Update of New Zealand smoking cessation guideline
Full colour PDF of the pages as they appeared in ‘best practice’.
Printer friendly PDF.
The recently overhauled New Zealand smoking cessation guideline is well presented and contains important new messages. The guideline has been delivered to all practices and we advise clinicians to take a look.
The guideline is structured around a new memory aid and takes a fresh look at the evidence on methods for assisting smoking cessation. The most effective approach to smoking cessation is judged to be a combination of multi-session face-to-face or telephone support in combination with medication.
In addition, the guideline discusses the problem of assisting smoking cessation for people from population groups who are at particular risk including: Māori, Pacific people, Asian people, children, adolescents, pregnant or breastfeeding women and people with mental illness.
ABC for smoking cessation
|Ask||Ask about and document smoking status|
|Brief advice||Provide brief advice at least once per year to all people who smoke*
Personalise the advice
Acknowledge it may take several attempts to quit
Document that the advice was given
|Cessation support|| Prescibe medication (usually NRT)
Provide support such as Quitline or Aukati Kai Paipa
|* NNT =40 for abstinence at six months when advised by doctor.|
Primary care has a central role in increasing the number of quit attempts, which is the key to increasing quit rates. The emerging evidence seems to be that this role should be “broad” rather than “deep” – very brief advice to a lot of smokers is better than intensive advice to a few. Ensuring that patients are provided with NRT and shown how to use it is a good investment of time – any additional follow-up by primary care may be of lesser value and is resource intensive.
The basic principles of support are:
- Set a quit date
- Prescribe medication
- Emphasise the importance of complete abstinence
- Provide at least four support sessions
Nicotine replacement therapy (NRT) is safe and effective
Key points presented in the guideline are:
- NRT is safe and effective (NNT=14 for abstention at six months).
- The choice of NRT product can be guided by individual preference.
- Combining two NRT products (for example, patch and gum) increases abstinence rates.
- NRT should be taken for at least eight weeks.
- People who need NRT for longer than eight weeks (for example, people who are highly dependent) can continue to use NRT.
- NRT can be used to encourage reduction prior to quitting.
- People with cardiovascular disease can use NRT. However, if they have experienced a serious cardiovascular event (e.g. MI or stroke) in the past two weeks or have a poorly controlled disease, treatment should be discussed with a physician. Intermittent NRT products, for example, gum, inhaler, microtabs or lozenges are recommended rather than the longer-acting patches for such people.
- Pregnant women can use NRT after discussion of the risks and benefits. Intermittent NRT should be used in preference to patches.
- Young people (12–18 years of age) who are dependent on nicotine can use NRT if it is believed that the NRT may help. However, it is not recommended for occasional smokers, such as those who smoke on weekends only.
Nortriptyline, as effective as NRT
Nortriptyline is approximately as effective as NRT for smoking cessation (NNT=11 for abstinence at six months). There is no evidence that it is any more effective when combined with other smoking cessation medications.
Nortriptyline needs to be used with caution in people with cardiovascular disease and the other well known problems of the tricyclics need to be considered. There is insufficient evidence to recommend its use in adolescents or pregnant women.
Bupropion, as effective as NRT
Bupropion appears to be as effective as nortriptyline and has less potential for serious side effects. It is safe when used by people with stable cardiovascular or respiratory disease but has some contraindications, such as seizure disorders, CNS tumour, bulimia or anorexia nervosa, abrupt alcohol or sedative withdrawal, MAOI use and lactation. In addition, there is a wide range of precautions.
Bupropion is not currently subsidised in New Zealand.
Varenicline is effective
Varenicline is effective (NNT=8 for abstention at six months). It binds to nicotine receptors in the brain, reducing the severity of tobacco withdrawal symptoms and reducing the rewarding effects of nicotine.
Although it appears to have a good safety profile, adverse event data from general use are not yet available. There is insufficient evidence for its use in adolescents, pregnant women or people with unstable cardiovascular disease.
