MedicineToday PEER REVIEWED ARTICLE POINTS: 2 CPD/1 PDP Strategies to help smokers who are resistant to treatment include intensive combination pharmacotherapies and the use of nicotine replacement therapy to reduce the harm caused by smoking. RENEE BITTOUN
It often amazes healthcare professionals that in denial about the consequences to them, thatpeople with asthma continue to smoke given they hold a self-exempting belief (‘it won’t happen
the widespread information available to them to me’).3 However, the group of ‘sick smokers’
detailing the harmful effects smoking has on
already face the consequences of their smoking.
health, and on theirs in particular. Recent National
Are they not serious about stopping smoking
Health Surveys have shown that in Australia about
and only make half-hearted quit attempts? Are
26% of people with current asthma were smokers,
they more dependent on smoking than other
which is considerably more than the national
smokers, and less likely to respond to behavioural
or pharmacotherapies? While most smokers want
Why do people with asthma and others that we
to quit, it is probable that there is a hierarchy of
see in clinical practice with respiratory, cardiac, vas-
quitting where the more dependent a smoker is,
cular and other sequelae from their smoking carry
the more resistant they may be to treatment and
on smoking despite our strong recommendations
the more intensive the intervention may need to be
to them to quit? Why do they continue when they
in order to effect a positive outcome.4 Table 1 lists
have heard the message to quit ‘a million times’?
features of smoking that indicate an individual
Are these smokers impervious to quit campaigns?
Is there something particular about this group, the
According to the DSM-IV, the definition of
a drug addiction incorporates the fact that ‘the
There is some evidence that some smokers are
substance use is continued despite knowledge
• There is a hierarchy of strategies available to help tobacco smokers that begins with permanent cessation and provides safe options for those people unable to achieve this.
• Some smokers respond well to some pharmacotherapies and others do not. Every smoking cessation pharmacotherapy for which there is substantiated evidence should be tried – a patient just might strike the most suitable one for them.
• The harm reduction strategy of reducing smoking by the use of nicotine replacement therapy (NRT) should be considered for treatment-resistant smokers. It is less harmful IN SUMMARY for a person to smoke while using NRT than it is to smoke without it.
• There is good evidence that it is never too late to quit smoking. Reducing smoking by the transient use of NRT may be a gateway to quitting for treatment-resistant smokers.
• Algorithms are provided for smoking cessation therapy options and the use of combination NRT in treatment-resistant smokers. 16 MedicineToday ❙ August 2007, Volume 8, Number 8 Table 1. Who needs extra help The treatment-resistant smoker Features indicating more help needed •
Smoking or symptoms of nicotine withdrawal
Features of little relevance in quitting ability •
of having a persistent or recurrent physical or psychological problem that is likely to have beencaused or exacerbated by the substance’.5 Thus thelikelihood that these ‘sick smokers’ are dependentis very high. If they are, then how can we helpthem? Can we expect spontaneous, unaided quit-ting in this group? The DSM-IV tells us that thistype of tobacco addict cannot quit in this way:‘there is a persistent desire or unsuccessful effortsto cut down or control substance use’.5 Is the preva-lence of smoking in Australia now low enough thatthose who could quit have quit, leaving a group ofhard-core resistant tobacco dependents?
Clinical judgement and psychological tact are important in helping smokers
It is immediately apparent that the resistant
quit. Patients who are persistent smokers can be helped towards better
smoker may have issues other than their own
health using the strategies of combining therapies or reducing harm.
physical health regarding their smoking. Smoking
Nicotine replacement therapy is but one of the available therapies.
in Australia today is associated with poorer mental
health.6,7 Depression and/or a history of depressionis a comorbidity extraordinarily common in activesmokers,8-12 and has been strongly linked in smok-
have antidepressant effects that maintain smoking,
ers with chronic respiratory disease and heart and antidepressants may substitute for this effect’.20disease.13,14 Smoking is also linked to socioeco-
Depression may be a feature of a smoker’s depen-
nomic status, lower income and poorer education
dency but, with the exception of bupropion and
being strongly linked with current smoking.15
the anxiolytic nortriptyline, unfortunately there is
Nicotine is a formidable antidepressant,16-18 and
no evidence to date that currently available anti-
self-medicating with it is a feature of smoking.
depressants generally help in smoking cessation.20
Depression can be measured by the amount of
The efficacies of bupropion and nortriptyline are
smoking and it is current best practice to assess
equal to those of nicotine replacement therapy
depression in some format in all chronic relapsing
(NRT);20 bupropion (Clorprax, Prexaton, Zyban
smokers. Even a simple one-line question such as
SR) has been indicated for smoking cessation but
‘Do you feel depressed?’ might be a pointer towards
risk of relapsing during a quit attempt.19 A recent
What then can be done for these ‘resistant’ or
Cochrane review acknowledges that ‘nicotine may
MedicineToday ❙ August 2007, Volume 8, Number 8 17 continued Table 2. Assessing risk factors for smoking cessation relapse Time to first cigarette (number
comes.22 Specialists in smoking cessation
and type irrelevant)
there is substantiated evidence should be
up the slogan, ‘More better, longer better’,
tried – a patient just might strike the most
for example bupropion, is not ‘successful’
Dealing with the ‘too late to quit’ patient Psychiatric history
patient then this does not imply that other
Psychologically, it is advisable to avoid
treatments may be equally unsatisfactory.
