Nicotine replacement therapy for smoking cessation

Case scenario

Harry is a 60-year-old regular patient who comes in to ask for your advice. He has smoked 20 cigarettes a day for the past 40 years and has never seriously considered giving up smoking before. However, he spoke to his doctor about his smoking last week, and his doctor recommended he talk to you about nicotine replacement therapy products.

Introduction

One of the biggest preventable causes of death and disease in Australia is tobacco smoking.¹ It is a key focus at a national level, with the Australian Government including tobacco control as a key part of its 10-year National Preventive Health Strategy 2021–2030.² There is a wide range of support available for people who wish to quit smoking. Pharmacists can play an important role in supporting patients to quit smoking,³ along with general practitioners, helplines and online services.⁴

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Epidemiology

In Australia, tobacco smoking is estimated to account for 13% of all deaths each year.1 In 2015–16, it was estimated that tobacco use cost the Australian community $137 billion.² In 2020–21, an estimated 10.7% of Australian adults smoked daily¹ with men more likely to smoke daily compared to women.⁴

Tobacco smoking increases the risk of a range of health conditions, including heart disease, diabetes, stroke, cancer and respiratory conditions.^1,4-6 In addition, smoking has been linked to reduced health overall, increased absences from work, and increased use of healthcare resources.⁵ Exposure to second-hand smoke is also associated with a range of negative health effects, including coronary heart disease and lung cancer in adults, sudden infant death syndrome (SIDS) and other serious health outcomes in young children, and psychological distress.⁴ Encouragingly, daily tobacco smoking has been decreasing in Australia since 1991.⁴

Strategies for smoking cessation

Successful smoking cessation can take people numerous attempts over several years.⁴ Most people take five to six serious attempts to successfully quit smoking.⁷ People who smoke fewer than 20 cigarettes a day are more likely to be successful in changing their smoking behaviour compared to those who smoke a packet a day.⁴

Ceasing smoking often leads to withdrawal effects such as cravings, anxiety, irritability and hunger.⁷ These effects can start within a few hours of someone having their last cigarette and peak after several days. Symptoms will rarely last for more than 1 month.

Pharmacological treatments 

These include: 

• Prescription Only medicines: Bupropion doubles the chance of smoking cessation compared to placebo, and its effectiveness is increased when used in conjunction with nicotine replacement therapy (NRT).⁷ A Cochrane review found there was insufficient evidence to determine whether bupropion in combination with NRT was more effective than NRT alone.8 Varenicline is more effective than bupropion and has similar efficacy to combination NRT.7 Bupropion and varenicline should be reserved for patients who are nicotine dependent and committed to quitting smoking.⁷
• NRT: Compared to placebo, NRT almost doubles the number of people who quit smoking.⁷ NRT may also be used by patients who want to reduce their smoking but are not ready to quit completely. This increases their chances of successfully quitting smoking in the future.⁷ Individuals may^7,9:
  • Use the highest strength patch for 2 weeks before quitting smoking, and then continue using a patch and fast-acting form of NRT
  • Replace some cigarettes with a fast-actin NRT product. 
  • Nicotine vaping products: There is inconclusive evidence for nicotine vaping products to support smoking cessation.¹⁰ They are not first-line treatment.¹⁰

Non-pharmacological treatment 

• Complementary therapies (e.g. hypnotherapy, acupuncture): there is limited evidence to support their effectiveness and they are not recommended in treatment guidelines.⁹
• Quitting cold turkey (quitting smoking suddenly without any support [include pharmacological treatments or professional support]): a popular strategy; however, it has a much lower success rate compared with other strategies.^11,12

Behavioral advice and support 

Patients should be provided with advice on behavioural techniques that can be used to support smoking cessation, regardless of whether pharmacological treatment is being used7 (see ‘NRT patient advice’). 

