Tobacco

  • Can be inhaled, chewed or put behind ear (topical skin absorption) — including native tobacco, eg pitchuri, mingkulpa
  • E-cigarettes deliver vapour which may or may not include nicotine — can be prescribed for smoking cessation after recommended smoking cessation medicines (NRT, varenicline, bupropion) have failed. Long-term safety is unclear
  • Second-hand smoke from cigarettes can cause lung and heart disease, ear infections in children, SIDS in babies
    • Ask everyone not to smoke around children — smoke-free house and car

All people who use tobacco should be offered help to stop

Pregnant or breastfeeding women

  • Smoking causes major problems for baby
  • Try non-medicine approaches first
  • Medical consult for risk-benefit assessment of short-acting NRT products — gum, lozenges, inhalator
  • Do not use other oral medicines

People with heart disease

  • Advise quitting is most important action to lessen risk of heart attack
  • NRT and oral medicines can be used
  • Talk with cardiologist about NRT patch if less than 4 weeks since heart attack, or severe angina

Assist with stopping smoking

Ask

  • For all patients record at least past 10 years of smoking status — current smoker, ex-smoker (when quit), never smoked
  • Assess dependence — smoking within 30 minutes after waking, more than 10 cigarettes a day, withdrawal irritability in previous attempts

Do

  • Brief interventions
  • Counselling and support —  eg Quitline. Aboriginal counsellors available
  • Consider nicotine replacement therapy (NRT) or medicines to reduce urge to smoke

Follow-up

  • Make management plan
  • Talk with person about relapse prevention — action strategies to prevent starting tobacco use again, eg Tackling Indigenous Smoking (TIS) programs, QUIT program
  • Offer resources — Remote AOD Program (Yarning about tobacco)

Medicines to help quitting

  • Many people prefer to quit smoking without medicines
  • Medicines helpful with higher levels of nicotine dependence
  • Combine with counselling and support for best effect
  • May need to use for 8–12 weeks

Nicotine replacement therapy (NRT)

  • 2 types of NRT can be used together if one alone not working
  • Can use with urge reduction medicine
  • Can use after urge reduction medicines to prevent relapse
  • Offer oral intermittent NRT (not patches) to all pregnant or breastfeeding women who are interested in using them

Nicotine patches

  • Available over the counter or on PBS — prescription with commitment to quit smoking counselling program (eg Quitline), for up to 12 weeks
  • Only if person regularly smokes more than 10 cigarettes per day — start 21mg/24 hours
  • If irregular smoker but potentially averaging 10 or more cigarettes a day — can try lower dose patch 14mg/24hours with gum or lozenges
    • If less than 10 per day — use gum or lozenges only
  • Put nicotine patch on upper arm in morning, take off at bedtime
    • Change site of patch each day
    • Patch may cause local skin reactions, eg redness, itch, rash
  • Smoking while using nicotine patches can cause nausea, vomiting, palpitations, chest pain, other symptoms
  • May be used in pregnancy if heavy tobacco use (continuous smoking) and all non-medicine approaches have been unsuccessful — medical consult first for risk-benefit assessment

Oral NRT

  • Available over the counter and available on prescription with commitment to counselling
  • Nicotine absorbed by buccal mucous membrane (of mouth)
  • Do not eat or drink while using — reduces absorption
  • More suitable for low dependence or occasional smokers
  • To be used before cravings start

Nicotine gum

  • Assess dental health
  • 2mg strength for low to moderate dependence — maximum 10 pieces/day
  • 4mg strength for moderate to high dependence — maximum 3–4 pieces/day
  • After 4–8 weeks reduce to 2mg, taper then stop based on person's craving
  • Tell person
    • Do not swallow gum
    • Do not chew gum all the time
    • Use only when needed
    • Chew slowly until peppery taste then rest inside cheek until taste fades
    • Chew and rest each piece of gum for 20–30 minutes

Nicotine lozenges

  • Do not chew or swallow whole
  • Best used for break-through cravings with patches
  • 2mg strength for low to moderate dependence
  • 4mg strength for moderate to high dependence
  • If used alone — 1 lozenge every 1–2 hours for 6 weeks, 1 lozenge every 2–4 hours for 3 weeks, then 1 lozenge every 4–8 hours for 3 weeks
  • Dissolve lozenge in mouth — move from side to side

Nicotine inhalator

  • Plastic tube with replaceable nicotine cartridge inside
  • Amount of nicotine released depends on cartridge size. If 15mg — maximum 6 cartridges/day
  • Use short, shallow puffs
  • Takes about 24 seconds for nicotine from inhalator to start working on brain — takes about 20 minutes of active puffing to empty cartridge
  • May be good for people who miss hand-to-mouth action of smoking
  • Works best in warmer weather conditions — try keeping in warm pocket

Nicotine spray

  • 1mg nicotine spray
  • Spray into mouth — nicotine absorbed through mouth lining
  • Use 1–2 sprays when cravings — up to 4 sprays per hour

Flowchart 5.1   NRT initial dosage guideline

Urge reduction medicine

Varenicline reduces desire to smoke

  • Medical consult before giving varenicline
  • Do not use if pregnant, breastfeeding, under 18 years
  • Need authority prescription with commitment to quit smoking counselling program, eg TIS programs, Quitline
  • Start medicine at least 7 days before stopping smoking — check product information
  • Can use with NRT — but both not covered by PBS at the same time
  • Nausea — minimised by taking with food or reducing dose
  • Other side effects decrease with time — sleep disturbance, unusual dreams 

Supporting resources

  • Tackling Indigenous smoking website
  • Deadly choices quit smoking resources