Addictions

Tobacco smoking:
Nicholas A Zwar
Colin P Mendelsohn
options for helping
smokers to quit
Robyn L Richmond

Background There has been great progress in tobacco control in

Although great progress has been made on tobacco control, Australia. Smoking rates in the population have fallen
smoking remains one of the most important causes of and, currently, approximately 15% of people aged 14 years
preventable disease and death in the Australian population. and over are daily smokers.1 However, certain groups, in
The general practice team has much to offer in helping particular Aboriginal and Torres Strait Islander peoples,
smokers to quit.
have much higher smoking rates.2 Smoking remains
Objective common in people with mental health problems.3 Despite
This article provides practical advice on structuring smoking the falling overall prevalence, tobacco use still causes a
cessation support in primary care using the 5As (Ask, Assess, higher burden of disease than any other behavioural risk
Advise, Assist and Arrange follow-up) framework. Up-to-date factor. On average, smokers live 10 years less than non-
information on pharmacotherapy and issues for special groups smokers and 60% of long-term smokers will die prematurely
are also covered.
from a smoking-related disease.4,5 Most smokers are
Discussion nicotine-dependent and for these people smoking can be
The chances of successful quitting are maximised if the considered a chronic medical illness that requires ongoing
patient receives behavioural support combined with drug care.6
treatment, if nicotine-dependent. Special groups needing
support include Aboriginal and Torres Strait Islander peoples,
Most smokers would like to quit and approximately 40% have made
people with mental illness and pregnant women.
at least one attempt to do so in the past year.7 The good news is that
Keywords smoking cessation has substantial and rapid health benefits.4 Primary
tobacco smoking; preventive medicine; smoking cessation care has a major role in helping smokers to quit successfully. Brief
products; treatment advice from a general practitioner (GP) increases cessation rates
by about two-thirds, compared with no advice, and is highly cost-
effective.8 Practice nurses also have an important role in providing this
support.9

The 5As approach

The 5As provide health professionals with a framework for structuring
smoking cessation support. The elements of the 5As are ask, assess,
advise, assist and arrange follow-up.10 Figure 1 shows this approach
in detail. The key features are:
• Ask: regularly ask all patients if they smoke and record the
information in the medical record.
• Advise: advise all smokers to quit in a clear, unambiguous way
such as ‘the best thing you can do for your health is to stop
smoking’.
• Assess: assessment of interest in quitting helps to tailor advice
to each smoker’s needs and stage of change. Nicotine dependence
should also be assessed as this helps to guide treatment.

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 Assessment of other relevant problems, such as mental health • Describe withdrawal symptoms and cravings and explore ways of
conditions, other drug dependencies and comorbidities, is necessary managing these (eg distraction strategies such as doing exercise).
to develop a comprehensive treatment plan. • Agree on a quit date and promote the ‘not-a-puff’ rule.
• Assist: all smokers should be offered help to quit. • Address barriers to quitting and how to overcome these (Table 1).
• Arrange: follow-up visits have been shown to increase the • Assist with choice of medicines and ensure that patients have a
likelihood of long-term abstinence and are especially useful in the realistic expectation of how these medicines can aid quit attempts,
first few weeks after quitting. for example, by reducing withdrawal symptoms.
When time is short, the approach of ‘very brief advice’ developed • Identify smoking triggers and discuss strategies to cope with them.
by the United Kingdom National Centre for Smoking Cessation and For example, minimal or no alcohol in the early weeks of a quit
Training (see Resources) is an alternative. The steps for this are: attempt is advised.
establish smoking status (ASK), ADVISE that the best way of quitting is • Get support from family and friends, patient support services and
with a combination of behavioural support and drug treatment, REFER printed materials.
– provide a referral to a specialised service. • Promote lifestyle changes, such as exercise and avoiding high-risk
In the Australian context, referral options outside the general situations.
practice include: • Provide relapse prevention advice.
• Quitline (137 848), which provides free telephone counselling Relapse is defined as a return to regular smoking. It is most
Australia-wide. Referral from general practice to the local state or common early in the quit attempt (in the first 8 days).13 Follow up
territory Quitline can be provided by fax or email (Victoria and SA) with professional and social support is encouraged to try to prevent
and some states (Victoria, SA and NSW) now provide feedback to relapses but there are currently no proven behavioural interventions.14
the referring practitioner. Most smokers make repeated attempts to quit before finally achieving
• The Australian Association of Smoking Cessation Professionals long-term abstinence. Each attempt is a valuable learning experience,
website (www.aascp.org.au) has a searchable listing of accredited making the next attempt more likely to succeed. Smokers should be
tobacco treatment specialists. encouraged to keep trying to quit and to make use of evidence-based
support to maximise their chance of success.
Counselling and behavioural therapy
If support is being provided in the practice by the GP or practice Smoking cessation pharmacotherapy
nurse, the following counselling and behavioural strategies can assist Meta-analyses of clinical trials provide high-level evidence that
smokers to quit successfully.11,12 medicines can assist smoking cessation.15 Pharmacotherapy should be
• Build rapport and boost motivation. offered to people who are nicotine-dependent and is most effective

