Nicotine Replacement Therapy (NRT) can increase the chances of a smoker quitting by 60% in comparison to unassisted quit smoking attempts, writes Leanne Philpott.
- Despite a decrease in the number of smokers over the last decade, smoking remains the leading cause of preventative death and disease in Australia.
- Combination therapy is safe and well tolerated.
- Single product NRT increases quit rates by 60%.
- Combination NRT is significantly more effective than monotherapy.
- Pre-cessation NRT use increases quit rates by 35% compared to starting on quit day.
- NRT is more effective if smokers receive counselling and support.
Speaking at the Australian Smoking Cessation Conference last year Dr Stuart Ferguson, senior research fellow at the Cancer Council Tasmania, explained that since first being introduced in Australia in the mid-1980s with nicotine gum, nicotine replacement therapy (NRT) has become the most widely used pharmacotherapy for smoking cessation.
However, there are common misconceptions among smokers that NRT is harmful, addictive and ineffective.
“NRT is considered safe and effective for first-line treatment and has been on the World Health Organisation’s (WHO) Essential Medicines List since 2009,” says Ferguson.
Yet despite this he says, “Smokers often fear that NRT is just as dangerous as smoking because they both contain nicotine, but this is not the case. NRT products are medications and are much, much safer than continuing to smoke.
“Smokers often mistakenly believe that the harmful effects of cigarettes and smoking are due to nicotine, but this isn’t true. The negative effects from smoking are due to the cigarette smoke itself, rather than the nicotine,” Ferguson explains.
Dr Colin Mendelsohn, GP and tobacco treatment specialist adds, “There are no serious harmful effects from therapeutic nicotine use, except in pregnancy. NRT is always safer than smoking. All forms of NRT can be used by patients with stable cardiovascular disease, but should be used with caution in people with recent myocardial infarction, unstable angina, severe arrhythmias and recent cerebrovascular events.”
In terms of NRT being addictive, Dr Mendelsohn says, “The risk of becoming addicted to nicotine replacement therapy (NRT) is very low, mainly because these products deliver nicotine much more slowly to the body than cigarettes and at much lower doses.
“About 5% of users are still using NRT after one year and in most cases this is to avoid relapse to smoking, which is a far more serious health concern. In most cases, users can cease persistent NRT use by abrupt or gradual cessation. A small number of smokers transfer their nicotine addiction from cigarettes to NRT, and this can be treated with varenicline or nicotine patches.”
Dr Mendelsohn adds, “Overthe-counter NRT is often used in inadequate doses, ceased prematurely and used incorrectly, so it may appear to be ineffective. In fact, Cochrane Reviews show that single product NRT increases quit rates by 60% compared to placebo. Combination NRT is as effective as Champix and triples success rates.”
THE CASE FOR COMBINED NRT
“Combination NRT (nicotine patch plus short-acting nicotine gum, lozenge, mouth spray, inhalator, or oral strips) is significantly more effective than monotherapy and is recommended for most smokers, especially more dependent smokers and those who are unable to quit using one NRT product alone, or experience cravings using only one form of NRT. The Cochrane Review found that combination NRT increases quit rates by 34% compared to monotherapy,” says Dr Mendelsohn.
“Combination NRT works against two types of cravings. Nicotine patches relieve background cravings due to low nicotine levels (but are not effective for acute cravings). Quick acting NRT is effective for breakthrough cravings. The combination also results in a higher dose of nicotine being used, which may further increase effectiveness,” he explains.
Ferguson says, “It’s important to talk to patients about the role of each of the products and why we think it is more beneficial to use combination treatment versus just patches or gum separately.”
He adds, “When and how NRT is used is as important as if the products are used, because it can have a huge impact on how effective they are. Thus it’s crucial to take patients through the usage instructions and make sure that they understand how they should use the medications, how much to use, and for how long.”
Dr Mendelsohn says, “Best practice is to start nicotine patches two weeks before quit day. Pre-cessation use increases quit rates by 35% compared to starting on quit day.
“Oral NRTs are effective as rescue medications for breakthrough cravings, especially the mouth spray and oral strips. Both products start to work in a minute and reach peak blood levels after 10 minutes. They are effective for cue-induced cravings, such as the urge to smoke when having a cup of coffee or seeing another person smoking.
