(AAAA=ask, advise, assist, arrange follow-up.)RCT78 Ask about smoking in all consultations, not just those on smoking-related diseases (be subtle; patients won't listen if you do not share agendas).
- Advise according to need. Ensure that advice is congruent with beliefs; motivate patients by getting them to list the advantages of quitting.
- Assist in practical ways, eg negotiate a commitment to a quit date when there will be few stresses; agree on throwing away all smoking junk (cigarettes, ash trays, lighters, matches) in advance. Inform friends of new change.
- Nicotine gum, chewed intermittently to limit nicotine release: ten 2mg sticks may be needed/day. Transdermal nicotine patches may be easier. A dose increase at 1 week can help. Written advice offers no added benefit to advice from nurses/GPs. Review at 2 weeks; people sense (and act on) your committment. Only re-prescribe if abstinent.
- Bupropion ups the quit rate to perhaps 30% at 1yr vs 16% with patches: consider if the above fails. Dose: 150mg/24h PO (while still smoking; quit within 2 weeks); the dose may be doubled from day 7; stop after 7 weeks. Give enough to last 3 weeks, then review; only re-prescribe if abstinent ie the abtsinent contingent treatment (ACT) regimen. Warn of SEs: Seizures (risk <1:1000), insomnia, headache, ?arrhythmias. CI: Epilepsy; cirrhosis; pregnancy; lactation; bipolar depression; eating disorders; CNS tumours; alcohol/benzodiazepine withdrawal; 18yr old.Interactions: Antimalarials, antipsychotics, antidepressants, antihista- mines, antiepileptics, quinolones, theophylline, tramadol, steroids.
For those who do not want to give up
Give them a health education leaflet, record this fact in the record, and try again later.
25% of school leavers smoke regularly. The Health Education Council has a smoking education project for schools. It has been commented that smoking rates may not be rising too fast in children owing to cost, and to mobile phones, which are cheaper, and just as good a fashion accessory.
Every health outlet
should have a policy on promoting nonsmoking, and offering practical advice: primary health care teams; hospitals; midwives; pharmaciesand also, perhaps, schools and employers. Health commissioners also needed to promote knowledge and training in this area.
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