Home' Australian Pharmacist : Australian Pharmacist December 2014 Contents Australian Pharmacist December 2014 I ©Pharmaceutical Society of Australia Ltd.
CONTINUING PROFESSIONAL DEVELOPMENT
symptoms and cravings.
(Zyban, Prexaton) inhibits neuronal
uptake of dopamine and noradrenaline.
The mechanism by which it reduces
nicotine withdrawal symptoms and
the urge to smoke is unknown, but is
presumed to be noradrenergic and/or
Varenicline was found to be more
effective than bupropion in two
randomised controlled trials.
As bupropion is less effective than
varenicline, it should be reserved for
people for whom varenicline is not
appropriate (due to patient preference,
contraindications or adverse effects).
How should I use NRT?
Treatment with NRT requires
consideration of nicotine dependence,
and thus likelihood of withdrawal
symptoms (see Box 1). Higher-strength
dose forms are more effective for
smokers with a high level of nicotine
See Table 1 for information
on specific dose-forms. NRT should be
used for at least 12 weeks to maximise
the chances of treatment success.
Using a combination of two forms
of NRT has been shown to be more
effective than using a single form.
A patch (providing a steady level of
nicotine) plus short-acting NRT such
as a gum or lozenge (for breakthrough
cravings) can be useful for people who
do not have success with one form
alone, or who suffer from withdrawal
symptoms while using one type
For smokers not ready to quit abruptly,
cutting down the number of cigarettes
smoked with the use of NRT can increase
the number of people who continue
through to complete abstinence.
Smokers who use this method should
be informed that support is available for
them when they are ready to quit.
Long-term use of NRT (beyond
12 months) is not typically
recommended. However, in some
people, this may assist them in
remaining abstinent and it is considered
safer than returning to smoking.
COUNSELLING IN PRACTICE
Are there any side effects of NRT?
Adverse effects associated with NRT are
usually minor and transient; common
adverse effects include dizziness,
headache, nausea, vomiting, hiccups,
indigestion, abdominal pain, myalgia and
vivid dreams. Some adverse effects are
related to dose-form; oral and inhaled
products may irritation of throat and
mouth and sinusitis, patches may be
associated with application site reactions.
Several adverse effects associated with
NRT may be attributed to smoking
withdrawal symptoms, especially
headache, dizziness and sleep
Will NRT affect my other
There are no known clinically significant
drug interactions associated with NRT.
However, it is important to consider the
effects of smoking cessation on other
medicines the patient may be taking,
as some dose adjustments may be
necessary. See Table 2.
Is it safe to use NRT if I have other
Any risks posed by the use of NRT
outweigh those of the dangers of
be recommended for people with
cardiovascular disease. However, people
who have unstable angina or severe
arrhythmias, or have experienced
a recent myocardial infarction or
cerebrovascular event should seek
medical advice before use.
with these people is the effect that
nicotine has on the sympathetic nervous
system – increasing the heart rate, blood
pressure and cardiac output.
the use of NRT is still considered to be
safer than smoking, and smoking itself
increases the rate of cardiovascular
Particular dose forms may be less
suitable for certain people with7:
• dentures – avoid gum products
• asthma or COPD – avoid inhaled
• skin disorders – avoid patches
Box 1. 5As of smoking cessation1,4,7,8
Ask all patients about their smoking status
and record this information.
Provide recent quitters (<1 year) with
information about preventing relapse.
Assess the readiness to quit.
• How do they feel about smoking?
• Are they ready to stop smoking now?
• Would they consider quitting within the
next 6 months?
Assess nicotine dependence to determine
the likelihood of withdrawal symptoms and
the intensity/nature of support required.
• High: waking during the night to have a
cigarette or smoking within 5 minutes
after waking, smoking >30 cigarettes
• Moderate: first cigarette within
30 minutes of waking, smoking 20–30
cigarettes per day.
• Low-to-moderate: no smoking within the
first 30 minutes after waking, smoking
10–20 cigarettes per day.
• Low: no smoking within the first
60 minutes after waking, smoking
<10 cigarettes per day.
Provide repeated, consistent, positive and
non-confrontational messages about the
benefits of quitting at any life stage.
Offer brief advice at any appropriate
opportunity. For example:
• during pregnancy or when planning
• discussing health problems associated
with or worsened by smoking.
Offer advice, assistance and encouragement
to all smokers. Tailor assistance to the
smoker’s readiness to quit.
Arrange on-going follow up to discuss
progress and provide support. Scheduled
first follow up within a week of the quit
• congratulate and reinforce benefits of
• review progress and any challenges that
• assess treatment success and issues
• discuss coping strategies for high-risk
situations (i.e . emotional stress or social cues)
• encourage the use of ongoing support
services, e.g. QuitLine (137 848).
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