“Pharmacists should advise that all oral NRTs should not be used while eating or drinking or within 10 minutes of eating and drinking, as this significantly uses nicotine absorption,” he says.
Dr Mendelsohn says pharmacists should give smokers careful instructions on the correct use of NRT:
- instruct the patient on the ‘chew and park’ method of gum use;
- advise that the nicotine inhalator is not to be inhaled into the lungs, only into the mouth;
- recommend the patient doesn’t cease NRT prematurely. A full course of 8-12 weeks is recommended;
- counsel on nicotine doses. The smoker should use enough to satisfy cravings and control withdrawal symptoms. Nicotine toxicity is rare;
- address myths about NRT, such as the belief that it is not safe to use NRT and smoke. In fact, there is no evidence that this is harmful; and
- address misconceptions about the safety, addictiveness and effectiveness of NRT. Research has shown that providing accurate information increases compliance.
COUNSELLING AND COMPLIANCE
“NRT is more effective if smokers receive counselling and support from a pharmacist,” says Dr Mendelsohn.
This advice is especially important given that just recently the ‘Prospective Cohort Study of the Effectiveness of Smoking Cessation Treatments Used in the “Real Word”’ found that OTC NRT without behavioural support is no more effective, or is even less effective, than no treatment at all.
The authors of the study did point out that this ineffectiveness might be largely due to ‘inappropriate usage and low adherence in the real world’—but this further highlights the importance of counselling patients and not just selling NRT without discussion.
Dr Mendelsohn says, “The message for pharmacists is that they need to provide effective counselling with NRT or their treatment may be ineffective, or even less effective than doing nothing.”
Quit Victoria executive director Fiona Sharkie says, “As a pharmacist, you can play a very important role in encouraging smokers to quit; you are one of the most frequently visited health professionals in Australia.
“Pharmacists often see their clients regularly so you can also provide reassurance and reinforcement about the benefits of quitting as well as monitor withdrawal symptoms and check on medication use,” she says.
Pharmacist Swarup Afsar from Pharmacy 777, Nollamara, WA, says, “You have to do more than simply provide the patches, the tablets or the gum. You need to understand the stress behind the whole quitting process for the consumer. For example, they might put on weight, they may suffer from anxiety or feel generally more stressed so you have to have a solution for this; but you can’t recommend anything too strong to address these symptoms as you don’t want them becoming addicted to something in place of nicotine.
“Ideally I sit down with the client one-on-one and find out why they want to quit in the first place, so I know that the will power is there. I discuss the withdrawal symptoms such as irritability, fluid retention, the anxiety that can occur and I’d mention some herbal options they can use to cater for these symptoms, if needed.
“It’s really about engaging customers so that they know you care. We have a monitor that records their carbon monoxide levels; the first time they use it the readings are high, but we see them after a week and it’s generally 60-70% less than the first reading—so we know their lungs have gone into the detox state already. Lungs can repair themselves pretty quickly and showing this is a good way to motivate a smoker. It helps remind them why they’re quitting and why it’s worth putting up with the possible symptoms of the nicotine withdrawal,” he says.
Afsar points out, “The NRT products come secondary to the advice and motivation.
“There are different NRT formulations and it’s about finding out which method is best-suited to the customer. Some people don’t like the patches as they may give them a rash—although they are very good. In this instance a spray or micro-tab might be a better option. You cater to the individual.”
He says the choice of NRT is also open to change. “Recommend they try one method of NRT but advise them that if it doesn’t work well for them they can change to something else.
“Every time you see someone who is trying to quit you should sit down with them and talk to find out if they are getting the relief they need from their NRT,” says Afsar.
Smoker counselling – TOP TIPS
Dr Mendelsohn says smoker counselling strategies include:
- providing information about what to expect when quitting such
as withdrawal symptoms and weight gain;
- identifying smoking triggers and planning coping strategies;
- discussing smoker barriers, such as weight gain, coping with stress, fear of failure, concerns about withdrawal;
- suggesting lifestyle changes, for example exercise and keeping busy;
- notivational interviewing—to motivate ambivalent smokers;
- social support. Enlisting the support of family and friends;
- promoting rewards as a motivational tool;
- setting a quit day; and
- follow up support and encouragement.