How to quit smoking

And most importantly, smokers should just keep trying to quit. It's okay to fail, and that's part of the journey of quitting, but the biggest failure is to stop trying at all.

[Music] Welcome to the Australian Prescriber Podcast. Australian Prescriber, independent, peer-reviewed, and free.

Hi, I'm Jo Cheah, and this is the Australian Prescriber Podcast. Joining me today is Dr Colin Mendelsohn, a GP based in Sydney who has written an article on smoking cessation pharmacotherapy which we will discuss today. Welcome to the podcast, Colin.

Thank you, Jo.

To start us off I wanted to ask you about some statistics in Australia at the moment. I'm interested to know about our current population who smoke, or who are smokers, who have quit smoking, or who intend to quit.

Well in the last National Drug Strategy Household Survey in 2019, 14.7% of adult Australians smoke, which is still one in seven adults smoking in Australia. Seventy per cent of those smokers said they wanted to quit, and that's a pretty standard figure over time. But, for example, in the lowest socioeconomic quintile the smoking rate is two and a half times that of the most affluent quintile. People with mental illness have double the smoking rates of the general population, and 43% of indigenous people still smoke. So we need to target those groups in particular. The good news is that only 3% of 14- to 17-year-olds currently smoke.

In your article you've mentioned Ask-Advice-Help, as well as motivational interviewing. So I just wanted to ask you for some examples of motivational interviewing.

Many smokers have ambivalence about their smoking, and motivational interviewing is a style of counselling which can help them explore the pros and the cons of continuing to smoke, and decide for themselves whether they want to continue. It's a patient-centered non-confrontational technique, and there are four simple steps. So firstly we ask what they like about smoking, then we ask them what they don't like, and then we summarise that, and give them the pros and cons that they've told us, and then have them reflect on what they've said and what that means. For example, you might say, "On the one hand you've told me you enjoy a cigarette with coffee and when drinking with your friends, and smoking relieves stress for you, but you're finding it's a struggle financially, and you're worried about getting lung cancer. Well, where does that leave you?" And you let the patient consider that obvious discrepancy in what they're saying, and often that will lead to change.

How do we establish nicotine dependence in people who smoke?

Medication is only indicated when there is nicotine dependence, and understanding the level in that individual gives us a guide to how intense the treatment might need to be and how much difficulty they may have in quitting. Dependence can be fairly easily assessed by asking two questions. How long after waking do you have your first cigarette of the day? Smoking within 30 minutes of waking is a pretty reliable indicator of nicotine dependence. Smoking within five minutes of waking indicates more severe independence.

The second question is the number of cigarettes smoked a day. Now this is less predictive because people can smoke a small number intensely, and vice versa, but if they smoke more than 10 a day, it's associated with a higher likelihood of dependence. And these two questions make up the Heaviness of Smoking Index, and that can be used to give a score out of six to rank their severity of dependence. Cravings and withdrawal symptoms in the past with previous quitting attempts can also be a useful guide.

And how can nicotine dependence, or other factors, impact the therapy you choose to help your patients stop smoking?

If a previous pharmacotherapy was effective and was well tolerated, it's generally best to use the same one again, because we know that that's worked and we know it's something the patient can take. But other factors guiding the choice of drugs include, as you say, nicotine dependence, so the more dependent they are the greater the effectiveness of treatment and the combinations you might use. We also go by the patient's personal preferences. Some people will say, look, I just don't like chewing, or tablets could make you sick and I don't want to have that. There are contraindications, for example, if you've got dentures you probably shouldn't use the gum because it sticks to dentures. There are drug interactions, particularly with bupropion, which need to be taken into account, and cost. So all the first-line pharmacotherapies are available on the PBS, but only one at a time. So if you wanted to use a patch and the gum together, for example, the patient would need to pay for one of those options.

So that's for patients who go to a doctor for a prescription. What about patients who buy things over-the-counter from a pharmacy, for example?

Nicotine replacement’s available over-the-counter, and it's certainly less than the cost of smoking. The problem with that is that the research suggests that NRT over-the-counter without support is not very effective. In fact, may not be effective at all. So it's not an option we would choose as a first-line therapy.