Varenicline is not currently subsidised in New Zealand.
Face-to face support
Face-to-face support increases abstinence rates at six months (NNT=20). Both individual and group sessions are effective.
Multiple telephone calls for proactive telephone support increase long-term abstinence rates and the addition of telephone support to medication increases smoking cessation rates above those of medication alone. Quitline works.
There appears to be no additional benefit from adding telephone support to multiple session face-to-face support.
Māori smokers want to quit and try to quit.
Smoking is a significant contributor to ethnic and socio-economic health inequalities. Parental smoking is a key risk factor for children and young people starting. Students with two parents who smoke are much more likely to be smokers (33%) than if only one (19%) or neither parent smokes (8%).
Māori smokers want to quit and try to quit. They are just as likely as non-Māori smokers to have made a quit attempt in the past year.
Most quit attempts in Māori, just as in the general population, end in relapse. The average smoker will make around 14 quit attempts before quitting successfully long term. The key is to encourage and support another quit attempt as soon as possible.
The focus should be on getting more smokers making more quit attempts
Health care professionals and health care providers have both the mandate to prompt quitting – most smokers want to quit – and the evidence, by way of the updated guidelines, of what to do.
Advice to stop smoking is often overlooked as an essential part of care for smokers. Nicotine replacement therapy doubles the likelihood of a quit attempt being successful. Regardless of the circumstances, adding support increases this likelihood.
Encourage Māori smokers to quit by providing NRT and promoting a variety of support options including those that take a whānau based, Māori specific approach in a Māori setting – such as Aukati Kai Paipa.
Peter Ellison, Māori Health Advisor, bpac.“Your smoking is the main influence on whether your children will smoke or not. So if you quit, you will not only improve your health but also the health of your children and your children’s children.”
Interventions are equally effective for Māori who smoke
Interventions that work in the general population (cessation support plus medication) are equally effective in Māori. For example Māori who call Quitline are just as likely to stop smoking as non-Māori callers and bupropion has been trialled and found effective for Māori.
Smoking rates for Māori are high, with 46% of over 15 year olds smoking and approximately 60% of Māori women between the ages of 15 and 39 years smoking.
Some Māori may be more likely to undertake smoking cessation programmes if they are informed that culturally appropriate services are available. For example Aukati Kai Paipa is a smoking cessation approach developed by Māori for Māori and the Quitline service offers the support of Māori Quit Advisers.
Like Māori, Pacific people and those of Indian ethnicity are at increased risk of cardiovascular disease. There is likely to be higher uptake of smoking cessation interventions if they are presented in a culturally appropriate way.
Pregnancy and breast feeding
When pregnant women stop smoking, there are benefits to mother and child.
The benefits of using oral NRT for smoking cessation in pregnancy and breastfeeding outweigh any potential adverse effects of nicotine on the infant. There is a wide range of toxins in tobacco smoke that are harmful to both mother and child, whereas NRT used intermittently, such as by gum, inhaler, microtab or lozenge, results in a very low level of nicotine exposure to the foetus or breastfeeding infant.
Children and young people
Although there is limited evidence about smoking cessation in children and young people, NRT is less harmful than smoking and can be used along with cessation support, if it is likely to benefit that individual.
People with mental illness
People with mental illness often have not been advised to stop smoking but are likely to benefit from smoking cessation. Caution is required around medication dosage as tobacco smoke speeds up the metabolism of some drugs used to treat mental illness.
Bupropion has been shown to be effective, at least in the short term, for this population group and appears to have a good safety profile.
Guideline reference: Ministry of Health. 2007. New Zealand Smoking Cessation Guidelines. Wellington: Ministry of Health. August 2007.
Evidence of lack of effectiveness
There is evidence that the following interventions are no more effective than placebos which provide the same amount of time and attention to the participant.
- Laser therapy
- Electro stimulation
There is insufficient evidence on the following methods to be able to draw a conclusion on their effectiveness or lack of it.
- Allen Carr’s method
- St John’s wort