Quit Smoking

5 A’s: Ask, Assess, Advise, Assist, Arrange F/U.

ASK

• Smoking History:
  • Duration of smoking
  • Frequency and quantity
• Previous Quit Attempts:
  • What methods were tried
  • Reasons for previous failures
• Reasons for Continuing:
  • Personal motivations for smoking

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ASSESS

• Readiness to Change:
  • Not ready, contemplating, ready to quit
  • Ask how they feel about their smoking and if they are ready to quit now
• Barriers to Cessation:
  • Fear of failure
  • Fear of weight gain
  • Triggers (social, stress)
• Nicotine Dependence:
  • Use the Fagerström Test for Nicotine Dependence:
    • How soon after you wake up do you smoke your first cigarette? (0-3)
    • Do you find it difficult to refrain from smoking in places where it is forbidden? (0-1)
    • Which cigarette would you hate most to give up? (1)
    • How many cigarettes per day do you smoke? (0-3)
    • Do you smoke more frequently during the first hours after awakening than during the rest of the day? (0-1)
    • Do you smoke even if you are so ill that you are in bed most of the day? (0-1)
• Assess Other Organ Disease:
  • Heart disease
  • Other cardiovascular risk factors

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ADVISE

• Discuss the pros and cons of smoking
• Discuss health complications associated with smoking
• Tailor the message to the individual’s readiness and concerns

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ASSIST

• Develop a Quit Plan:
  • Set a quit date
  • Identify triggers and develop coping strategies
• Encouragement:
  • Advise not to be discouraged by relapse; most quitters require several attempts
  • Any reduction is positive—focus on encouragement
• Support Resources:
  • Connect with someone who has quit
  • Provide QUIT packs or online resources
  • Distribute support information/pamphlets
• Coping with Barriers:
  • Use behavioral strategies for high-risk situations
  • Delay the urge to smoke
  • Take deep breaths (3 times)
  • Drink water
  • Find distractions (e.g., chew gum, use a toothpick)
• Cognitive Strategies:
  • Redirect thoughts away from smoking
  • Use logical reasoning to challenge cravings

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ARRANGE FOLLOW-UP

• Schedule follow-up within 1 week and again at 1 month after the quit date
• Discuss relapse prevention:
  • Identify high-risk situations and triggers
  • Plan coping strategies in advance
• Monitor Withdrawal Symptoms:
  • Inquire about nicotine withdrawal symptoms (cravings, anxiety, irritability)
  • These typically begin within hours of quitting, peak after a few days, and subside by 1 month

Pharmacotherapy

The strongest evidence supports using registered pharmacological therapies (e.g., bupropion, varenicline) combined with behavioral support.

Nicotine Replacement Therapy (NRT)

• Purpose: Relieves symptoms of nicotine withdrawal and facilitates abstinence.
• Forms Available: Long-acting patches and rapid-acting forms (gum, lozenge, inhaler, mouth spray, oral strip).Patches:
  • Advantages: Simple adherence, steady delivery.
  Acute-Dosing NRT:
  • Advantages: Allows for titration of dose and timing according to the individual’s needs.
• Combination Therapy: Using a nicotine patch with a faster-acting NRT (e.g., gum, lozenge) can increase six- to 12-month abstinence rates by about 5%.
• Duration: Normal course is 8 weeks, but can be extended if there are concerns about relapse.
• Contraindications:
  • Children aged <12 years
  • Known hypersensitivity to nicotine or any NRT component
  • Weighing <45 kg (lower dose may be needed)
  • Cardiovascular Disease: Generally safe in stable CVD; use with caution after recent myocardial infarction, unstable angina, severe arrhythmias, or cerebrovascular events.
• Pregnancy: Behavioral counseling is the first-line treatment. NRT safety in pregnancy is unclear; however, it may be less harmful than continued smoking. Discuss risks and benefits with the patient.
• Side Effects:
  • Patches: Skin irritation, redness, itching, rash
  • Gum/lozenges: Dyspepsia, nausea
  • Inhaler/mouth spray: Mouth and throat irritation
  • General: Insomnia, vivid dreams

Bupropion (Xyloban)

• originally developed and approved for use as an antidepressant.
• Bupropion has been shown to be less effective than varenicline for smoking cessation.
• Contraindicated if
  • history of seizures
  • eating disorders
  • taking monoamine oxidase inhibitorsprevious seziures
• not recommended for women who are pregnant or breastfeeding.
• Bupropion should be used with caution in people taking medications that can lower seizure threshold (eg antidepressants, antipsychotics, antimalarials, oral hypoglycaemic agents).
• SE:
  • insomnia
  • headache
  • dry mouth
  • nausea
  • dizziness
  • anxiety
• No additional effect to combine with NRT
• Dose:
  • 150mg dialy for 3 days
  • then 150mg BD for 9 weeks
  • patient should stop smoking in the second week of treatment.
  • Under PBS rules, a maximum of nine weeks of PBS-subsidised treatment with this drug is permitted per 12-month period