So I guess for pharmacists, in those instances, they could help guide the patient, but really a referral to a GP is important.

There's no reason why pharmacists can't provide that behavioural counselling and the support that is needed to make NRT effective if it's something that they're comfortable and trained in.

In your article you have mentioned a number of therapies. Could you please go through the first-line options and, briefly, main counselling points of each.

Sure. In Australia the first-line options are nicotine replacement therapy, varenicline, and bupropion. They all work best when combined with behavioural counselling and support. Nicotine replacement is the most widely used first-line therapy, and there are two main kinds of NRT. So there's the nicotine patch, which is applied in the morning and releases nicotine steadily through the day and relieves background cravings. And then there's the oral preparation, so this is the gum, the spray, the lozenge, and the inhalator, and these act more quickly, but they don't last as long. So they can be used on a regular, say hourly basis during the day, or in anticipation of cravings or triggers. So if a patient knows they're going to feel like a cigarette when they have a cup of coffee in 20 minutes, then having a piece of gum or a lozenge may help to alleviate those cravings and those triggers.

The best results though with NRT are from combining the patch and an oral product, and this is recommended for all nicotine-dependent smokers, especially the more dependent, and especially where a single agent hasn't been successful. It's really important when you're prescribing oral products to give clear instructions on how to use them, as they're often not used correctly. All oral products, including the inhalator, are absorbed in the buccal cavity. The nicotine's absorbed through the lining of the mouth, and not from the stomach or the lungs. So it's important to minimise swallowing, because it can lead to nausea, hiccups, and the nicotine's not well absorbed.

The health professionals need to explain specifically how to use these products. So with the gum you'd tell the patient to use the ‘chew and park’ technique, which involves having a few chews on the gum to release some of the nicotine, and then parking it in the side of the mouth for 30 seconds, or until the taste goes, and repeating that cycle for about 30 minutes. Nicotine from the inhalator is absorbed again through the lining of the mouth, and it requires shallow frequent puffs for at least 20 minutes for each dose. It's not absorbed through the lungs and doesn't require deep inhalations. Lozenges should be dissolved slowly in the mouth, usually over about 20 minutes, and the mouth spray is used under the tongue.

Whenever you prescribe NRT it's important to reassure patients about the safety and addictive potential. They often have exaggerated concerns, and we know that misinformation about those products can reduce adherence to treatment. So you need to explain that nicotine doesn't cause cancer, it doesn't cause lung disease, and it only has a minor role in cardiovascular disease. The key line to tell patients is that it's always safer than smoking. So if they have concerns about safety, what they're currently doing is far worse.

The other important thing is to make sure they get enough nicotine. Most patients don't use enough, and often it's because of those concerns about safety, but the dose is different for every individual but it should be enough to control withdrawal symptoms and cravings, and they should have extra doses, or larger doses, if they're still having those effects. And a course of at least 10 weeks is recommended. Most people tend to stop too soon, but we know that longer courses will give them a better chance of being successful.

Another tip is to start the nicotine patch two weeks before quit day, and we know that that increases success rates by 25% compared to starting on quit day. So they need to have time to adjust to it, and to sort out any side effects, and on quit day when they do quit it'll be working at full effect.

Side effects are common, but they generally are mild. The patch can cause skin irritation, so the application site should be rotated daily. If there's sleep disturbance, you can use a 16-hour patch, or take off the 24-hour patch at bedtime. Oral products can cause throat irritation, and if nicotine is swallowed, it can lead to nausea and hiccups. It's important to tell people to avoid or delay swallowing as long as they can. NRT is safe in stable cardiovascular disease, and it can be used in pregnancy, although in pregnancy larger doses may be needed.

The second first-line treatment is varenicline, and that's the most effective monotherapy for smoking cessation. It can be combined with the nicotine patch, and this will increase quit rates further, and that's a valid option for whom varenicline isn't controlling symptoms. Varenicline is up-titrated over the first week and should always be taken with food to reduce the risk of nausea, which is the main side effect. A full course of 12 weeks is recommended, and a second course can be given to prevent relapse if the patient has been successful within that first course.