Table 1. Barriers to quitting smoking

Barrier Discussion
Weight gain Weight gain after quitting is, on average, 4–5 kg after 12 months. The health benefits of quitting is
almost always greater than the health effect of the extra weight. Drinking water and choosing low-
calorie foods can help minimise weight gain. Suggest focus on stopping smoking in the short term and
deal with any weight gain later. About 1 in 5 quitters do not gain weight.
Coping with Explain to smokers that smoking actually increases stress and that they will be more relaxed after
stress quitting. Some smokers experience repeated episodes of anxiety and restlessness during the day due
to nicotine withdrawal between cigarettes. Understandably, when a cigarette relieves these symptoms
they assume that the cigarette is relaxing them. Other healthier and more effective ways to relax
include breathing and progressive muscle relaxation techniques.
Withdrawal Cravings last only 2–3 minutes, although that may feel like forever! Cravings get weaker and less
from nicotine frequent over time but can persist for many years. Nicotine withdrawal symptoms are at their worst
in the first week and typically last 2–4 weeks. They can usually be controlled with stop-smoking
medications and behavioural strategies such as distraction techniques and avoiding smoking triggers.
Fear of failure Explain that most ex-smokers made a number of quitting attempts before finally being successful.
Unsuccessful attempts at quitting can be reframed as learning experiences and can increase the
chance of success next time. Furthermore, with the right professional counselling, support and
medication, the odds of success are much higher.
Peer or social It may be best to avoid friends who smoke for the first few weeks. Suggest asking friends not to offer
pressure cigarettes and, if possible, not to smoke around your patient. If necessary, leave the room while they
smoke. Discuss how to respond if offered a cigarette. If the partner smokes, ask him or her to smoke
outside.

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 FOCUS Tobacco smoking: options for helping smokers to quit

Ask all patients Ask all patients • Affirm choice not to

Do you smoke tobacco? No Have you ever smoked? No smoke and record
smoking status
• Record smoking status
(current smoker) Yes (never smoked)

• Affirm decision to quit and record smoking status

(ex-smoker)
Yes • Give relapse prevention advice if quit <1 year,
and ongoing encouragement for 5 years

Assess Assess nicotine dependence

• Assess stage of change: • Nicotine dependence can be assessed by asking:
–– ‘How do you feel about your –– How many minutes after waking to first cigarette?
smoking at the moment?’ –– Number of cigarettes per day?
–– Are you ready to stop –– What cravings or withdrawal symptoms in previous quit attempts?
smoking now?’
• Smoking within 30 minutes of waking, smoking more than 10 cigarettes per
• Record stage of change day and history of withdrawal symptoms in previous quit attempts are all
• Assess nicotine dependence markers of nicotine dependence
• Pharmacotherapy for dependent smokers is proven to double the chances of
successfully quitting

Advise
All smokers should be advised to quit in a way that is clear but non-confrontational
eg. ‘The best thing you can do for your health is to quit smoking’

