Clinical tips: smoking cessation

man holding some cigarettes trying to stop from smoking

Louis Roller has some tips for pharmacists helping people quit smoking: now or in the New Year

Tobacco smoking and addiction is the major cause of preventable morbidity and mortality in Australia. The problem of smoking addiction is really two-fold:

  • firstly, the addictive nature of the nicotine, and
  • secondly, the toxic effects of cigarette smoke itself which affects virtually every body system.

Most adult smokers do not want to smoke, but cannot stop because of the nicotine  addiction. Most adults started smoking when they were at school.

Smoking rates among adults in Australia have been steadily declining. The 2016 National Drug Strategy Household Survey report found the smoking rate among adults was 12.8%. This is a very significant reduction in smoking since the 2011-2012 report of a 22.4% adult smoking rate.

There are now a wide range of effective aids which can make cessation easier. These include one or more of the following: non-pharmacological means such as willpower alone; health professional advice; self-help materials and various quit courses; pharmacological treatments such as nicotine replacement therapy (NRT) in the form of chewing gum, sub-lingual tablets, inhalers, lozenges and transdermal patches. There are also oral systemic bupropion and varenicline tablets.

It is important that the would-be quitter is given every bit of assistance possible by pharmacists.

People who continue to smoke despite having pulmonary disease or other smoking-related diseases are highly nicotine dependent and may require treatment with pharmacological agents to help them quit.

Nicotine dependence is a chronic condition with a high rate of relapse. Most former smokers had an average of five to six serious attempts to quit).

Nicotine replacement therapy (NRT). People must not continue to smoke when using nicotine replacement therapy. Treatment is usually required for up to 12 weeks. Doses can be tapered in the later stages. Combinations of nicotine products may be used for heavy smokers or those who have been unsuccessful previously. Before initiating nicotine replacement treatment or use of either bupropion or varenicline, contraindications should be carefully checked.

Bupropion is usually commenced 1-2 weeks before the quit date. It may be used in combination with NRT and treatment lasts for 12  weeks. Bupropion, which inhibits the uptake of dopamine and noradrenaline has antidepressant-like activity (indeed, in some countries, it is approved as an antidepressant as well as for smoking cessation) and exhibits antidepressant-like side effects.

Varenicline is a partial agonist of neuronal a4b2 nicotinic acetylcholine receptors (nAChRs), It blocks nicotine binding to these receptors, preventing the pleasurable effects of smoking, while its partial agonist activity only partially stimulates dopamine thereby reducing symptoms of nicotine withdrawal.  Varenicline is generally commenced 1-2 weeks prior to quit date and duration of treatment is 12-24 weeks. It is not recommended that nicotine replacement therapy be used when being treated with varenicline. Its major side effect is nausea, but there have been reports that some individuals may be “tipped” over into psychotic behaviours.

Smoking cessation is a process often described in terms of the Prochaska & DiClemente Stages of Change Model which depicts a circle commencing at the intention of not doing anything about it or not even acknowledging it as a problem through to a final maintenance of non-smoking behaviour.

The Prochaska & DiClemente Stages of Change Model

  • pre-contemplation stage (not currently considering change);
  • the contemplation stage (ambivalent about change at this point in time);
  • the preparation stage (some experience with change, trying to change);
  • the action stage (practising non-smoking);
  • the maintenance stage (continued commitment to not smoking) and unfortunately and all too often;
  • relapse (resumption of old habits) which then leads back to the pre-contemplation stage again.

Potential quitters should be counselled, that it is natural, normal and expected that smoking cessation is difficult and that they cannot expect to succeed the first time they try. Indeed, they may have many attempts to quit. The pharmacist should empathically indicate that that is perfectly alright.

Pharmacists and indeed, all health professionals should assess every patient’s smoking status, strongly urge all smokers to quit, identify these smokers willing to quit, develop a quit plan for these smokers, encourage pharmacological assistance, provide written materials and advice, follow-up and relapse prevention.

A really useful tool for pharmacists wanting to impress smokers with the cardiovascular and stroke risks associated with smoking is by means of demonstrating the cardiovascular Australian Risk Calculator for Cardiovascular and Stroke Disease which can be downloaded from

When you open this website, with the potential quitter, you can enter data for sex, age, smoking status, total cholesterol, HDL cholesterol, diabetes, and left ventricular hypertrophy (LVH).

The calculator allows the entry on yes/no, actual figures and yes/no or don’t know in the case of LVH. So, for example if you enter the following parameters for your potential quitter: sex (male) age (54), systolic blood pressure (145), smoking status (yes), total cholesterol (7.2), HDL cholesterol (0.9), diabetes (no) and left ventricular hypertrophy (don’t know) and then compare this result with the same data entered except that now the entry for smoking a no. This one change can reduce the total risk factor for cardiovascular and stroke disease from 22% (high risk) down to 13% (moderate risk).

This is a very powerful tool in that it is visual, the results are immediate and it clearly demonstrates the benefits of smoking cessation. In the above case, both the blood pressure and cholesterol were high and similar use of the calculator could motivate the individual to exercise and modify (if necessary) their diet to reduce blood pressure and cholesterol and increase HDL.

For more information about smoking and smoking-cessation programs call the Quitline 131848 or visit: National Tobacco Campaign

Associate Professor Louis Roller, from the Faculty of Pharmacy and Pharmaceutical Sciences Monash University, was the 2014 recipient of the PSA Lifetime Achievement Award.

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