Case 1.6 – Smoking Cessation (SDL)

Smoking is the leading preventable cause of death and disease. Health consequences include:

Cardiovascular disease:

• Coronary heart disease (2-4 times increased risk)
• Stroke (2-4 times increased risk)
• Peripheral vascular disease
• Aortic aneurysm
• Increased risk of sudden cardiac death

Respiratory disease:

• Chronic obstructive pulmonary disease (COPD) - 90% caused by smoking
• Chronic bronchitis
• Emphysema
• Increased respiratory infections
• Exacerbation of asthma

Cancer:

• Lung cancer (85-90% caused by smoking, 20-30 times increased risk)
• Other cancers: oral, pharyngeal, laryngeal, oesophageal, bladder, kidney, pancreatic, stomach, cervical, leukaemia

Other effects:

• Peptic ulcer disease
• Osteoporosis and fractures
• Impaired wound healing
• Erectile dysfunction
• Age-related macular degeneration
• Premature aging of skin
• Reduced fertility
• Complications in pregnancy (miscarriage, low birth weight, premature birth)
• Passive smoking effects on others

Mortality: Smokers die on average 10 years earlier than non-smokers. Up to half of all long-term smokers will die from smoking-related diseases.

The benefits of quitting smoking begin almost immediately and continue to increase over time:

Timeline of benefits:

Time after quitting	Health benefits
20 minutes	Heart rate and blood pressure drop
12 hours	Carbon monoxide level in blood returns to normal
2-12 weeks	Circulation improves, lung function increases
1-9 months	Coughing and shortness of breath decrease, cilia regain normal function
1 year	Risk of coronary heart disease is half that of a continuing smoker
5 years	Stroke risk reduced to that of a non-smoker. Risk of cancers of mouth, throat, oesophagus and bladder cut in half
10 years	Lung cancer death rate about half that of a continuing smoker. Risk of cancers of larynx and pancreas decreases
15 years	Risk of coronary heart disease returns to that of a non-smoker

Other benefits:

• Improved sense of taste and smell
• Whiter teeth, fresher breath
• Better skin appearance
• Increased energy and fitness
• Significant cost savings
• Better outcomes if surgery needed
• Protection of family/others from passive smoking

Important message: It's never too late to quit - even patients with existing smoking-related disease benefit from cessation.

Nicotine dependence:

Nicotine is highly addictive. It acts on nicotinic acetylcholine receptors in the brain, causing:

• Release of dopamine → pleasure and reward
• Increased alertness and concentration
• Appetite suppression
• Stress relief (perceived)

Dependence has three components:

• Physical dependence: Tolerance develops, withdrawal symptoms occur when stopping
• Psychological dependence: Smoking associated with certain activities, emotions, stress relief
• Social/behavioural factors: Habitual actions, social situations

Assessment of dependence - Fagerström Test:

• Time to first cigarette after waking (within 5 minutes = highly dependent)
• Number of cigarettes per day
• Difficulty refraining from smoking in forbidden places

Nicotine withdrawal symptoms:

• Cravings for nicotine (strongest symptom)
• Irritability, frustration, anger
• Anxiety and restlessness
• Difficulty concentrating
• Increased appetite and weight gain
• Depressed mood
• Sleep disturbance
• Headache

Withdrawal symptoms typically peak in the first week and gradually decrease over 2-4 weeks, though cravings can persist longer.

The "5 A's" is an evidence-based framework for smoking cessation counselling:

1. ASK about tobacco use

• Systematically ask all patients about smoking status at every visit
• Document smoking status in medical records
• Assess: current smoker, ex-smoker, never smoker

2. ADVISE to quit

• Provide clear, strong, personalised advice to quit
• "The best thing you can do for your health is to stop smoking"
• Link to current health problems or concerns
• Be non-judgmental and supportive

3. ASSESS willingness to make a quit attempt

• Determine readiness to quit (stages of change model)
• If ready to quit → proceed to Assist
• If not ready → use motivational interviewing, discuss barriers, provide information
• Assess level of dependence

4. ASSIST in quit attempt

• Help patient develop a quit plan:
  • Set a quit date (within 2 weeks)
  • Tell family/friends for support
  • Remove cigarettes and triggers from environment
  • Anticipate challenges (withdrawal, triggers)
• Provide practical counseling:
  • Avoid triggers
  • Develop coping strategies
  • Encourage alcohol reduction (often associated with smoking)
• Recommend pharmacotherapy (see next question)
• Provide self-help materials
• Refer to Quitline or cessation programs if appropriate

5. ARRANGE follow-up

• Schedule follow-up contact (phone or in person) within first week after quit date
• Assess progress, address problems, provide encouragement
• Continue follow-up as needed
• If relapse occurs → review what happened, learn from experience, encourage another quit attempt

Additional approach - "Ask, Advise, Help": A simplified version emphasizing brief intervention in every consultation.

Pharmacotherapy approximately doubles quit rates. Should be offered to all smokers making a quit attempt unless contraindicated.

1. Nicotine Replacement Therapy (NRT):

Provides nicotine without the harmful toxins in cigarette smoke, reduces withdrawal symptoms.

Form	Details
Patch	Provides steady nicotine level. Use for 8-12 weeks, gradually reduce strength. Can be combined with short-acting NRT
Gum	2mg or 4mg. Chew slowly, park between cheek and gum. Use when cravings occur, up to 15 pieces/day
Lozenge	Similar to gum, dissolves slowly in mouth
Inhaler	Mimics hand-to-mouth action of smoking
Nasal spray	Fastest nicotine delivery. Most effective for highly dependent smokers

Combination NRT: Patch (long-acting) + short-acting form (gum/lozenge) is more effective than single form alone.

Side effects: Local irritation, nausea, headache, sleep disturbance

2. Varenicline (Champix):

• Partial agonist at nicotine receptors
• Reduces cravings and withdrawal symptoms
• Blocks rewarding effects of smoking
• Start 1-2 weeks before quit date, continue for 12 weeks
• Most effective single pharmacotherapy
• Side effects: Nausea (most common), abnormal dreams, sleep disturbance. Rare: mood changes, suicidal ideation (monitor)
• Contraindications: Caution in psychiatric illness, pregnancy

3. Bupropion (Zyban):

• Antidepressant that reduces cravings and withdrawal
• Start 1-2 weeks before quit date, continue for 7-12 weeks
• Side effects: Dry mouth, insomnia, headache
• Contraindications: Seizure disorder, eating disorders, concurrent MAOIs
• Less commonly used than NRT or varenicline

Choosing therapy:

• First-line: Varenicline or combination NRT
• Consider patient preference, previous experience, contraindications
• All are more effective than placebo
• Should always be combined with behavioural support

Note: E-cigarettes (vaping) - role in cessation remains controversial. Less harmful than smoking but not harmless. Not currently recommended as first-line therapy in most guidelines.