Assist – not ready Assist – unsure Assist – ready Assist – action

• Discuss the benefits • Do motivational • Affirm and encourage and maintenance
of quitting and risks interviewing: ‘What are • Provide a Quit Kit and • Congratulate
of continued smoking the things you like and discuss a quit plan • Discuss relapse
• Provide information don’t like about your prevention
smoking?’ • Recommend
about not exposing pharmacotherapy for • Review and reinforce
others to passive • Explore motivation and nicotine-dependent benefits of quitting
smoking barriers to quitting smokers (see Assess) • Offer written
• Advise that help is • Offer written information • Discuss relapse information (e.g. Quit
available when they (eg. Quit Kit) and referral prevention Kit) and referral to
are ready to Quitline 13 7848 or Quitline 13 7848 or
a tobacco treatment • Offer referral to Quitline
13 7848 or a tobacco a tobacco treatment
specialist specialist
treatment specialist

Successful quitter Arrange follow up Relapse

• Congratulate and • For patients attempting to quit, arrange follow- • Offer support and
affirm decision to quit up visits, if possible reframe as a learning
• Discuss relapse • At these visits: experience
prevention –– congratulate and affirm decision • Explore reasons for
• Offer ongoing relapse and lessons for
–– review progress and problems
encouragement for future quit attempts
at least 5 years after –– encourage continuance of pharmacotherapy
• Offer ongoing support
quitting –– discuss relapse prevention
• Ask again at future
–– encourage use of support services consultations
OR
• Refer to Quitine 13 7848 or a tobacco
treatment specialist

Figure 1. The 5As structure for health professionals for smoking cessation.
Adapted with permission from the Royal Australian College of General Practitioners10

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 Tobacco smoking: options for helping smokers to quit FOCUS

when used in combination with behavioural support. The medicines Bupropion

approved for smoking cessation in Australia are nicotine replacement Bupropion is another effective medicine with similar efficacy as
therapy (NRT), varenicline and bupropion. These medicines have been NRT monotherapy.15 The major concern is a small risk of seizure
shown to be effective in a range of patient populations including (approximately 1 in 1000). Bupropion is contraindicated in patients
smokers with depression, schizophrenia, and cardiac and respiratory with a history of seizures, eating disorders and in patients taking
diseases. A recent Cochrane network analysis concluded that monoamine oxidase inhibitors. It should be used with caution in
combination NRT (nicotine patch combined with a fast-acting oral form) people taking medications that can lower seizure threshold, such as
and varenicline are the most effective forms of drug treatment and antidepressants and oral hypoglycaemic agents.10 The duration of
work equally well.15 Bupropion and NRT monotherapy are equivalent in treatment is 8 weeks.
efficacy.15 The choice of pharmacotherapy should be guided by clinical
suitability and patient preference (Figure 2).10 Even when smokers What are other approaches to
receive pharmacotherapy and professional support, overall cessation supporting smoking cessation?
rates from treatment are modest: 25–30% of smokers quit on any given Currently, there is considerable debate about whether e-cigarettes
attempt10,15 (Figure 3). have a role in assisting smoking cessation. E-cigarettes are battery-
powered devices that deliver nicotine in a vapour. There is some
Nicotine replacement therapy evidence that e-cigarettes can relieve cravings and other symptoms
NRT is available in a long-acting form (nicotine patch) and a variety of nicotine withdrawal but there is limited evidence so far on their
of fast-acting oral forms (gum, inhalator, mouth spray, lozenge, oral efficacy as aids to cessation and major concerns about their current
strip). All forms of NRT monotherapy have similar efficacy in increasing unregulated status.19,20 E-cigarettes have the potential to act as a
long-term cessation, compared with placebo (relative risk 1.60, 95% gateway to smoking and undermine progress on tobacco control by
confidence interval 1.53–1.68).16 There is increasing evidence, however, renormalising smoking behaviour.21
that combining the patch with an oral form of NRT is more effective Promising areas of research include the use of exercise to assist
than monotherapy and should be offered to all nicotine-dependent smoking cessation and the role of mindfulness strategies.22,23
smokers using NRT.16 Pre-cessation treatment with a nicotine patch
(usually started 2 weeks before quit day) has also been shown to
Special groups
improve success rates, compared with starting the patch on quit day. As Several population groups have either higher rates of smoking or
is the case with all forms of pharmacotherapy for smoking cessation, it greater risk of adverse effects. One in two Aboriginal and Torres Strait
is important to help patients understand that to gain maximum benefit Islander adults smokes and smoking is the largest single risk factor
they need to take a sufficient dose of NRT to relieve cravings and contributing to the health gap between Aboriginal and Torres Strait
withdrawal symptoms. NRT should also be taken for a sufficient length Islander and non-Indigenous populations. Smoking rates in prisoners
of time, generally at least 8–12 weeks. A helpful analogy is a plaster are around 83%.24 One in three people with mental illness smokes and
for a fracture – the support needs to be in place for long enough for the the level of nicotine-dependence is usually higher than in the general
healing process to occur. population.3 There is evidence that people with mental health problems
are just as motivated to quit but the intensity and duration of support
Varenicline needed is greater.25–27
Varenicline is a nicotinic receptor partial agonist, which acts centrally Pregnant women are in an important group due to the adverse
to relieve cravings and withdrawal symptoms as well as reducing effects of smoking on the fetus and the increased risk of pregnancy
the rewarding effect of smoking. Varenicline is the most effective complications. Counselling interventions reduce the proportion of
monotherapy currently available – a Cochrane network meta-analysis women who continue to smoke in late pregnancy by about 6%.28
found it more than doubled sustained abstinence rates at 6 months There is inconclusive evidence on the efficacy of NRT in pregnancy.29
follow-up, compared with placebo (risk ratio 2.88, 95% CI 2.40–3.47).15 However, expert opinion is that use of NRT in pregnancy is less
Nausea occurs in about 30% of users but can be minimised by harmful than continued smoking.30 If NRT is used, the possible risks
gradually up-titrating the dose and having the tablets with food.17 and benefits should be discussed. Fast-acting oral forms are generally
Although there have been concerns about neuropsychiatric adverse preferred to reduce total nicotine dose. For a more detailed discussion
effects with varenicline, the evidence from a recent meta-analysis of smoking in pregnancy see the article by Mendelsohn in the January/
is that, compared with placebo, there is no increase in rates of February 2014 edition of AFP.31
suicidal events, depression or aggression/agitation in patients taking
varenicline. This was the case in smokers with and without a history of Effects of smoking and smoking
psychiatric disorders.18 The usual duration of treatment is 12 weeks and cessation on drug metabolism
for those who have quit successfully at the end of treatment, a second Chemicals in tobacco smoke accelerate the metabolism of many
course of 12 weeks can be prescribed to reduce relapse. commonly used drugs by inducing the cytochrome P450 enzyme