It's really important to tell people that varenicline is safe in stable mental illness. There's no evidence that it causes depression, behaviour changes, suicidal ideation. The research has shown that some people do get these symptoms when they quit smoking, because people are at greater psychological risk when they're quitting. It's not the method of quitting that's doing that, it's just the quitting, and it's something we should warn all smokers about that when they quit they may get depressed, anxious, feel strange in a variety of ways, and that's all part of the process, but they should certainly warn the doctor if these are troubling them.

And finally, the third first-line treatment is bupropion. Again, this is a tablet taken as an eight-week course with quitting in the second week. It's about as effective as NRT, but it has a one-in-a-thousand risk of seizures, avoided really in people who are at risk of seizures, and used with caution in people taking drugs that can lower seizure thresholds such as antidepressants, and also shouldn't be used in pregnancy.

Another big part of your article is vaping, or the use of e-cigarettes. People might have heard in the media reports some vaping-associated lung injury that causes hospitalisations, or all sorts of things. Tell us about vaping, how it plays its role in the treatment of smoking cessation, and any risks that people should be aware of as well.

Vaping nicotine is a second-line quitting aid for adult smokers who haven't been able to quit with those first-line treatments. It's actually the most popular quitting aid in Australia and other western countries because it provides the nicotine that smokers crave, but also the rituals and the sensations of smoking, without most of the toxins and carcinogens from burning tobacco. It's at least 50% more effective as a quitting aid than nicotine replacement, according to the Cochrane Review. So in absolute terms, six out of 100 smokers will quit with nicotine replacement therapy, whereas nine to 10 will quit with vaping nicotine. But the vapour does contain low doses of some chemicals, and laboratory studies have associated vaping with impaired cell viability, impaired immune defences, increased inflammatory markers and oxidative stress, although these changes are much less than they are with smoking.

There was an outbreak of serious lung injury in North America in 2019 to '20 related to the use of illicit vaping products, cannabis oils that were contaminated with vitamin E acetate. Now there's never been a problem like that caused by nicotine vaping, so this was actually quite unrelated to what we're talking about. There is some evidence that vaping may worsen asthma and cause lung irritation and cough in non-smoking adolescents, but adults who switch to vaping generally have health improvements, and the research has shown improvements in asthma, COPD, lung function and blood pressure when people make the switch, and there are fewer respiratory infections. And people just feel a lot better.

Vaping can also be used as a long-term replacement for smoking, and that's tobacco harm reduction, a strategy to prevent the harm from smoking while still allowing the continued use of nicotine, which in itself is addictive, but relatively benign. The long-term risk of vaping is not known, but it's unlikely to be more than 5% of the risk of smoking, according to the UK Royal College of Physicians.

Apart from those who might use it as a long-term tobacco harm reduction therapy, is the goal for most other people who would be vaping nicotine to actually come off e-cigarettes totally at some point?

Yes, absolutely. Look, we say to all patients, "You should try to cease vaping at some point if you can, as long as you're confident of not going back to smoking."

Ideally most people would try to avoid, for example, secondhand cigarette smoke. Would you try and avoid secondhand vaping?

Secondhand vapour hasn't been shown to have any significant health effects, and the reason is that most of the vapour is absorbed and retained by the person vaping, so over 90% is absorbed, and there's no vapour released from the end of the vaping device. With smoking 80% of what's in the air, it comes from the end of the burning cigarette. And vapour’s a liquid air aerosol, it dissipates very quickly. Research so far has not shown any harmful effects from that, but still it's important that vapers generally avoid vaping around other people as a matter of courtesy.

And I understand that there's been a recent change to people gaining access to e-cigarettes containing nicotine, so could you just walk us through what those recent changes were and how that affects clinicians and patients?

People who vape need a nicotine prescription from a doctor to legally possess nicotine liquid and to import it. It can be accessed legally through two pathways, so it can be dispensed now by an Australian pharmacy, an online pharmacy, as long as the patient has a prescription from a doctor, and the doctor has to be an Authorised Prescriber of nicotine. But secondly, nicotine vaping products can be imported from overseas by the patient under the Personal Importation Scheme, and most people access supplies from New Zealand. People can order three months supply at the time for personal use up to a total of 15 months supply each year, and when the patient orders online they must arrange for a copy of their prescription to be uploaded to the vendor, and that has to be enclosed with the order when it's delivered to Australia.