Patient assessment 

Everyone who smokes should be advised to quit, in a way that is clear but non- confrontational.⁶ The benefits of quitting should be explained, including that it is never too late to quit.⁶

The ‘Ask, Advise, Help’ structure can be used to provide brief advice to patients on quitting smoking^10,13:

• Ask about smoking status and record response
• Advise to quit smoking and provide advice on the most effective methods available
• Help by offering referral and encouraging use of evidence-based treatments and behavioural interventions.

Pharmacists should assess a patient’s determination and motivation to quit smoking. This can include discussing health concerns, incentives and previous attempts to quit smoking.⁷ People who are motivated to quit smoking are more likely to be successful.⁷

Pharmacists should ask about^7,9:

• the number of cigarettes smoked each day
• how long until the first cigarette after waking
• previous attempts to quit smoking
• confidence and motivation to quit smoking
• medical and lifestyle history
• age
• pregnancy/breastfeeding status
• current medicines
• previous allergies or adverse reactions to medicines or excipients. 

Smoking within half an hour of waking, smoking >10 cigarettes/day, and a history of withdrawal symptoms when previously attempting to quit smoking all suggest nicotine dependence.⁹ Patients should be referred to a medical practitioner in the following situations^9,1:

• pregnancy
• breastfeeding (supply NRT and refer, see ‘Precautions’)
• NRT is unsuitable or contraindicated
• patient prefers to use a Prescription Only medicine
• patient is using a medicine that interacts with cigarette smoking, and may require a change in dose when ceasing smoking (e.g. clozapine, erlotinib, theophylline)
• patient has cardiovascular disease, respiratory disease, diabetes, mental health conditions (supply NRT and refer; NRT can be used in stable cardiovascular disease, but additional support may be needed)
• patient is aged <18 years (for patients 12–17 years, supply NRT and refer).

NRT treatments 

NRT works by reducing withdrawal symptoms from not smoking.⁷ Nicotine is rapidly absorbed through skin and the mucosal surfaces in the gastrointestinal and respiratory tracts.⁷ NRT is contraindicated in patients <12 years.⁹

The choice of which NRT product to use will depend on the patient’s preferences,⁷ their suitability for different NRT products and their level of nicotine dependence.⁹ Fast-acting NRT (see Table 1) can be used when strong cravings occur. They may be used alone or in conjunction with NRT patches, bupropion or varenicline to manage cravings.⁷ All forms of NRT are similarly effective when used at equivalent doses.⁹

Combination treatment with an NRT patch and fast-acting NRT can be used first line. It may be particularly helpful for patients who have had many unsuccessful quit attempts, or who experience cravings and/or withdrawal symptoms with monotherapy.⁷

Table 1 outlines NRT products that are available. Relevant product information and reference texts (e.g.  Australian Medicines Handbook) should be consulted for recommended doses for individual products. The NRT dose needs to be appropriate for the severity of the patient’s withdrawal symptoms. Underdosing may affect the individual’s confidence in the effectiveness of NRT.⁹

Precautions

Precautions to using NRT include^7,9,13:

• Cardiovascular conditions such as recent myocardial infarction or stroke, unstable angina, severe arrhythmias: non- pharmacological treatment should be considered first; however, risks of smoking are greater than the risk of using NRT.
• Oral, oesophageal, pharyngeal or gastric inflammation: oral NRT forms, including inhalers, may worsen inflammation.
• Asthma, chronic throat conditions: inhaled NRT should not be used.
• Pregnancy: NRT is pregnancy Category D, non-pharmacological strategies should be tried first. If non-pharmacological strategies are not successful, refer the patient to their medical practitioner for consideration of the suitability of NRT. Faster-acting NRT is usually preferred; if NRT patches are prescribed, they should be removed at night.
• Breastfeeding: non-pharmacological strategies should be tried first. The amount of nicotine in milk can be minimised by using a short-acting form of NRT and taking a dose just after feeding.

Table 1 outlines precautions and contradictions to using specific NRT products. 