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 FOCUS Tobacco smoking: options for helping smokers to quit

CYP1A2. This can substantially lower serum concentrations and Harm reduction
effectiveness of these drugs in smokers (Table 2). Conversely, blood Simply cutting down on smoking has not been shown to be sustainable
levels of these medications may rise when smoking is stopped. or have health benefits but there is some evidence to support harm
Patients should be monitored for adverse effects, and dose reductions reduction using NRT. The most important finding is that in smokers
may be required. Particular care is needed for drugs with a narrow unwilling or unable to quit, cutting down with NRT nearly doubles the
therapeutic index, such as clozapine, olanzapine and warfarin.32 chances of smokers progressing to quitting altogether.33

Choice of pharmacotherapy
• Suggest therapy based on assessment of clinical
suitability and patient preference

Nicotine replacement therapy Varenicline Bupropion sustained release

(NRT) Clinical suitability Clinical suitability
Clinical suitability Can be used in adult smokers Can be used in adult smokers
Can be used in all groups of including those with chronic including those with chronic
smokers including adolescents. illnesses. Contraindicated in illnesses. Contraindicated in
Use with caution in pregnant pregnancy and under the age patients with current or past
women and patients with of 18. Caution with significant seizures, concurrent use of
unstable cardiovascular disease psychological/psychiatric disease. monoamine oxidase inhibitors,
(check product information [PI]). Nausea in 30% of patients. Reduce pregnancy. Caution with other
dose in severe renal impairment conditions or drugs that lower
Patient choice (check PI). seizure threshold (check PI).
• Reasons to prefer: Patient choice Patient choice
• Availability without Reasons to prefer:
prescription Reasons to prefer:
• on current evidence, varenicline is • oral non-nicotine preparation
• Concerns about side effects of the most effective monotherapy
varenicline and bupropion • relapse in past using NRT
• oral non-nicotine preparation
• Can be used in pregnancy after • evidence of benefit in chronic
• evidence of benefit in chronic disease and depression.
discussion of risks and benefits
disease
• Variety of delivery systems and
• lack of drug interactions.
dosage forms available.

