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People who smoke expect their health professionals to ask them about their smoking and to provide them with help to stop. The most effective care to support long-term smoking cessation is a combination of pharmacotherapy, as clinically appropriate, and multi-session behavioural intervention, such as Quitline.
A recent consultation project with general practitioners and community pharmacists aimed to gain insights into the provision of cessation care, knowledge gaps and emerging practice issues. The insights gleaned included limited understanding of Quitline, which has informed the development of a four-minute video outlining how health professionals can partner with Quitline to support their patients who smoke.
A major review on the health effects of vaping has recently been published. The review outlines that there is evidence that e-cigarettes can be harmful to health and that there is uncertainty regarding their impacts on a range of important health and disease outcomes.
Where first-line/TGA-approved pharmacotherapy (together with behavioural support) have not helped a person quit smoking, nicotine vaping products (NVPs) may be a reasonable intervention to recommend along with behavioural support. The Australian clinical guidelines suggest attempting to wean or cease NVPs after 12 weeks of use. According to the guidelines, transferring to nicotine replacement therapy (NRT) may be an option and other approved smoking cessation pharmacotherapies may have a role. Further research is needed.
There are promising international findings regarding the efficacy of Quitline for vaping cessation.
In Australia, Quitline has counselling protocols to support people who are using NVPs to quit smoking and also supports people who vape to quit, including young people. Refer patients at www.quitcentre.org.au/referral-form
Champix is currently unavailable in Australia due to a recall. Access the TGA Medicine Shortages Hub for updated information about supply impact dates.
APO-Varenicline 1mg tablets (Canada) have been approved for import and supply in Australia under Section 19A of the Therapeutic Goods Act 1989. This product is NOT registered in Australia.
Stock is currently available. See details of PBS listing. APO-Varenicline will come in a bottle presentation (whereas Champix was provided in a blister pack).
Combination nicotine replacement therapy (NRT) is as effective as varenicline. Access online training, including how to use NRT to support smoking cessation in patients.
From 21 July 2021, 18 new temporary items are available for patients to access nicotine and smoking cessation care through General Practice. The new temporary MBS items include six face-to-face, six telehealth and six phone services. These items are temporary and were initially scheduled to end on 30 June 2022, but will now be in place until 31 December 2023.
Medicare benefits are paid for telehealth health care services relating to nicotine and smoking cessation counselling, without the requirement for the patient to have an established clinical relationship with the general practitioner. Each consultation with a patient who smokes is a potential opportunity to offer brief advice.
From 1 October 2021, consumers require a prescription for nicotine vaping products (NVPs), such as nicotine e-cigarettes, nicotine pods and liquid nicotine. This includes products purchased both in Australia and imported from overseas.
View Clinical guidelines for smoking cessation, including place in treatment for NVPs.
Access Online training for health professionals, including considerations for prescribing and dispensing NVPs.
Visit Therapeutic Goods Administration for detailed information on how to legally access, prescribe and supply NVPs.
Visit National Prescribing Service (NPS) MedicineWise for information on the nicotine regulatory changes.
View the Quit and Heart Foundation Position Statement: Smoking and Vaping Cessation, which has been endorsed by other peak health and medical groups.
A PMR of medicines for smoking cessation is currently underway. Medicines included in the review are nicotine replacement therapy (NRT), varenicline and bupropion.
The Pharmaceutical Benefits Advisory Committee (PBAC) released their recommendations in response to the PMR on 17 June 2022.
Research
Results of the Australian National Diabetes Audit (ANDA) showed that people who currently smoke had poorer glycaemic and lipid control and higher odds of macrovascular and microvascular complications compared to those who had never smoked.
Results of data collected from 15,352 patients, including 72.2% with type 2 diabetes and 13.5% who were currently smoking, showed that people who currently or have previously smoked, have a median HbA1c 0.49% and 0.14% higher than those who have never smoked, respectively, as well as higher triglyceride and lower HDL levels (all p values < .0001). People who currently or have previously smoked had higher odds of myocardial infarction, stroke, peripheral vascular disease, lower limb amputation, erectile dysfunction and peripheral neuropathy (all p values ≤.001), with no significant change over time.