NRT patient advice 

Pharmacists should provide patients with advice on how to use, store and dispose of NRT products safely.^7,9 Patients using oral or inhaled products should be advised not to eat or drink while NRT is used, if possible, as this can reduce the amount of nicotine absorbed.⁷ In particular, acidic drinks (e.g. coffee, soft drinks) should not be consumed within 15 minutes of usingthese NRT products.⁹ If patients using patches find the adhesive is not sticking, adhesive skin tape may be used.⁹

Tobacco smoking induces cytochrome P450 enzymes (particularly CYP1A2).9 Caffeine is metabolised by CYP1A2, so patients should be advised to reduce their caffeine intake by half when quitting smoking to reduce the risk of anxiety, restlessness and insomnia.⁹

All patients should be provided with behavioural strategies to assist with quitting smoking.⁹ The chances of successful long-term smoking cessation are increased if NRT is used in conjunction with multi-session behavioural interventions that are evidence-based.⁹ Pharmacists can refer patients to Quitline or apps (e.g. My QuitBuddy) for ongoing support.⁹ Quitline also has services specifically for Aboriginal and Torres Strait Islander peoples.¹⁴

The Australian Pharmaceutical Formulary and Handbook (APF) Non-prescription medicine guide: Nicotine replacement therapy for smoking cessation outlines behavioural strategies to assist with quitting smoking that pharmacists should discuss with patients.⁹

Adverse effects

Adverse effects associated with NRT include⁷: 

• common: dizziness, headache, nausea, vomiting, hiccups, indigestion, abdominal pain, myalgia
• infrequent: tachycardia, palpitations, chest pain, changes in blood pressure
• rare: arrhythmias

Adverse effects are usually mild and limited. Some perceived adverse effects may actually be related to quitting smoking, such as sleep disturbances, dizziness, weight gain and headache.⁷ Certain adverse effects are related to the form of NRT used⁷ (see Table 1).

Nicotine overdose can cause nausea, vomiting, bradycardia and convulsions.⁹ As nicotine is intended for transdermal and buccal/sublingual absorption, nicotine that is swallowed can worsen symptoms of oesophagitis, gastritis and gastric ulcers.⁹

Table 1– NRT products

Follow-up

Regular advice and support increases the patient’s chances of successfully quitting.⁷ Suggest patients return within 1 week of quitting smoking, and also plan additional follow-up visits to review progress.⁹ Encourage patients to contact the pharmacist if they have any questions about NRT or the advice they have been given.⁹

During follow-up visits, congratulating and encouraging the patient can help with motivation, as can affirming the decision to quit smoking and reiterating the benefits of smoking cessation (e.g. financial and health benefits).¹³ Pharmacists should ensure that the NRT used is adequately managing the patient’s cravings and withdrawal symptoms.⁷

Patients who relapse should be supported and encouraged to have another attempt at quitting smoking.⁹ Encouraging the patient that it often takes numerous attempts before quitting smoking long term can be helpful.⁹ This can also be used as an opportunity to identify triggers for relapsing, situations that increase the temptation to smoke, and strategies that have been found to be helpful in avoiding smoking.⁶

While the optimal duration of use has not been determined, NRT is usually continued for up to 12 weeks, with most people requiring 6–8 weeks of treatment.^7,9 However, some patients may benefit from longer treatment.⁷ Dose tapering has not been found to affect the success of long-term cessation.^7,9

Knowledge to practice

Pharmacists working in multiple practice settings, including community pharmacy, hospital and general practice, have been shown to play a valuable role in supporting patients to quit smoking.^15-17 Pharmacists can assess patients for suitability to use NRT products, refer patients to other health professionals if required, provide counselling on appropriate use of NRT and offer ongoing behavioural support.^9,15

Conclusion

While tobacco smoking is responsible for more than 1 in 10 deaths each year in Australia, its use is decreasing. NRT has been shown to assist patients in successfully quitting smoking and is available in various formulations. Pharmacists play a key role in advising and supporting patients in the effective use of NRT.

