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THE BOG
BLOG:
A technical update - July 2015 v1.0
Understanding Nicotine receptors We are all born with nicotine
receptors: when triggered, they release dopamine, the happy
hormone. But then dopamine levels quickly dip below baseline,
person feels low & anxious, so they smoke more. The dips in
mood caused by quitting smoking are acute. Regular smoking leads to
a 300x-increase in nicotine receptors, so for most smokers, smoking
is a chronic relapsing organic brain disease - not a lifestyle
choice.
Why quitting is so difficult It takes 24-48 hours for nicotine
to leave the body, but 6-8 weeks for nicotine receptors to be
down-regulated. The period in-between is hell. This is why only
2-3% of smokers succeed in quitting each year (and note that
success rates are validated by one-year quit rates). Willpower +
pharmacotherapy enables 4-6% to quit, trained support + willpower
10-15% but best of all is trained support + pharmacotherapy, the
combination achieving 20-30% quit rates. The trained support needs
to be available, accessible, empathetic & non-judgemental &
trained in motivational interviewing. The problem with advice to
stop smoking This is a negative message, you inevitably sound like
youre nagging, its not new information, frustrates both doctor and
smoker and encourages conflict and denial. And because it doesnt
work, so youre discouraged from doing it again!
So instead, Alex advocated the concept of Very Brief Advice
(VBA) for smokers:1. Establish & record smoking status (a QOF
point)2. Advise how to stop - best way is with support &
treatment3. Offer support & treatment (QOF).
Note that VBA deliberately does not advise them to stop, ask how
much or what they smoke, or even ask if they want to stop (they
nearly all want to stop). Its completely the opposite of a smoking
history! The advantages of VBA are many. Its quick (under 30
seconds), records smoking status (important, as even with optimal
help, 70%+ will relapse), opportunistic, positive, avoids nagging,
is informative, engaging - for most its new information, is
evidence based, and satisfies QOF. It is, however, not a smoking
cessation consultation - thats the next step, at which you have to
get across that its the nicotine that makes you smoke, but the
smoke that kills you - and how vital it is to take not one single
puff or youll wake up the nicotine receptors youre trying to switch
offThe drug options As well as NRT (see box, right) there are two
other pharmacological options: Bupropion (Zyban) 300mg OD for 10
weeks modifies dopamine levels & noradrenergic activity,
significantly increasing odds of a successful quit (1.94 LR) but is
now rarely used, mostly due to scare stories in the Daily Mail -
though its safety is comparable to SSRIs. Its still a valid choice,
but not as good or safe as Champix. Champix (verenicline) is a
partial nicotine agonist that both blocks & stimulates nicotine
receptors - it reduces the hit if the smoker does takes a sneaky
puff, but also reduces withdrawal symptoms. Main problem is nausea
- about one third of patients, tackled by adjusting dose,
anti-emetics, and taking it with food & water. There are no
clinically meaningful drug interactions, but its contraindicated in
ESRF, under 18s and pregnancy, and caution in mental health
problems and breastfeeding. However, MH patients have much more to
gain from quitting: monitoring is required during a
Champix-facilitated quit attempt, but theres no evidence of higher
rates of fatal/non fatal self-harm or depression cf. NRT.
Here are some (belated!) notes from 12 Dec 2014 Ysbyty Gwynedd
Grand Round - v good session
Feedback to this Bog Blog? Contact Linda Dykes (Consultant in EM
& occasional locum GP!) Email [email protected] -
www.mountainmedicine.co.uk
NW Wales CPD Catch-up SMOKING CESSATION Talk by Dr Alex
Bobak
The scale of the problem Cigarettes are a weapon of mass
destruction and a drug delivery system. It takes 7-10 seconds for
nicotine to hit the brain after inhaling - like a potentiated
intra-arterial drug delivery system (IV takes 3040 seconds).
Smoking is the single largest cause of premature death and over 50%
of smokers die prematurely, often after decades of morbidity.
Nicotine replacement Therapy- Nine different forms - the best is
the one the smokers wants to use - The hit is slower and
less addictive, significantly reducing withdrawal symptoms and
cravings cf. placebo.
- OR of successful quit vs. placebo = 1.77.
- Treat for 8-12 weeks with gradual withdrawal - don't stop
early. Also need to use enough: avoid under-dosing and irregular
use.
NB: e-cigarettes not yet recommended.
