Put out the smoke

The guilt of Christmas binging and New Year’s partying will lead to a surge of people looking to give up smoking and losing weight. Pupinder S. Ghatora looks at how community pharmacy can be at the forefront of helping people achieve their New Year’s resolutions.

New Year’s resolutions provide an opportunity for Community Pharmacists to help the population with their own personal health goals, a favourite of which is to quit smoking. Recently, some Primary Care Trusts have introduced a Patient Group Directive for smoking cessation and funding has been agreed to match that of local General Practitioners.

With smoking being such a headline issue, pharmacists would be foolish not to maximise the benefit for patients and in the process raise their profile by coming up with ‘rock solid’ methods to help patients quit smoking and stay smoke free!

As the recent drastic category M claw backs are causing serious concerns in the industry, pharmacists must look into other revenue streams to try and compensate for some of this major loss.

There are now various products available to aid quitters; however all of them would be of no use if the patient does not have the willpower to want to give up There are the following main categories of products:

• Patches
• Inhalators
• Oral dosage forms

The aim for our patients is to be smoke free within an eight week period, for some it is longer, for others shorter, but the overall result is to quit in about two months.

An abrupt withdrawal for some smokers leads to undesirable withdrawal symptoms and the temptation to light up again prevails. The reasons for the withdrawal symptoms is simply due to the increase in nicotine receptors in the brain as a result of the stimulation caused by smoking. That is why nicotine replacement therapy is a very effective tool in contributing to the quitting process. They help to reduce the cravings by gradually aiding the reduction of the ‘extra’ nicotine receptors and therefore result in a much lower risk of unpleasant withdrawal symptoms.

With the majority of patients, there are a number of factors which help gauge the level of addiction:

• How many cigarettes they smoke
• Do they need a cigarette on waking?
• Do they like the habitual acts associated with smoking?

If a patient is smoking less than five cigarettes per day, the treatment that a pharmacist should recommend is quite different
to someone who is smoking twenty to thirty a day.

Once the severity of a patient’s addiction has been established, the next step is to tailor the nicotine replacement therapy to their individual needs.

I have devised a simple questionnaire that takes no longer than a few seconds and helps to focus treatment for the patient. Below is an example of the form:

1) How many cigarettes do you smoke per day?
1-5  5-10  10-20  30+

2) Do you need a cigarette on waking?
Yes   No

3) Do you like the habitual aspects of smoking, e.g. holding the cigarette?
Yes No

4) Do you like to smoke your cigarette(s) quickly (lasts a few seconds) or slowly (lasts a few minutes)?
QUICK   SLOW

As you can see this is a very basic and quick form and is used as a template to build the plan for the patient.

Below is an example of a patient:
• How many cigarettes do you smoke per day?
1-5  5-10  10-20  30+

• Do you need a cigarette on waking?
Yes   No

• Do you like the habitual aspects of smoking, e.g. holding the cigarette?
Yes   No

• Do you like to smoke your cigarette(s) quickly (lasts a few seconds) or slowly (lasts a few minutes)?
QUICK   SLOW

From the number of cigarettes, you can establish that the patient is not a heavy smoker and can therefore is a candidate for the lower strength products, e.g. Niquitin 2mg lozenges, Niquitin patches step 3, Nicorette patches step 3, Nicotinell 1mg lozenges, Nicorette microtabs, Nicorette ihalators or Niquitin minis 2mg.

If a patient needs a cigarette on waking, then perhaps a 24 hour low strength patch can be recommended, e.g. Niquitin step 3 patch. This will give the patient a prolonged low dose of nicotine or you can recommend the Nicorette inhalator, this will give the patient control over the amount of nicotine they inhale and if smoking is more of a habit for them this will be the ideal treatment. Every patient I treat has a very personal treatment regimen. Some patients may even be put on a combination of products if they smoke a large quantity of cigarettes and hence require a large dose of nicotine.

I have some patients on a high strength 24 hour patch as well as Nicorette microtabs or inhalator or another oral therapy.

It is also a very common occurrence for the therapy to change throughout the quit programme. For example, initially the patient will need a high dose of nicotine to curb their initial cravings, so a high strength patch (24 hour if a cigarette is needed on waking or 16 hour if not). This could be combined with other oral therapy: a gum formulation if the patient likes to have a surge of nicotine and a break followed by another surge. If the patient wants an almost instant dose then a Nicorette microtab
or inhalator is recommended. If the patient feels they would like a sustained dose of nicotine, then you can recommend a lozenge formulation, a new one of which is the Niquitin Mini range. These are proving very popular due to their small size and nicotine release nature.

After a couple of weeks the patient’s physiological dependence on nicotine from smoking is significantly reduced and then the
type and strength of therapy will most likely be honed again to suit the patient’s current need. For example, the patient may not feel the urge for a cigarette first thing in the morning but still requires a dose of nicotine to see them through the day. In this case, the patient can opt for a lower strength patch and perhaps even change from a 24 hour to 16 hour formulation.

The pharmacist can also look at reducing the strength of oral therapy and perhaps even the type. Maybe moving away from a preparation that gives an initial high concentration of nicotine, to something that will give a lower dose over a longer period of time, i.e. changing from a Nicorette microtab to a Niquitin mini.

The important thing in any smoking cessation plan is to constantly modify and evolve the therapy to suit the patient and also monitor the progress. There is no point in giving the patient masses of information and nicotine replacement if you are not prepared to help them through the whole quitting cycle.

Your input as a pharmacist to this patient will undoubtedly increase the chance of him or her quitting rather than leaving them to their own devices. I have many patients who have managed to quit smoking due to my input into their therapy regime and for want of a better word ‘coaching’. You will find that the majority of smokers do want to quit they just need some
guidance from their local healthcare expert, which is YOU, to help them along the way.

A community pharmacists smoking cessation service can show that they are an essential part of transforming the country’s health for the better.