¶ Intro / Opening
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¶ Introduction and Kym Yuke's Role
It's Christina from The Good GP. In today's episode on smoking cessation, I interview Kim Muke, an Aboriginal health worker. who specializes in this very topic. We found we had so much content to get through, lots of really practical tips and clinical pearls that actually there was enough information to go over two parts.
So stay tuned for this first section where we talk about assessing a patient who is wanting to quit smoking as well as looking at options in terms of nicotine replacement therapy and make sure you tune in for the second part as well where we talk about special population groups as well as the use of non NRT. supports for smoking cessation, including Verena Klein. I hope you enjoy the podcast. Welcome to the podcast, Kim, and thanks so much for joining me today.
Thank you, Christina.
Now, Kim, you are working in primary care and almost exclusively really in the area of smoking cessation. Do you want to tell me a bit more about your role and how you got into that?
Sure. I have a background as an indigenous background to start with, so hence I've ended up working in Indigenous health. I started off as a nurse. and then did health promotion, later on did public health. I was working in this role originally in broader health promotion, looking at healthy lifestyle generally. We noticed as a service that there was a great need for tobacco treatment as well as promoting a healthy lifestyle with with non smoking, but to actually help people to quit.
So my service has really evolved from that. So I do a lot of one on one. I've got a very flexible way of working um because we're in the indigenous community. I offer home visits for people that can't come in. I also have a great deal of support from management to offer free NRT. I work closely with the GPs who can support me by prescribing Champic.
And so yeah, uh um as a result I have have a very, very busy practice because as peop most people would know, the indigenous community has very high rates of smoking.
Yeah, absolutely. Excellent. And so I mean I can't thank you enough for joining me today. You bring a lot of ex expertise and experience with this topic so I really appreciate it. I think it's a great topic for us as GPs to learn a bit more about and it's a great opportunity to update ourselves with the latest evidence and guidelines and quite
timely because the RAC GP has recently released their updated guidelines, the Supporting Smoking Cessation, a Guide for Health Professionals. A great resource, very evidence based and I'd encourage the GPs and you know, even other health professionals out there that might be listening to have a look through that um if they do want some extra information.
Yeah.
¶ Assessing Readiness and Nicotine Dependence
what we cover today. Now I'm really keen to get right into this subject matter. I'm not even gonna go into the whole benefits of smoking cessation and why our patients should quit. I think as GPs we are really well versed in that and have had it drummed into us right from the start. I really want to get into Get into the nitty-gritty about actually supporting our patients with the quitting. Now I know that in the recent guidelines there's been a bit of a change in terms of.
how we assess our patients' readiness I guess to quit. Did you want to tell me a little bit about that?
Sure. The old guidelines used um a stages of change model, which is a an addictions model that's been around for a long time. I've always had issues with the stages of change because it's always given people an opportunity to sort of say, Oh, maybe the client's not ready, wait until the client's ready. What the new
new guidelines to talk about is the five A's. This is a much much better model because it really encourages people prescribing or supporting smokers to really start some treatment or opens up that way of conversation instead of just saying are you ready? So it's It's it's a five A's, it's you're probably familiar with it anyway, but it's ask, assess, advise, assist and arrange follow-up. So it it gives you an opportunity to ask about smoking status.
and most clients expect a health professional to ask about their smoking status. So it doesn't come as a shock. Most people, you know, will be very disappointed if their GP doesn't doesn't discuss smoking with them. And assessing nicotine dependence, I think that was something that you wanted me to mention, Christina. Yeah.
Yes. Um we use a modified phagostrom scale. So that's only three questions. So how many cigarettes do you have in a typical day? When do you smoke your first cigarette? Is it within sixty minutes of waking? And if you've ever tried to quit smoking have you had a history of withdrawal symptoms?
is a really simple way, you know, just three questions, it doesn't take long. No, yeah.
Fantastic. Yeah, and I think people really understanding that they're not going to jeopardize that relationship with the client is really, really important. And again, it it doesn't even necessarily have to be the GP. This can be done by practice nurses, health workers, whoever else is around. Again, clients are
Are expecting to be asked about their smoking when they come into a health facility. And those three questions can be done very easily by anyone in the facility. They're not offensive, they're not particularly personal. And I find generally people are very honest about it. And that's really the one of the major changes in those new guidelines and I think um that that's a real advantage having those professionally endorsed.
