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COPD Supplement
A practical guide for Primary Care Nurses

The Burden of COPD COPD Guide PDF
Spirometry
Smoking Cessation
Pulmonary Rehabilitation
Appendix One - Resources and contacts
Update on Managing Smoking Cessation - BMJ review July 2007

Smoking Cessation4

Task of primary care | Smoking cessation programmes | Quit group services | Personal quit plan | NRT | Other pharmacological interventions | Risks of cessation

Tobacco smoking causes almost all COPD, and smoking cessation is the only intervention that has been shown to halt the accelerated decline in lung function that occurs with COPD. The earlier a person stops smoking the greater benefit they will gain. Adolescents who stop smoking will have increased lung growth.

The Fletcher-Peto Diagram

The risks of developing chronic obstructive pulmonary disease:
The lines illustrate the natural decline and the effects that smoking and stopping smoking can have on FEV1. This graph shows the rate of loss of FEV1 for a hypothetical, susceptible smoker, and the potential effect of stopping smoking early or late in the course of COPD. Other susceptible smokers will have different rates of loss, thus reaching “disability” at different ages. The normal FEV1 ranges from below 80% to above 120% so this will affect the starting point for the individual's data (not shown).

The task of the primary care team

The task of the primary care team is to move the patient at least one step around the smoking cessation cycle. For example: getting a pre-contemplative smoker to think about smoking cessation as an option for them would constitute a successful consultation. Smokers move around this cycle an average of three or four times before achieving permanent success, so if a smoker relapses this does not mean the task is hopeless.

The smoking cessation cycle:

Brief counselling is an effective way of progressing people around the smoking cessation cycle and should be provided at every visit by either the individual practitioner or a suitably trained practice member.

The 5-A strategy is currently accepted best practice:

  • Ask and identify smokers - record smoking status in the notes.
  • Advise smokers about the risks of smoking and benefits of quitting and discuss options - use clear personalised but non-confrontational language.
  • Assess the readiness to quit, motivations to do so and the degree of nicotine dependence - “How do you feel about your smoking?”.
  • Assist cessation - prepare a personal quit plan, consider referral to a formal cessation programme plus pharmacological interventions.
  • Arrange follow-up in person or by phone to reinforce the message.

Smoking cessation programmes

Although most people stop smoking independently, formal smoking cessation programmes have success rates of around 15% and increase the likelihood that individual smokers will quit. Free smoking cessation practitioner training is available from The National Heart Foundation of New Zealand. Contact details are available in 'Appendix One - Resources and Contacts'.

Quit Group services

The Quit Group co-ordinates national smoking cessation programmes to help New Zealanders quit smoking. These services include:

  • QUITLINE -A free telephone support and advice helpline.
  • QUIT CARDS - A programme that lets health providers with an interest in smoking cessation register to distribute exchange cards for patches or gum to smokers wanting to quit.

QUITLINE - 0800 778 778

The Quitline is a free quit smoking telephone help line. Callers can:

  • Request a quit pack which has practical quit smoking advice and information.
  • Talk to a Quit Advisor for one-on-one support.
  • Get exchange cards for subsidised nicotine patches or gum where suitable.

Quit Advisors are expertly trained to help smokers with their quitting. ManyAdvisors are ex-smokers or have whanau and friends who have been affected by smoking-related illnesses.

QUIT CARDS

The Quit Card programme lets health providers distribute exchange cards for subsidised nicotine patches and gum to people wanting to quit smoking.

Any health provider in New Zealand who has trained in smoking cessation may apply to become a Quit Card provider. Free national smoking cessation training is available from The National Heart Foundation - http://www.nhf.org.nz

Personal Quit Plan

The decision to stop smoking is very personal and each individual will have their own motivations and barriers to consider. These can be laid out in a personal quit plan. Although this plan will have components common to all quitters there is not one plan that will suit all people. For this reason bpacnz has produced a modifiable one5. The Quit Book produced by the Ministry of Health gives more in depth information for patients to support their smoking cessation.

Nicotine replacement therapy (NRT)

Quit rates are doubled with the use of NRT and it is suitable for most people who are making a serious attempt to quit smoking. NRT is safe in people with stable cardiac disease such as angina pectoris, and because it produces lower peak levels than smoking, NRT should theoretically be safer, even in patients with unstable disease. However, recent MI, acute stroke, unstable angina and severe cardiac arrhythmias are considered contraindications. People with high cardiovascular risk factors will get even greater benefits from smoking cessation than those with lower risk.

NRT does not contribute to weight gain in smoking cessation and often mitigates against it whilst it is being taken.

There is little evidence for the effectiveness of NRT in people who smoke fewer than 15 cigarettes per day. Indeed, people who smoke fewer than 10 cigarettes per day may become addicted to the NRT.

