feeling of pleasure)

– These changes explain the symptoms of withdrawal and cravings

2. An average pack a day smoker will make the physical action of holding a cigarette to their mouth 73,000 a year– Intense cravings for cigarettes can be induced by both

environmental or emotional cues i.e. smoking with daily coffee.

Tip: Remember its not just about selling the NRT, you have

to assess their behaviour!

Quitting with NRT- Nicotine replacement doubles chances of

quitting

- Combination therapy is more effective than using single form of NRT – increases quit rate by 34% compared to using single form of NRT (>15 cigarettes/day)

The Pre – Quit MethodThis method of quitting is the most effective and increases quit rates by 35%

– Plan a start day: on this day the customer uses a high dose NRT patch whilst gradually reducing the number of cigarettes smoked per day (recommended for >15 cigarettes per day)

– Plan a quit day: this day is one to two weeks after the start day. On the quit day they stop smoking and continue to use the NRT patches • Oral NRT can be added for cravings• Step down patch every 2 – 6 weeks (depending on

patient)

Tip: The most common time for relapse is in the first week of quitting, that’s why

we overlap NRT and cigarette

reduction

Contraindications for Pre- Quit

• <15 cigarettes per day, or have cardiovascular disease, or weigh less than 45 kg, should not use a patch while continuing to smoke.

• These customers still need a Quit day• The start date is optional where they can begin to

cut down smoking and they can begin using oral NRT for cravings in this time

• However some evidence suggests that cutting down is less successful than having an abrupt quit day – discuss with patient as to what works best for them

Adverse effects of NRT- Explaining the ADRs of quitting is important to help

the patient prepare - so they know what to expect when attempting to quit.

- E.g. weight gain – 5kg average in year 1“weight gain may occur because of the loss of the appetite

supressing effect of nicotine, but remember the health effects of gaining weight are far less than those of continuing to smoke”

- Most forms of NRT have common adverse events of headache, nausea and dizziness (reduce dose if problematic)

Is it withdrawal or a side effect?

Nicotine Withdrawal Symptoms

Common side effects of therapeutic nicotine

anxietyirritability/restlessness dizziness nausea

malaise/weakness

increased appetite headache

sleep disturbances/vivid dreams+

mouth ulceration

reduced concentration Hiccups* Coughing*

increased cough dyphoric mood

Sore mouth and throat* Dry mouth*

insomniacraving for tobacco*with oral dosage forms, +more common with 24- hour patch

.

Tip: Can you differentiate

between symptoms of nicotine withdrawal and side effects of

NRT?

Special precautionsPregnant or breastfeeding

- Consider non drug therapies first (counselling or cognitive behavioural therapy. - NRT is always safer than continuing to smoke.- Oral NRT is preferred to deliver a low daily dose of nicotine and to avoid continuous

nicotine exposure. If using patches, remove at night. - Mothers who make an informed decision to use NRT whilst breastfeeding should

minimize nicotine in breast milk by choosing a short acting product and taking a dose just after feeding the baby.

- Refer person to seek their doctor’s advice.

Heart problems Can be safely used in cardiac conditions including angina and previous myocardial infarction. Refer to their usual health care provider if concerned.

Asthma Avoid nicotine inhaler

Dentures or recent dental work Avoid nicotine gum

Oral and gastric inflammation Avoid using gum and lozenges.

Tip: These patients must be referred onto the

pharmacist. As well as patients with medical conditions and taking

medication

The “My Quit Plan” – The My Quit Plan is an individualised management plan

which can be completed for a patient who is ready to quit– There are 6 steps to cover (step 2-6 are to be completed

on the “My Quit Plan”)– The plan is an editable PDF document which can be

completed with the patient via computer, or fields can be hand written. If computer access is not available

– The program involves follow up where the pharmacist can review the patients progress and the patient has the opportunity to purchase more NRT product and reduce dose when necessary.

What to tell the customerWhat’s involved?– It is an individualised 12 week program with 5 follow up datesWhy 12 weeks and why do I have to be followed up?– It takes at least 12 weeks for your brain chemistry to return to

normal after you quit smoking and NRT should be taken for a minimum of 8-12 weeks.

– Combined with one to one support, up to 4 times more likely to quit than if quitting alone.

– There is an optional incentive for the patient where they can choose to deposit $20 at visit one, if they reach week 9 after quit date, they received $20 credit from their purchase

– The benefit is for both the patient AND the pharmacy, in doing this, it will ensure the patient returns to the pharmacy to purchase their NRT and it is an economical incentive for the patient to reach their goals.

Follow UpsTiming of follow up

Reason for follow up

1 week after quit date

Tobacco withdrawal peaks during week 1 and this is the most common time of relapse .

3 weeks after quit date

Withdrawal peak can last for 2 -4 weeks after quit date

6 weeks after quit date

At this point NRT dose should be reviewed and reduce IF POSSIBLE (don’t rush this!)