¶ Treatment Options and Counseling Support
Yeah, excellent. Okay, if we've got a patient in front of us and we've started to talk to them about it and we've done those initial screening questions to to assess their dependence and they are keen to quit and wanting some options in terms of support. What's out there? What options are there and what actually shows some evidence behind it?
With the client themselves, one of the best ways of doing it, because what we know about nearly all smokers, nearly all of them have had quit attempts at various times. So usually if they've had some success with one product or another, that's often a really good starting point or to have a conversation with them them about
why it worked or why it didn't work. And usually people were really up front they'll say, No, Verena Klein it was a nightmare literally. Um or no the patches worked really, really well but you know I was
using one and I did it for weeks and weeks and it didn't seem to help. So that gives us a really good starting point around dosing what's acceptable to the client. So that's your starting point with your client. With the actual evidence base for smoking cessation treatment we know that combination in RT is first line along with Verona Klein.
They give similar results but we know we double the chances of any client quitting with some counselling. My experience with Verena Klein, because it reduces people's desire to smoke and reduces their experience of pleasure from that smoking
They can often do it by themselves but there seems just in my practice to be relapse because they haven't learnt some of those skills of becoming a non smoker. So that's how the counselling kind of supports both the medical nicotine addiction but then the counselling's really, really important to support the social skills and s to support those skills of developing non smoking behaviours.
Yeah, and that's a great tip, isn't it?'Cause I think often give the prescription and go away, here you go, do the discussion around how to take it, but that follow up counselling is actually really important. And can be done by anyone. I mean if the GP themselves has an interest in following up and counselling, there's other professionals like yourself and then even I guess some online phone type of services too.
Yep, certainly Quitline is available throughout Australia and Quitline has amazing results. Most Quitline services in Australia also provide a nicotine replacement therapy via the mail. So that's another really good option if the GP or the facility hasn't got the capacity for ongoing counselling or whatever. Quitline is
really good at making those phone calls. They'll make numerous phone calls to contact the client. They'll provide the NRT in the mail and they'll provide the the problem solving around the NRT. I guess that's one of the things we when we're talking about any of the nicotine replacement products None of them are perfect. So the role of the GP or the pharmacist or the quit line is to really work with that client and when they say I've stopped using the patches
is to work out what the problem was and to do some problem solving with it with them. Changing the time of the patches, providing tape. showing them the kinds of tapes to buy, using hydrocortisone cream under the patch to to solve the itching problem, changing the brand of patch. There's a whole bunch of stuff that can be done to make sure that the products are working for the client.
¶ NRT Patches: Dosing and Usage
Yeah, okay, so you've leaped into the nicotine replacement therapy, so let's keep going down that line. Sure. So you've mentioned a couple of things. Do you want to go through what actu Actually, it is available now. There's there's a multitude of products and seems to be new things coming on all the time. So, did you want to run through what is actually available and how you'd sort of decide which type of nicotine replacement therapy is best?
for a patient.
Sure. So the Nixine replacement patches are available in a number of brands. There's a number of differences in those patches in terms of the release time of the nicotine into the bloodstream. So generally that doesn't matter because they all release over generally 21 hours. There's some patches that have a a shorter time frame. I think that most of the clients that I see are very heavy smokers generally and I very rarely use a lower dose than 21 milligram patch.
There's no evidence for tapering off those patches, so there's no role for the you know the old-fashioned 21-14 seven seven milligram thing. The only exception to the 21 milligram patches is would be a very very low level smoker or a very small person. So if I saw an older lady who was 45 kilos or even a younger woman who was 45 kilos, I would be likely to titrate up. The other thing of course
we have to remember about patches is traditionally the one twenty one milligram patch i is really generally underdosing for people. So what we know is that the quit lines now are double patching. There was certainly one study out, it was a small study, but it showed most smokers could tolerate between four and five patches.
So wow working with your client, uh moving up towards that I always start with one patch, we check back in around symptoms. I I've got access to a smoke alyzer which is a carbon monoxide monitor. Once we see w how they're going with the smoking, whether that one patch has actually dropped. or whether they've dropped their smoking in that period of time. But often for a very heavy smoker they'll come back and say nothing happened. So I've got numerous clients on um four patches and some on five.