What are your thoughts on the effectiveness of public health measures for quitting smoking, and do you have any further suggestions for what more could be done?

Australia's done very well over the years. Our public health policies have been very effective in bringing smoking rates down, so that includes cigarette taxes, advertising bans, smoke-free policies and plain packaging. But the decline in smoking has slowed down in recent years, and we certainly need to do more. Some of the other strategies that we should be using are the reintroduction of mass media campaigns. These were very successful in the past, we haven't had any major campaigns for nine or 10 years. We need to reduce the number of retail outlets for cigarettes. I mean, there are just too many, 20,000 outlets in Australia, we’re making it too easy for people to buy cigarettes. And overseas experience has shown that raising the minimum age of smoking or sale of products to people to 21 has a significant impact on smoking rates, so I think that's worthwhile.

But I think the policy change that would make the biggest difference and have the greatest effect at the population level would be to make nicotine liquid in low concentrations more widely accessible as a regulated adult consumer product, and this is how it's done in other countries, whereas in Australia at the moment it's far easier to purchase cigarettes, which are deadly, than it is to buy the much safer alternative.

In terms of clinicians who have patients who are smokers and who may encounter people who do smoke, what are your main takeaway points for them when they have the opportunity to discuss quitting smoking with their patients?

Smoking is still a leading preventable cause of death and illness in Australia, and health professionals should address it at every opportunity, especially when smokers come in with smoking-related conditions, and particularly in those high-risk groups and the groups with high smoking rates. But it's also important to target young smokers. Smokers who quit by the age of 35 reverse all the harm that they've done from smoking, and they'll have a normal life expectancy, whereas continuing to smoke shortens your life by 10 years.

The most effective first-line therapies, as I mentioned, are combination NRT and varenicline, which work best with behavioural counselling and support. And if you're using NRT, it's important to provide advice on the correct use of each product to ensure adequate dosage and duration of use, and to reassure patients about the safety of NRT. It's always safer than smoking.

And finally, if first-line treatments have not been successful, vaping is a legitimate and effective quitting aid. It can act as a long-term, safer alternative to smoking for smokers who need to continue using nicotine, or continue with the smoking ritual. And most importantly, smokers should just keep trying to quit. It's okay to fail, and that's part of the journey of quitting, but the biggest failure is to stop trying at all.

Lastly, I'm interested to know where doctors or pharmacists or other allied health clinicians can learn more about smoking cessation, and for example, for those who've never prescribed or dispensed nicotine liquid before, do you have any references or guidelines that you would point people to?

The Smoking Cessation Guidelines are those from the College of GPs, and they're available online. There isn't a lot available on vaping in Australia. There have been a number of articles in medical journals in Australia and the Australian Doctor, I actually had an article on vaping several months ago, and there will be an article in former Australian Family Physician [now called Australian Journal of General Practice] towards the middle of the year. People can get more information, health professionals, from the ATHRA website, which is the Australian Tobacco Harm Reduction Association, which has a log in area for health professionals who want to find out more about vaping.

Excellent. And of course, people should check out your article as well in Australian Prescriber. Thank you, Colin, that takes us to the end of our episode. It was lovely chatting to you today, and I've learned a lot about smoking cessation, so thank you.

Great, Jo, thank you for asking me.

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Dr Mendelsohn has not received any payments from electronic cigarette or tobacco companies. He has a special interest in tobacco-harm reduction and vaping nicotine and was the founding chairman of the Australian Tobacco Harm Reduction Association (ATHRA), a health promotion charity established to raise awareness of safer alternatives to smoking, but is no longer on the Board. ATHRA received funding from the vape industry to establish the charity which was publicly declared. He is the author of a self-funded book called Stop Smoking Start Vaping.

The views of the host and the guests on the podcast are their own and may not represent Australian Prescriber or NPS MedicineWise. I'm Jo Cheah, and thanks for listening to the Australian Prescriber Podcast.