9 weeks after quit date

NRT should be taken for a minimum of 8-12 weeks. Some people may have cravings for up to 8 weeks. Optional credit of $20.

12 weeks after quit date

NRT should be taken for a minimum of 8-12 weeks. Some people may have cravings for up to 8 weeks. These dates are needed to ensure maintenance.

Step 1- Assess patient’s readiness to quit

– Thoughts and motivations are crucial in the success of quitting smoking: advice and treatment must match the patient’s stage of change.

– Roll with resistance if patient is not ready to quit: provide a brief educational intervention

Is the patient ready to quit?

“What are your thoughts about quitting?"

Stage of Change Goal of Intervention

Precontemplation"I enjoy smoking."

Introduce benefits"Your emphysema will improve after you've quit smoking."

Contemplation"I like to smoke, but I know I need to quit."

Resolve resistance"How will your life be better after you've quit smoking?"

Preparation"I want to quit smoking."

Identify successful strategies"Choose a 'quit day' and let's make plans for it."

Action“I often think about smoking."

Provide solutions to specific relapse triggers"How can you deal with your desire to smoke in those situations?"

Maintenance"I have been smoke free for a year."

Solidify patient's commitment to a smoke-free life"you should share your success and experience with other people."

Step 2: Discuss quitting

– Reasons for quitting – health, children etc.– Reinforce the benefits of quitting – Recommended the pre – quit method

Tip: the use of

motivational interviewing techniques is

recommended to encourage a future

attempt

Step 3: Assess the customers smoking habits

– Fagerstrom Test for Nicotine Dependence.– Attempted quitting before? What happened?

Double check technique and usage, correct if appropriate and try again.

– Behavioural triggers – identify and overcome using the four D’s

Overcoming Behavioural Trigger

Triggers Four D’s of behavioural strategies

Drinking coffeeFinishing a mealDriving your carUsing the phoneStressful situationsDrinking alcoholSocial events

Drink water DelayDo something elseDeep breathe

Tip:Most cravings only last 10 - 20 minutes.

Distract yourself, and the cravings

will pass. When you

think about using, talk to yourself and keep yourself

busy

Tip:Download the MyQuit Buddy App for games

and distractions

when craving!

Step 4: Preparation - discuss tips before you

quit – Set a start date – the day to start the therapy.– Set a quit date – the day to stop smoking.– Tell family and friends; quit buddy and support

line.– Reinforce methods to overcome behavioural

triggers.– Locate all cigarettes.

Tip:The first day will be the

hardest, but remember it is only 24 hours long. Avoid

alcohol in first week. read your list of reasons for quitting and put it by your bedside.

Tip: Read your reasons

for quitting the morning of your

quit date and put it by your bedside or

on your fridge.

Step 5: Therapy plan – Prescribe NRT dosage based on level of

dependence: instruct on how to use (patch and/or gum).

– Explain symptoms of withdrawal vs nicotine overdose and common ADRs (weight gain)

– Follow up dates inform of the importance setting goals and rewarding success.

– Extra quitting incentive payment of $20 upfront which will be credited with NRT product purchase if they follow up 9 weeks after quit date (see My Quit Plan Procedures).

– Explain the difference between relapse and slip ups

Step 6: Follow up – See My Quit Plan Procedures– Patient contact: phone or SMS reminder two days

before F/U– Review progress - triggers and rewards “How is your

current therapy working for you?”– How to manage slip ups –reinforce that the patient

has not failed. Review circumstance and ensure patient is using NRT correctly.

– Under-dose vs overdose – adjust the prescribed dose if appropriate.

– Complete the treatment course – even if the patient is not smoking to prevent relapse.

What should you do if you slip up?

– Relapse is when a patient goes back to regular smoking– Slip ups are common and occur when a patient has 1 or 2

cigarettes and is usually associated with stress, social situations and alcohol

– A slip up is a high risk time: • This should not be viewed as defeat, ensure the patient

does not relapse due to the feeling of failure.• Avoid all or nothing thinking. • Throw out the rest of the pack. • Learn from your experience. What you could have done

differently. • Never forget your reasons for quitting in the first place.

How Long Should You Use NRT?

– 8 - 12 weeks as per product recommendations – However, if they feel they need to continue using the

product for longer in order to quit, it is safe to do so in most cases

– It is reasonable to use the patch for up to 5 months as long as the patient is being reviewed by a health care professional.

– Many people relapse when they taper down too quickly from the full strength 21 mg patch to the 14 mg patch. Ensure you educate the patient that they need to be assisted in this step

ReferencesRose J, et al. Nicotine Tob Res 2009;11(9)

Benefits of Quitting. 2012 10-2-2012

Steal LF, et al. Cochrane Database Syst Rev 2012

Department of Health, Western Australia. Clinical guidelines and procedures for the management of nicotine dependent inpatients. 2011. ,

Ward, M. M., SwanG. E., & Jack, L. M., Self-reported abstinence effects in the first month after smoking cessation. Addict Behav, 2001. 26(3): p. 311-27.