Varenicline – (Champix or Varenapix)

• Most effective
• Partial agonist nicotine receptors – helps to relieve cravings and withdrawal symptoms, and reduces rewarding effect
• A second course of varenicline can be considered to reduce relapse.
• Combining varenicline with NRT may improve quit rates
• Varenicline can be used in those who smoke with mental health problems, but must be monitored during quit attempts. should be advised to report
  • unusual mood changes
  • depression
  • behaviour disturbance
  • suicidal thoughts
  • stop using the medicine if these occur
• not recommended for pregnant and breastfeeding women, nor for adolescents.
• two options of starting
  • fixed option
    • setting a date to stop smoking
    • varenicline should start one to two weeks before this date
  • flexible approach
    • continues to smoke while starting varenicline dosing
    • then quits smoking between days 8 and 35 of treatment
• dosing
  • days 1–3: 0.5 mg daily
  • days 4–7: increase to 0.5 mg twice daily; and
  • continue with 1 mg twice daily from day 8 to the end of a 12-week treatment course
• Side Effects
  • Nausea – can be minimised by taking tablets with food, titration and self-regulation of varenicline (0.5–2 mg/day) Lower doses of varenicline are also effective if the full dose cannot be tolerated
  • Sleep disturbance
  • abnormal dreams
  • drowsiness
  • headache
  • constipation
  • dizziness
  • flatulence
  • Serious postmarketing adverse events include
    • Stevens–Johnson syndrome
    • erythema multiforme
    • myocardial infarction
    • cerebrovascular accident (including ischaemic and haemorrhagic events)
    • hallucinations
    • unusual or serious changes in behaviour or thinking
    • psychosis
    • suicidal ideation and suicide

note:

Champix (varenicline), a medication used for smoking cessation, was temporarily unavailable in Australia due to safety concerns. In June 2021, Pfizer voluntarily paused the global distribution of Champix as a precaution after detecting nitrosamine impurities (specifically N-nitroso-varenicline), which are considered potentially carcinogenic, in the drug.

Since the nitrosamine impurity is related to the manufacturing process of varenicline itself, it’s not limited to a specific brand like Champix. As a result, any varenicline-containing medication, such as Varenapix, could potentially have similar issues unless the manufacturer takes steps to mitigate or eliminate these impurities during production.

The Therapeutic Goods Administration (TGA) in Australia, along with other international regulatory bodies, reviewed the safety of Champix. Although there is no immediate risk from these impurities at the detected levels, the distribution halt was a precautionary measure while further assessments were conducted.

Nortriptyline

Overview: An antidepressant sometimes used for smoking cessation.

Side Effects: Dry mouth, constipation, nausea, sedation, headaches, arrhythmia.

Dosage: Start 10–18 days before the quit date and continue for 12 weeks; typically starts at 25 mg daily, gradually increasing to 75 mg.

E-cigarettes and Vapes for Smoking Cessation

Not a First-Line Treatment

• E-cigarettes are not recommended as a first-line treatment for smoking cessation. Established therapies, such as nicotine replacement therapy (NRT), bupropion, and varenicline, are preferred due to their stronger evidence base for efficacy and safety.
• The Royal Australian College of General Practitioners (RACGP) emphasizes the use of these registered pharmacotherapies in combination with behavioral support as the primary approach to smoking cessation.

Harm Reduction Perspective

• E-cigarettes may pose less harm than traditional cigarettes, but their long-term health effects remain unclear, and their use should be approached cautiously.
• For smokers who have not successfully quit using first-line therapies, vapes may be considered as a harm reduction tool in the context of an informed decision-making process and under medical supervision.

Caution for Young People

• There is increasing concern about the rising popularity of e-cigarettes among young people and non-smokers, raising the risk of nicotine addiction in this population.
• Guidelines stress the importance of preventing nicotine dependence in youth, as early nicotine exposure can have significant neurodevelopmental consequences.

Clinical Efficacy Evidence

• The efficacy of vapes for smoking cessation is still mixed, and large-scale, high-quality studies are needed to confirm their role.
  • A Cochrane Review (November 2022) assessed 78 studies involving 22,052 participants:
    • Nicotine vaping products (NVPs) had higher quit rates than NRT (RR 1.63, 95% CI 1.30-2.04), translating to four additional quitters per 100 people using NVPs.
    • Vapes containing nicotine showed higher quit rates than non-nicotine vapes (RR 1.94, 95% CI 1.21-3.13), representing seven additional quitters per 100 using nicotine vapes.
    • Compared to behavioral support/no support, quit rates were higher with nicotine e-cigarettes (RR 2.66, 95% CI 1.52-4.65), with two additional quitters per 100, though evidence quality was low due to potential bias.
• An Australian National University meta-analysis (September 2021) found a small benefit of freebase nicotine vapes over NRT for smoking cessation, although the evidence was of low certainty. Significantly higher quit rates were seen for freebase nicotine vapes compared to no intervention or usual care.