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Key points

• Tobacco smoking is one of the biggest preventable causes of death and disease in Australia. 
• Most people take five to size attempts to successfully quit smoking. 
• Every person who smokes should be advised to quit. 
• NRT almost doubles the number of people who quit smoking compared to placebo. 

References

1. Australian Bureau of Statistics. Pandemic insights into Australian smokers, 2020–21. 2021. At: www.abs.gov.au/articles/pandemic-insights-australian-smokers-2020-21
2. Australian Government Department of Health. National Preventive Health Strategy 2021–2030. Canberra: Commonwealth of Australia; 2021.
3. Saba M, Bittoun R, Kritikos V, et al. Smoking cessation in community pharmacy practice – a clinical information needs analysis. Springerplus 2013;2:449.
4. Australian Institute of Health and Welfare. Alcohol, tobacco & other drugs in Australia. 2022. At: www.aihw.gov.au/reports/alcohol/alcohol-tobacco-other-drugs-australia/contents/drug-types/tobacco#consumption
5. Centers for Disease Control and Prevention. Health effects of cigarette smoking. 2021. At: www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smoking/index.htm
6. Smoking cessation. Therapeutic guidelines; [updated July 2013]. At: https://tgldcdp.tg.org.au/viewTopic?etgAccess=true&guidelinePage=Addiction%20Medicine&topicfile=smoking-cessation&guidelinename=Addiction%20Medicine&sectionId=toc_d1e198#toc_d1e198
7. Rossi S, ed. Psychotropic drugs. Australian medicines handbook [updated 2023 Jan]. At: https://amhonline.amh.net.au/chapters/psychotropic-drugs?menu=vertical
8. Howes S, Hartmann-Boyce J, Livingstone-Banks J, et al. Antidepressants for smoking cessation. Cochrane Database Systematic Reviews 2020, Issue 4.
9. Sansom LN, ed. Nicotine replacement therapy for smoking cessation. Australian pharmaceutical formulary and handbook; [updated 2023 May]. At: https://apf.psa.org.au/non-prescription-medicine-guides/nicotine-replacement-therapy-smoking-cessation/nicotine-replacement
10. Pharmaceutical Society of Australia. Guidelines for pharmacists providing smoking cessation support. Canberra: PSA; 2021.
11. Australian Government Department of Health and Aged Care. Quitting methods. 2023. At: www.health.gov.au/topics/smoking-and-tobacco/how-to-quit-smoking/quitting-methods
12. Cancer Institute NSW. Quitting methods. 2023. At: www.icanquit.com.au/quitting-methods/cold-turkey
13. The Royal Australian College of General Practitioners. Supporting smoking cessation: a guide for health professionals. 2021. At: www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/supporting-smoking-cessation
14. Quit Victoria. What to expect when you call Quitline. 2022. At: www.quit.org.au/articles/what-expect-when-you-call-the-quitline/
15. Carson-Chahhoud KV, Livingstone-Banks J, Sharrad KJ, et al. Community pharmacy personnel interventions for smoking cessation. Cochrane Database of Systematic Reviews 2019, Issue 10.
16. Creswell PD, McCarthy DE, Trapskin P, et al. Can inpatient pharmacists move the needle on smoking cessation? Evaluating reach and representativeness of a pharmacist-led opt-out smoking cessation intervention protocol for hospital settings. Am J Health Syst Pharm 2022 Jun;79(12):969–78.
17. Deeks LS, Kosari S, Develin A, et al. Smoking cessation and the general practice pharmacist. Journal of Smoking Cessation 2019;14(3):186–9.

Our author

Naomi Weier (she/her) BPharm(Hons), GradCertPharmPract, GradDipClinEd, MClinPharm, CertIV TAE, MPS-AACPA, AICGG is an accredited pharmacist and PhD candidate with experience working in various pharmacy sectors, including Aboriginal and Torres Strait Islander health, community pharmacy and hospital. She has previously worked as a Project Pharmacist at the Pharmaceutical Society of Australia.

Our reviewer

Victor Senescal (he/him) BPharm(Hons), AACPA, BArts(Writing)