VOLUME 8 NUMBER 3 • SEPTEMBER 2011
119
SA JOURNAL OF DIABETES & VASCULAR DISEASE
HANDS ON
CASE STUDY: LIAM, 24
SMOKING HISTORY AND MOTIVATION TO QUIT
Liam started smoking 10 years ago. He smokes 20-30
per day. He attends the surgery saying that he wants
to quit because he simply cannot afford cigarettes
since he lost his job.
ASSESSMENT
Liam seems to be well-motivated but you could use
the 5 As tool to assess him further. If he seems keen to proceed with his quit
attempt you could choose to work with him yourself or you could refer him to
the local smoking cessation team.
RECOMMENDED ACTION
As well as providing ongoing support to make behavioural changes, you could
prescribe NRT for Liam, using patches with or without ‘back-up’ NRT in the form
of gum, for example. If saving money is a priority for Liam, you could use the
Department of Health’s smoking cost calculator that will allow him to calculate
how much money he will save by quitting his smoking habit (
.
nhs.uk/quittools/cost-calculator/). Liam may like to use the Smokefree website
to enable him to take a more interactive approach to quitting.
CASE STUDY: ALISON, 44
SMOKING HISTORY AND MOTIVATION TO QUIT
Alison smokes 30 cigarettes a day. She also has a
family history of early cardiovascular disease. A recent
appointment for a cardiovascular risk assessment
showed that her risk was 8% over the next 10 years,
which is much higher than the average risk for some-
one her age and sex, of only 1%.
She has decided that she would like to stop smoking
to reduce her cardiovascular risk. She has tried several times before but has
always gone back to smoking after a few weeks, despite using NRT.
ASSESSMENT
Alison has been frightened by her younger brother’s recent hospital admission
with an acute coronary syndrome. He was also a smoker but has quit since his
event. She is very motivated to quit but is mindful of her previous failures and
fears that she cannot risk another failed attempt.
RECOMMENDED ACTION
In view of this, and after careful discussion of the options available, Alison de-
cided to try varenicline. She is aware that nausea may be a side-effect but has
decided that this may help her to avoid the snacking and weight gain that has
accompanied previous quit attempts, and which she admits may have been a
key reason for her going back to smoking in the past. You agree to continue to
monitor her progress over the next 12 weeks.
CASE STUDY: ARTHUR, 68
SMOKING HISTORY AND MOTIVATION TO QUIT
Arthur’s wife recently tried to give up smoking but was
not successful. However, this has spurred Arthur on
to give it a go and he is feeling quite competitive! He
smokes 15–20 cigarettes per day.
ASSESSMENT
It might be an idea to encourage Arthur’s wife to have
another attempt at quitting as they are both more likely to succeed with each
other’s support. It is important to discuss with Arthur any previous attempts he
has made to quit, including why these were unsuccessful – this may help him
to identify and avoid any future stumbling blocks.
RECOMMENDED ACTION
Arthur is likely to benefit from NRT in patch or other form, depending on his
personal preferences. As always, ongoing support should be provided.
for people with a history of cardiovascular disease and for women during
pregnancy.
Nicotine is a vasoconstrictor, which is why caution was advised in the
past when using NRT in those at high risk of acute cardiovascular events;
however, as previously stated, NRT is far preferable than continued ciga-
rette smoking. As with all drugs, NRT is better avoided in pregnancy, but is
safer than continued smoking; NRT is therefore licensed for use in preg-
nancy, although shorter-acting products, if appropriate to the patient’s
needs, may be better in order to minimise foetal exposure.
Bupropion
Bupropion (Zyban) is a prescription-only drug. It is available as a 150-mg
tablet, which was originally developed as a treatment for depression but
was discovered to be very effective as a smoking cessation drug. The
usual dosing regimen for bupropion is 150 mg daily for six days, followed
by 150 mg twice daily for the next two months. It takes one to two weeks
to take effect so it is recommended that patients start taking the drug
while they are still smoking and stop smoking in the second week of
taking the tablets.
Side effects include a dry mouth and sleep disturbance (although these
may also be side effects of quitting smoking) and nausea in some people.
Bupropion also seems to increase the risk of fits so should not be given to
people who may already be at increased risk such as those with epilepsy
or a previous history of seizures.
Varenicline
Varenicline (Champix) is also available only on prescription but is not
licensed for use in pregnancy or in people under 18. It can be pre-
scribed initially as a starter pack, which allows the patient to uptitrate the
dose over the first two weeks of use, reducing the risk, of side effects.
The main side effect is nausea, although this tends to subside with on-
going use.