mentioning the ‘Quit or you’ll die’ black
Also, a patient doing extremely well on a
sider it is too late to quit smoking. They
• Alcohol abuse strongly predicts relapse
have invariably heard this before (proba-
with ‘rogue’ or mutant neuronal nicotine
be distressed by this ‘threat’, and this may
• Poor history of previous quit attempts
receptor subtypes are poor responders lead to a more anxious smoker. There
is good evidence that it is never too late
to quit. Every single smoker, irrespective
able that target these receptors, a patient
may just ‘luck-in’ and respond to these
usage of all pharmacotherapies to date for
smokers may require the delicate politics
smoking cessation, primarily because it is
of easing into quitting – a softer approach. Dealing with the ‘been there, done that’ patient
pharmacotherapies and others do not.
chewing gums, lozenges, inhalers and their nicotine intake is suppressed and
sublingual tablets) in treatment-resistant
relapsing will greatly improve your ability
gas are also reduced.23,24 It is, therefore,
algorithm is self-explanatory, some of less harmful for a person to smoke
‘off-label,’ but we are finding that more
pies head-to-head have been successful and more patients are requiring higher
doses of nicotine as ‘replacement’ to effect
interventions have been a great deal less successful outcomes. We have also found
that these intensive interventions are both
cessation therapies on page 21 shows safe and effective.
resistant to quit attempts or even to quit-
ting at all. There are no readily available
Temporary abstinence using NRT
markers, biological or psychosocial, have also been devised to target this Using NRT to provide temporary absti-that help us determine who will do better
18 MedicineToday ❙ August 2007, Volume 8, Number 8 continued Smoking cessation strategies for the treatment-resistant smoker The treatment-resistant smoker
If no absolute quitting, try harm reduction strategy‡
* NRT = nicotine replacement therapy. † Combination NRT = transdermal nicotine patch plus nicotine gum, lozenge, inhaler or sublingual tablet. ‡ Harm reduction strategy = alternating NRT with smoking to reduce number of cigarettes smoked or achieve temporary abstinence.
Note contraindications and that new drugs will be available soon.
encouraged as harm reduction. The British
smoking a cigarette with any form of NRT.
MedicineToday ❙ August 2007, Volume 8, Number 8 21 continued Bittoun combination nicotine replacement therapy algorithm Smokers in whom nicotine replacement therapy is appropriate
Try one 21 mg nicotine transdermal patch a day (apply each night
Before starting therapy, check for contraindications (pregnancy or
possible pregnancy, or cardiovascular event within 48 hours)
eliminated, go to C
go to B (i.e. two
patches plus B)
Continue for two weeks, then reduce added ‘breakout’ nicotine replacement therapy
Continue one 21 mg nicotine patch a day for a minimum of seven to eight weeks, then either stop completely or
wear patch on alternate days for a further week and then stop completely‡
* Applying patch before sleep allows the slow rise of nicotine overnight, strongly reducing the ‘urge’ for the first cigarette of the day. † No evidence in the literature or in the author’s experience of toxicity. ‡ No evidence in the literature for weaning (or reduction) of patch strengths.
Source: Bittoun R. A combination nicotine replacement therapy (NRT) algorithm for hard-to-treat smokers. J Smoking Cessation 2006; 1: 3-6. 22 MedicineToday ❙ August 2007, Volume 8, Number 8 continued
not particular to Australia alone. It repre-
abstinence is an appropriate strategy sents a typical confounding dilemma of
• relief of cravings and other nicotine
dependent non-Indigenous population. Identification, education and brief inter-vention are just some of the basic strate-gies aimed at this group, and culturallyappropriate strategies such as these will,in time, reduce smoking rates in thisgroup as well.
and ethnic (and also gender) differencesin nicotine metabolism through theCYP2A6 gene, and that these differencesaffect ability to quit smoking.28 These vari-ants have not been studied in Australianpopulations. Conclusion As with all medical conditions, clinical judgement and psychological tact are important in helping smokers quit. The strategies of combining therapies or reduc- ing harm are important avenues in these matters and can be pursued by clinicians keen to help their persistent smoking patients towards better health. A list of references is available on requestto the editorial office.
DECLARATION OF INTEREST: The author has receivedfinancial grants from time to time throughout hercareer from pharmaceutical companies producingsmoking cessation products. CPD Journal Program
for the online version, and a chance to win
a Navman F20 Portable GPS Navigator. 24 MedicineToday ❙ August 2007, Vol 8, Number 8
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