Wow. And so you'd start on the one patch.
I do.
So and then up titrate what sort of an interval, how long would you have to wait before you went, oh okay, this isn't enough.
Yeah, I usually see people weekly, but again, that's maybe a big ask for a G P But that's where your quit line comes in as well. So they can easily titrate up to two and possibly three. They're providing up to two. So that's sort of the patches, that's a slow release, it's a background dose. But then we have the intermittent forms.
Can I ask just before we move away from the patches, just one other question is whether to wear it at night. or not. What can you tell us w your decision making around, you know, whether you have it on for the t full twenty four hours or whether someone takes it off before bed, puts it straight on in the morning?
So that goes back to what I was originally talking about, the time of the of release. So we know some of the brands have got a six to eight hour release. So you have the maximum amount of NRT in your system at eight o'clock in the morning or seven o'clock in the morning, which is the time for the heaviest smoking. So people normally are in withdrawal overnight because they haven't smoked for eight hours.
So the nicotine receptors are really wanting a large dose of nicotine. So you'll often get them drawing very heavily, taking a lot of carbon monoxide, having two, three, four cigarettes. So when you put the patch on at night you have the highest dose being delivered at that early morning. So that's the rationale behind night. But there's always a but. As I said, none of these products are perfect. Some people do experience restless sleep
Some dreams.
Now basically the restless sleep the evidence doesn't tell us really whether that's nicotine withdrawal and the dreams very, very, very rarely are they violent and awful. Mostly they're weird. Mostly it's weird roller coasters and and whatever. But very occasionally someone will complain. The other thing that happens with the those particular side effects is they usually only last for a week or so. Most of the people that I see would have been smoking for forty years.
But basically weighing up that these are probably fairly minor side effects for a medication to use for three months or six months compared to smoking this damage of smoking for forty years and ongoing for another twenty years. So again, not perfect products, having that complication.
conversation around whether those side effects are tolerable. Of course if the client's not happy and and it's very very distressing for them, more than happy to go to that daytime dose. I would still recommend the twenty one milligram patch because of the nicotine needed and then you can introduce your your pulsatile, your intermittent forms of NRT and so you can prescribe something to be had in the morning before that patch actually starts to work. So
¶ Intermittent Nicotine Replacement Therapy Options
Okay, so let's talk about then that intermittent dosing. What's available? Yeah.
Um, so we've got gums. The gums come in two different strings and two different flavours, plus there's about three or four brands, all of them are slightly different formulations, so finding a product that's acceptable to your client is pretty important. Uh so that's the gums. Then there's lozenges and there's various kinds of lozenges. Some of them are different sizes, some of them are different shapes, some of them have got more filler so that the the nicotine's not as harsh on your throat.
And there's probably one, two, three, four or five different brands of those. And again, different strengths and different flavours. There's an inhaler. which is small cartridge thing that's used similar to a cigarette. It doesn't give off any smoke. It's a nice clean dice of nicotine that's just sort of puffed on but, you know, no smoke. The other option is a quit mist.
And so that's a oral spray that's um sprayed on the inside of the mouth and that gives a very rapid relief from from cravings and very rapid dose.
And how would you sort of go about deciding between those? Is it just a matter of putting it all on the table and seeing what the patient prefers or do you have a preference?
I guess for a GP to start with we we know it's combination therapy, but we also know PBS, certainly in Queensland and I someone has mentioned it's different in different states. But in Queensland, only single form that's Ven RT are available. So the patches are probably the most expensive. So the secondary form is
make a decision as to whether it's going to be acceptable to them or not. Sometimes it's dependent on um the condition of their teeth, sometimes it's dependent on the time of the day that they want to use it. So for example, some of my clients use um cigarettes in the car.
So the inhaler's a very, very good product to use in the car because it can be used in exactly the same way as you would be s smoking in the car. So it's exploring that with that element of counselling and working it out. Unfortunately it's no quick kind of oh
this will work because there are so many products out there. Smoking is a very entrenched behaviour, you know, as you know it's a relapsing condition, so there's a lot of personalization to be done to make sure that the clients are getting what they need to support them to quit.