• Discuss benefit of follow up • Give initial prescription and • Give initial prescription and
visits, especially if there are arrange follow-up visit arrange follow-up visit
adverse effects such as skin • Encourage use of support services • Encourage use of support
irritation, sleep disturbance services
• At follow up, review progress and
• Encourage use of support common adverse effects such as • At follow up, review progress
services nausea and abnormal dreams and common adverse effects
• Encourage completion of at • Check for neuropsychiatric such as insomnia, headache
least 8 weeks of therapy symptoms and dry mouth
• Consider combination NRT • Encourage completion of 12 weeks • Monitor for allergy problems
(patch and quick-acting oral of therapy (skin rash)
form) if highly dependent or • Encourage completion of 8
withdrawal not controlled on • If quit further 12 weeks available
on PBS to reduce relapse weeks of therapy
monotherapy
• Arrange further follow-up visits as • Arrange further follow-up
• Arrange further follow-up visits visits as needed.
as needed. needed.

Figure 2. Pharmacotherapy treatment algorithm for nicotine dependent smokers.

Reproduced with permission from the Royal Australian College of General Practitioners10

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 Tobacco smoking: options for helping smokers to quit FOCUS

Conclusion advice on smoking cessation programs to Pfizer and GlaxoSmithKline

Australia and has received support to attend smoking cessation
The general practice team has much to offer in helping smokers to
conferences; Colin Mendelsohn has received honoraria for teaching,
quit. This can range from a very brief intervention where smokers
consulting and conference expenses from Pfizer, GlaxoSmithKline and
are identified and referred for treatment, to a structured program of Johnson & Johnson Pacific.
evidence-based support provided within the practice. The chances of
Provenance and peer review: Commissioned, externally peer reviewed.
successful quitting are maximised if the patient receives a combination
of behavioural support and drug treatment. Resources
• Australian Smoking Cessation Guidelines, www.racgp.org.au/your-
Authors practice/guidelines/smoking-cessation/
Nicholas A Zwar MBBS, MPH, PhD, FRACGP, Professor of General
• United States Smoking Cessation Guidelines, www.ahrq.gov/
Practice, School of Public Health and Community Medicine, University
professionals/clinicians-providers/guidelines-recommendations/
of New South Wales, Sydney, NSW. n.zwar@unsw.edu.au
tobacco/clinicians/treating_tobacco_use08.pdf.
Colin P Mendelsohn MBBS (Hons), Tobacco Treatment Specialist, The • Tobacco in Australia: Facts and issues. 4th edn. Melbourne: Cancer
Sydney Clinic Consulting Rooms, Bronte, NSW Council Victoria; 2012. A comprehensive review of the major
Robyn L Richmond MA Syd, MHEd, PhD, Professor of Public Health, issues in smoking and health in Australia, compiled by the Cancer
School of Public Health and Community Medicine, University of New Council Victoria, www.TobaccoInAustralia.org.au.
South Wales, Sydney, NSW • Society for Research on Nicotine and Tobacco and the Society for
Competing interests: Nicholas Zwar has received honoraria for providing the Study of Addiction. The website has links to clinical practice

Table 2. Drugs that interact with smoking: blood levels rise after cessation of smoking
Class Medication
Antipsychotics Olanzapine, clozapine,
Antidepressants Duloxetine, fluvoxamine, tricyclic antidepressants, mirtazapine
Antianxiety agents Alprazolam, oxazepam, diazepam
Cardiovascular drugs Warfarin, propranolol, verapamil, flecainide
Clopidogrel (efficacy increased in smokers)
Diabetes Insulin, metformin
Other Naratriptan, oestradiol, ondansetron, theophylline, dextropropoxyphene
Others Caffeine, alcohol

28%
Active drug Placebo

24%

19% 19%

17%
16% 16%
% Quit

12% 12%
11%
10% 10%
9%
8%

Nicotine gum Nicotine patch Nicotine lozenge Nicotine Nicotine inhaler Bupropion Varenicline
nasal spray

Figure 3. Long-term (>6 month) quit rates for widely available cessation medications15–17

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 FOCUS Tobacco smoking: options for helping smokers to quit

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