“James Packer takes a deep draw of his menthol cigarette and for a few moments stares out the window at the lush polo field…”
- Damon Kitney, “I was terrified”, Weekend Australian Magazine, Oct 21-22 2017.
Among the many misconceptions that smokers have about their habit is that weaker/milder cigarettes are “better”, although there is no evidence for this. Indeed, they can be worse because of increased inhaling to build up nicotine levels. As for mentholated cigarettes - first developed by Lloyd "Spud" Hughes of Mingo Junction, Ohio in 1924 - evidence shows that the cool (or ‘Kool’) ingestion of menthol causes an increased metabolism of nicotine.
Regardless of the scientific evidence about the damage that smoking causes to human health - the practice has a 68% death rate, a statistic that few smokers are aware of - there are many myths about consumption, and even more challenges about quitting.
Not the least of these challenges is the one faced by smokers who have tried but not succeeded. Whose fault is it? That of the smoker, addicted to a substance that causes more dependency than, say, heroin? Or the cessation methods that are often found not to ‘work’?
Studies consistently show that the great majority of smokers wish to give up, and regret having ever started. That said, smoking rates in Australia are now about 14.5% according to the National Health Survey 2014-15, low on the global stage, especially compared to neighbouring countries such as Indonesia and China where control measures are only starting to be introduced. In both of these massive countries a smoking-related cancer tsunami is now gathering.
Sadly, smoking rates are considerably higher among Australians with the most socio-economic disadvantage. In 2014-15, 21.4% of people living in areas of the greatest disadvantage smoked daily, compared with 8.0% of people living in areas of the least disadvantage. Further, about 42% of Aboriginal and Torres Strait Islander people smoke, although it is heartening to know that this prevalence is decreasing at the same rate as the overall Australian smoking population.
At a recent Australasian Lifestyle Medicine Society conference a renowned leader in the field of smoking cessation, Professor Renee Bittoun gave an illuminating talk with many take home messages.
Many old methods and guidelines may need to be reviewed to deal with the smokers who have already had many unsuccessful attempts to quit. Here are some of the tips presented.
Cutting down and advising to do so may be counterproductive because people tend to compensate by inhaling deeper and smoking more of the cigarette (down to the filter butt).
The timing of the first cigarette of the day is useful information to ask our patients. If within 5 minutes of arising this indicates high dependency and it is harder to quit.
People can be fast or slow metabolisers of nicotine. Fast can decay nicotine in 5 minutes and they tend to be strongly addicted, smoke more and have an increased risk of lung cancer. They do not do so well with nicotine replacement therapy (NRT) patches. They also have higher carbon monoxide (CO) levels if measured by a Smokerlyzer CO breath test monitor.
Caucasians are faster metabolisers compared to Asians. Japanese people are slow metabolisers and have high rates of smoking but lower lung cancer rates. European people are faster metabolisers.
The younger that smokers start the harder it is to withdraw. Hence the need to try to reduce taking up smoking in adolescent years.
There is no evidence that weaker/milder cigarettes are better. In fact they can be worse because of increased inhaling to build up nicotine levels. Also the menthol in some cigarettes causes increased metabolism of nicotine.
There is no evidence that hypnotherapy, acupuncture, or laser creams help quitting.
There is good evidence for combination NRT therapies such as patches with chewing gum, lozenges and there is no risk of overdose of nicotine.
People can continue to smoke whilst using the patches; nagging or advising a quit date has not shown to be effective.
There is evidence for separating smoking from habits such as having a cup of coffee, or an alcoholic beverage – advise smoking outside houses and cars.
Smokers drink twice as much alcohol as non-smokers. Alcohol induces liver enzymes which alters nicotine metabolism and increases its use.
Nicotine reduces anxiety and depression and has a short half-life (40mins to 2 hours) - when the effect wears off these symptoms return. Smokers manage stressors better when on NRT. After cessation they are calmer and less reactive but this may take time (up to 3 months).
Nicotine has some cough suppressant effects and the combined use of cannabis and nicotine is common and exaggerates the somatic, psychological and social consequences of each drug. It potentiates co-dependency and blurs the withdrawal from one or the other drugs. This increases the risk of relapse and reduces motivation to care, making the therapeutic process of smoking cessation harder.
Smoking produces polycyclic hydrocarbons that enhance liver enzyme inductions
Caffeine intake is double in smokers and caffeine toxicity is common in withdrawals. Hence the need to halve caffeine intake during quit attempt. Smokers need more insulin, pain relievers, anti-psychotics, anticoagulants, caffeine and alcohol for them to be effective. Quitters need less of these and this needs to be monitored and adjustments made to doses.
Nicotine toxicity and overdose is rare – nicotine withdrawal symptoms are common
Evidence-based pharmacotherapy for cessation
1st line – NRT, Bupropion (Zyban), Combination of all NRTs, Combination of NRT and Bupropion, Varenicline (Champix), Combination of Varenicline and NRT
2nd line – Nortriptyline (registered for this use in New Zealand), Naltrexone
Combination therapies often succeed when single therapies fail, particularly for fast nicotine metabolisers.
As blood levels vary most smokers are under-dosed with single 21mg patch and combination NRTs or more than one patch at a time may be needed (can cut them into halves if needed to increase dose). There is no evidence for cutting down (21 to 14 to 7 mgm). They are safe in all forms except pregnancy where the 24-hour patch should be taken off at night.
If not pregnant, patches should be put on at night so that the slowly absorbed nicotine is on board after waking in the morning. Expired carbon monoxide can be monitored with a Smokerlyzer in some smoking cessation clinics and it can provide useful feedback for both patient and therapist.
Smokers trying to quit can alternate pulsatile NRT (i.e. the fast acting gum, lozenges, spray or inhaler) and still smoke to replace the nicotine and therefore the urge to smoke tobacco. When starting use of patches it is safe to continue to smoke to allow craving to gradually subside. Smokers realizing that they can manage without tobacco for a few hours provides them with increased motivation to quit. There is no danger of overdose by smoking whilst using NRT and patients tend to be unaware of this and therefore fail and wrongly assume the patches don’t work.
NRT use in pregnancy
NRT should be recommended to all nicotine dependent pregnant women who have been unable to quit using non-pharmacological approaches because this is less harmful that continuing to use tobacco with all its many toxic products and carcinogens.
Intermittent NRT (gum, lozenge and inhalant) is preferred as it more closely mimics nicotine levels from smoking and delivers a lower overall dose. However, intermittent NRT may not be tolerated by some pregnant women as the higher peaks of nicotine may be associated with side effects such as gum and throat irritation and worsening of pregnancy-related nausea. For these women, transdermal patches should be recommended and used for 16 hours rather than 24 hours.
Ingest tablet with food to avoid nausea. Space the two daily tabs 8 hours apart (no longer) to avoid sleep disturbances. Don’t confuse withdrawal symptoms with side effects from Varenicline. May need to keep taking it up to 6 months after cessation to prevent withdrawal symptoms – may need to wean down dose during withdrawal. Adding NRT (usually pulsatile or patch) at some stage for short term urges, even weeks after abstinence may be needed to prevent relapse.
We owe it to our smoking patients to provide a non-judgmental service to help them deal with their addiction to nicotine, using the pharmacotherapy available to reduce harm to health from the many toxic products in tobacco. There is a role for one-to-one advice as well as referral to appropriate smoking cessation clinics.
Smoking cessation support in our area:
Northern NSW Local Health District Contact:
Phone: 02 6674 9517
Mobile: 0417 474 417
Fax: 02 6674 9599