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

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