Regulation and Quality Control

• In Australia, vaping products are subject to varying regulations, and medical professionals must be aware of the quality control issues surrounding these products. Unlike conventional tobacco products, e-cigarettes may not be as tightly regulated, leading to potential concerns about product safety and consistency.

Dual Use

• Patients should be discouraged from using e-cigarettes as part of dual use (i.e., smoking traditional cigarettes alongside vaping), as this strategy may not significantly reduce overall health risks and may undermine efforts to quit smoking altogether.

Counseling and Support

• Behavioral counseling remains essential regardless of the cessation method chosen. Whether patients opt to use e-cigarettes or not, healthcare providers should offer comprehensive support and counseling to optimize quit rates and reduce relapse.

Research and Monitoring

• Ongoing research and monitoring of e-cigarette use are critical to understanding their safety, effectiveness, and long-term health impacts. Continuous evaluation will provide more clarity on whether e-cigarettes should play a larger role in smoking cessation programs.

References

• Royal Australian College of General Practitioners (RACGP) – Supporting Smoking Cessation: A Guide for Health Professionals.
• Cochrane Review (November 2022) – Nicotine Vaping Products for Smoking Cessation.
• Australian National University Meta-Analysis (September 2021) – Freebase Nicotine Vapes vs. NRT for Smoking Cessation.

Quit Plan

https://www.makesmokinghistory.org.au/quit-planner

Step 1 – Choose your reasons for quitting

Step 2 – Identify your triggers

triggers can be emotional, habitual, physical or social. Knowing your triggers will help you avoid them or find ways to handle them.

Step 3 – Fight your cravings

• fight your cravings.
• Cravings only last a few minutes at a time.
• When you feel like picking up a cigarette, there are many tricks you can use to push through the urge to smoke

Step 4 – Choose other tools to help you quit

• Different strategies work for different people.
• From quitting cold turkey to talking to a trained counsellor, there will be something that works for you.
• It may take some trial and error, but hang in there. You can quit.

Step 5 – Reward yourself

Resisting a lifelong habit is hard, you deserve to celebrate your milestones!

Celebrating small wins can help you achieve larger ones. Enter the milestone rewards that you will use to celebrate your success after 1 day, 1 week, and 1 month!

Example Quit Plan

1. Set a Quit Date

• Choose a specific date within the next 2-4 weeks to quit smoking. This allows time to prepare mentally and gather resources.
• Example Date: November 1, 2024.

2. Identify Triggers

• List situations, feelings, or activities that trigger cravings to smoke.
  • Drinking coffee or alcohol
  • Stressful situations
  • Social gatherings
  • After meals
• Develop strategies to cope with these triggers:
  • Substitute coffee with tea.
  • Practice deep breathing exercises during stressful moments.
  • Avoid high-risk social situations initially.

3. Choose a Quit Method

• Select one or a combination of methods:
  • Nicotine Replacement Therapy (NRT): Patches, gum, lozenges, inhalers, etc.
  • Prescription Medications: Bupropion or varenicline, as discussed with a healthcare provider.
  • Behavioral Support: Counseling or support groups.

4. Inform Friends and Family

• Share your quit plan with friends, family, and coworkers for support.
• Example Message: “I’ve decided to quit smoking on November 1. I’d appreciate your support during this time.”

5. Develop Coping Strategies

• Identify and practice strategies to manage cravings:
  • Physical Activity: Go for a walk or exercise when cravings hit.
  • Distraction Techniques: Use stress balls, chew gum, or engage in a hobby.
  • Relaxation Techniques: Practice deep breathing, meditation, or yoga.

6. Plan for Challenges

• Anticipate potential challenges and how to handle them:
  • Withdrawal Symptoms: Understand that cravings and irritability may occur; plan to use NRT or medications as needed.
  • Relapse Triggers: If you encounter a stressful situation, have a plan to cope without smoking (e.g., call a friend, go for a walk).

7. Track Progress

• Keep a journal or use an app to track cravings, moods, and successes.
• Celebrate milestones: Reward yourself for reaching goals (e.g., 1 week, 1 month without smoking).

8. Follow-Up Support

• Schedule follow-up appointments with a healthcare provider or counselor.
• Consider joining a support group: Local or online groups can provide encouragement and accountability.

9. Prepare for Relapse

• Acknowledge that relapse can happen; if it does, review what led to it and how to prevent it in the future.
• Revisit your quit plan: Make adjustments based on what worked and what didn’t.

Example Reflection Questions

• What made you want to quit?
• How will you handle cravings?
• What support do you need from others?

https://www.racgp.org.au/getattachment/c07241b0-9dc1-41bd-b25b-764389a675c9/Pharmacotherapy-for-smoking-cessation.aspx