Caution is also advised in adolescents because of lack of evidence of effectiveness in this age group. It is probably acceptable for heavily addicted adolescents to use NRT as long as they have discussed the issues with a parent or other responsible adult.

It is preferable for pregnant women to quit smoking without pharmacological help. However, the use of NRT may be considered. Continued heavy smoking will expose the woman and foetus to the inhaled nicotine and other noxious components of tobacco smoke. This must be balanced against the exposure to the nicotine in NRT.

In New Zealand, NRT is subsidised through Quitline and providers who are registered with the Quit Card programme. Quit Cards can be exchanged for a four-week supply of NRT - a surcharge of $5.00 applies. All forms of NRT appear to be useful in aiding smoking cessation. It is the patches and gums which are subsidised through the Quit Card programme. NRT is also available in New Zealand as lozenges and sublingual tablets although neither of these is subsidised. They can be considered as comparable to the gum as they all depend on the buccal mucosa to absorb the nicotine.

The use of patches provides a steady nicotine level sufficient to reduce withdrawal symptoms, but does not provide the peak nicotine levels of smoking which reinforce the addiction. The addition of a gum may further improve abstinence rates.

The strength of patch used depends on the number of cigarettes smoked daily. Three strengths are available in doubling doses, e.g. 7, 14 and 21mg. Both 24 and 16-hour patches are available. The 24-hour patches achieve higher blood nicotine levels and provide more relief from morning cravings but both patches have about the same efficacy. Six to eight weeks of use are generally required with tapering of the nicotine dose every two weeks. The only significant side effect is skin irritation which is generally mild and rarely leads to cessation of use.

Nicotine is rapidly absorbed from gum through the oral mucous membrane. The gum is chewed only two to three times per minute to avoid excessive salivation, swallowing of nicotine and gastrointestinal side effects. It should then be parked inside the cheek. Patients should taper the dose gradually but dependence on the gum can occur in up to 20% of users. Most patients should have ceased the gum within three months.

Other pharmacological interventions

Nortriptyline can be used for smoking cessation and has similar efficacy to NRT. It can be prescribed for smoking cessation in New Zealand, but patients need to be informed of the evidence for its risks and benefits and that it is not registered for this indication.

The manufacturers recommended dose of nortriptyline for smoking cessation in adults is 25mg per day starting 10 - 28 days prior to the quit date; increase gradually to 75 - 100mg per day over 10 days - five weeks; continue for 12 weeks (or up to six months). Elderly reduce dosing frequency6.

Bupropion is an atypical antidepressant which is registered for use in smoking cessation but not funded in New Zealand. It has a similar efficacy to NRT and nortriptyline, but has a wider range of adverse reactions which include the potential for increased risk of seizures, particularly in those who are already at risk or are taking drugs which lower the seizure threshold.

The suggested dose of bupropion is 150mg daily for three days increasing to 150mg twice daily thereafter. There should be an interval of at least eight hours between successive doses. Patients should be treated for at least seven weeks. The recommended dose should not be exceeded.

Potential risks of smoking cessation

When hydrocarbons are no longer inhaled, liver enzymes down-regulate and return to “normal” over about a one-month period. This means that the clearance of medicines metabolised by these enzymes will be reduced with a resulting increase in their concentrations. Of particular importance are caffeine, chlorpromazine, clozapine, flecainide, haloperidol, imipramine, mexiletine, olanzapine, propranolol, theophylline, warfarin and also insulin. Patients on these drugs may need to be monitored for potential problems associated with increased concentrations of the drugs.

Care should also be taken with those who have poor control of potentially brittle health conditions such as heart failure, diabetes, hypertension or mental illness7,8.

“Remember, smokers aren't the problem. Tobacco is the problem. Smokers can be part of the solution even if they can't quit at this time. Smokers can provide a smoke free environment for their family and fellow workers by smoking outside and not smoking in the car. This reduces the 'vertical transmission' of smoking-related illness and puts smokers in a win: win situation, assisting them to become active participants in a smoke free strategy.”
Dr Paparangi Reid
Public Health Medicine Specialist and Maori Health Researcher


4 The majority of the information in this section is adapted from “Guidelines for Smoking Cessation” published by the National Health Committee in 2002, or the COPD handbook, 2002.
(no longer available, Guidelines for 2006 here)

5 ‘My Quit Plan’ is available from the bpacnz. You are welcome to download this and modify it to suit your needs, available for MS word and in .rtf format. A printed version can also be ordered from here.

6 MIMS. Nov 2004. Issue 2 (98).

7 Chronic Obstructive Pulmonary Disease. Australia and New Zealand Management Guidelines and the COPD Handbook. Thoracic Society of Australia and New Zealand, Australian Lung Foundation, 2002. http://www.nzgg.org.nz (Accessed March 2005).

8 Guidelines for smoking cessation. National Health Committee, 2002. http://www.nzgg.org.nz (Accessed March 2005).


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