Absolutely. And so you're really supportive of that combination therapy using multiple um forms of nicotine replacement therapy versus one one alone. And Mm majority of patients or clients are fairly engaging with that, that d they don't have any issue with that.
I think for any smoker to ask them to go and spend money on trying out different forms of NRT, that's a bit of a challenge. Something that happens in the indigenous community and probably in broader communities is someone will be using something. So they'll come in and go, Oh, Sauronie had an inhaler, you got any of those? So it's that kind of word of mouth stuff and I guess
It's probably reflected in advertising as well, so people are a lot more likely to try a lozenger or a piece of gum if they've seen some advertising around it. But one of the things that I'll often talk to people about is starting on probably the least. expensive option and a very small packet of the inhaler is only about ten dollars at the moment so that's possibly a good option to go along with those patches.
Hopefully they've they've accessed the patches on PBS. Quitline will provide the patches and also an option so they will possibly provide gum, possibly lozenges and sometimes spray. It depends what they've got available and the needs of the client. So they're quite good too at promoting a range of things.
¶ Quitting Process and NRT Duration
Yeah, okay. And we were talking a little bit before we started recording about
pre quitting
start of the nicotine replacement and I think this is something that's really changed in terms of our advice. It used to be pick a quick date and that's when you stop all of your cigarettes and that's when you start your nicotine replacement. Whereas now there's more acceptance of having this Did you wanna touch on that?
So w one of the gurus of Tobacco treatment talks about talking to the client about the quick date picking them. So we'll start using some nicotine replacement or some champeks and then as you see the client you're discussing how their smoking's going with them, whether they're still enjoying the cigarettes, that sort of stuff.
what usually happens and again I've got the privilege of seeing people regularly is by usually week two or three they'll have a look at the smokeliser they'll see that the effect of the um nicotine replacement or the varenocline is working and on
they've done that, they start to feel quite motivated or even if they're reporting the number of cigarettes they'll say, Oh actually I'm only smoking half a cigarette what they'll usually say is right this week I'm not gonna buy any more tobacco. I've got you know six cigarettes left, I'm not buying any more after that. So that's
usually how I approach that quitting thing. So for GP I think it would probably be the same. It would be start the medication, come back and and check in with me or you know the practice nurse or whoever else is doing this and see how you're going. that gives you your opportunity to adjust the dose if if absolutely nothing's happening and to see how those medications are being tolerated.
Excellent. And what about stopping benicotine replacement therapy? I mean, when is it sort of someone's actually managed to stay off the cigarettes? When do they actually stop the patches, stop the gum?
So the recommended treatment cycle for nicotine replacement patches is 12 weeks. So I absolutely use 121 milligram patch for the 12 weeks. If someone was up using the four or five, again what I usually find with clients, they're pretty much self-titrating by that stage. They will start to say, I um I've taken it back to one, two, whatever, feeling good on two.
So it's really 12 weeks is the prescribed dosage, and that would be with whatever combination of NRT that you were using. What we then recommend is carrying some pulsatile NRT for the next twelve months. So it's really because again it's the behaviour
There's lots of those cues and if you've got a bit of a backup with I could have a cigarette or I might have a puff of you know mist or I might have a lozenge that's a much better option than relapsing. So it's 12 months of carrying something and 12 weeks of patches.
Yeah, right, excellent. And you can continue the patches if the patient or client, you know, really was keen to continue post that twelve weeks was still felt I'm just not right I'm not ready yet, um to lose my safety blanket almost, that would be acceptable.
Absolutely, it's always safer to use NRT than it is to continue to smoke. So it's as far as we understand nicotine is a fairly low danger drug. There's very few side effects. So to continue with the clean form of nicotine, it's harm reduction. It's not perfect. But it's uh much, much, much safer than continuing.
to smoke. I've certainly seen clients who've been on NRT for quite a long time until they decide themselves what usually happens with the behaviours they'll start to forget to put it on and then they'll come back and go, Oh, I haven't had patch on for a week, hey, I'm good.
So excellent. Okay. Thank you again for your time. Really appreciate it. Always. Talk to you soon.
Thank you very much.
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