These findings are supported by this retrospective cohort study of 3044 participants, examining the extent of the association between smoking and glycaemic control in patients newly diagnosed with type 2 diabetes. It shows that active smoking is associated with poorer glycaemic control with the difference in HbA1c reduction between people who smoke and those who don’t being 0.33% (95% CI, 0.05-0.62%) at 3 months of follow-up. Additionally, the benefits of risk factor management for prevention of cardiovascular events among patients with diabetes are attenuated by current and former smoking.
A recently published randomised clinical trial Efficacy and Safety of Varenicline for Smoking Cessation in Patients With Type 2 Diabetes concludes that varenicline use in a smoking cessation program is efficacious in achieving long-term abstinence without serious adverse events. The authors conclude that ‘varenicline should be routinely used in diabetes education programs to help patients with type 2 diabetes stop smoking.’
Dr Andrew Pipe urges all clinicians to prioritise smoking cessation, arguing that provision of smoking cessation care is a “fundamental responsibility”, with clinicians playing an essential role.
In the publication titled Smoking cessation: health system challenges and opportunities Pipe, Evans and Papadakis highlight the significance of provision of smoking cessation care as a key intervention in primary care, using a tabulated comparison (the number needed to treat [NNT] to prevent one death) for some common primary care clinical interventions such as statins for primary prevention and antihypertensives for mild hypertension.
Australian clinical guidelines recommend that the combination of behavioural intervention with pharmacotherapy approved by the Therapeutic Goods Administration (TGA), if clinically appropriate, is the best way to help people who smoke to quit.
Behavioural intervention involves multiple sessions of tailored behavioural counselling delivered by professional smoking cessation counsellors. Drawing on evidence-based behaviour-change techniques and approaches, such as cognitive behavioural therapy (CBT), acceptance and commitment therapy, and motivational interviewing (MI), the counselling helps motivate people to make a quit attempt and develop skills to manage withdrawal and adjust to life without smoking. In Australia, Quitline’s free service is the most accessible provider. It’s quick and easy to refer you patient. Refer at www.quitcentre.org.au/referral-form.
A recent study demonstrated that people who vape experience a (statistically significant) higher frequency of COVID-19 related symptoms when compared with age and gender matched people who don’t vape. Symptoms include chest pain and tightness, chills, myalgia and light-headedness. The study also found that people who vape and smoke tobacco (‘dual users’), and who test positive for COVID-19, experience a significantly higher occurrence of dyspnoea and emergency department visits.
Vaping could worsen COVID-19 outcomes by weakening the immune system, lung function or the circulatory system.
For people who are currently vaping to quit smoking, the RACGP clinical guidelines suggest to attempt weaning or ceasing nicotine vaping products (NVPs) after 12 weeks of use. NRT or other smoking cessation pharmacotherapies may have a role in supporting nicotine vaping cessation, however there is limited research to date. Dual use should be avoided.
Quitline have counselling protocols to support people trying to stop vaping.
Adherence to smoking cessation pharmacotherapy improves the rate of successfully quitting, however an Australian survey found only 28.4% of people (including those who currently smoke and have previously smoked) who used smoking cessation pharmacotherapy were adherent to these medications.
Health professionals have a key role in supporting their patients pharmacotherapy use. Health professionals may facilitate adherence to pharmacotherapies by providing advice on correct use of the products, addressing and managing any adverse effects and also by discussing the effectiveness of pharmacotherapy to enable realistic expectation-setting.
Access online training, including how to use pharmacotherapy to support smoking cessation in patients.
Facts and Issues is a regularly updated comprehensive online resource of the major issues in smoking and health in Australia, compiled by Cancer Council Victoria.
A complete Endnote library of all citations for all chapters and sections is available.
Media
7 March 2022: Many Australians who smoke or vape would like to quit. Now more of them will be supported to successfully give up, thanks to a new virtual resource and training centre for primary health professionals. Read more
Quit Centre Quarterly Newsletter
Last updated: 23 August 2022