Protocol for Smoking Cessation in Secondary Care

Protocol for Smoking Cessation in secondary care

Rationale

NICE public health guidance 48 (2013):

Stopping smoking at any time has considerable health benefits for people who smoke, and for those around them. For people using secondary care services, there are additional advantages, including shorter hospital stays, lower drug doses, fewer complications, higher survival rates, better wound healing, decreased infections, and fewer re-admissions after surgery.

Secondary care providers have a duty of care to protect the health of, and promote healthy behavior among, people who use, or work in, their services. This duty of care includes providing them with effective support to stop smoking or to abstain from smoking while using or working in secondary care services.

Aim

The aim of the protocol is to use hospital admission as an opportunity to encourage patients to quit or to abstain from smoking during their hospital stay (in accordance with Smokefree legislation and hospital policy). All patients identified as current smokers will be offered Very Brief Advice (VBA) on stopping smoking and pharmacotherapy on admission. Patients interested in quitting will be referred to North Yorkshire NHS Stop Smoking Service for support on discharge.

Referral system for patients

Role of Doctor, Pharmacist, Pharmacy Technician and Nursing Staff

Follow the Hospital Admissions flowchart (Appendix 1).

Stop smoking VBA (Appendix 2) will be given by the doctor clerking in the patient. If appropriate, a prescription will be requested for Nicotine Replacement Therapy (NRT) orvarenicline (Champix®) in accordance with the formulary and following the smoking pattern flowchart (Appendix 3). If no record of VBA is documented in the patient’s medical notes, the pharmacist or pharmacy technician will deliver VBA to the patient and arrange for the doctor to prescribe NRT or varenicline (Champix®) where appropriate, using the ePMA alert system.

All pharmacotherapy amendments will be flagged up on the ePMA patient alert system to aid communication to primary care at discharge.

During their hospital stay staff should offer support on the correct use of stop smoking medications and encourage patients to continue their abstinence/quit attempt.

For pre assessment patients

Current smoking status should be identified at pre assessment and stop smoking VBA and pharmacotherapy can be offered and planned into the admission.

For maternity patients

For maternity in-patients follow this protocol but note thatvarenicline (Champix®) is contra-indicated in pregnancy. Midwifery staff should also follow the policy for carbon monoxide monitoring in pregnancy available on HDFT intranet. On discharge refer to North Yorkshire NHS Stop Smoking Service by calling 7359 (or external 0300 303 1603), who will offer support from a Specialist Smoking in Pregnancy Advisor.

Consent to Referral to stop smoking services

Verbal consent should be sought from the patient for referral to the Stop Smoking Service and a patient alert added to the ePMA system to prompt referral at discharge. Thiscan be done by any member of clinical staff (doctor, nurse, pharmacist, pharmacytechnician)

Discharge

On discharge, the pharmacist or pharmacy technician will check the electric discharge letter to ensure that the patient has the correct stop smoking medications and instructions to take home. A minimum of 2 weeks supply of pharmacotherapy will be issued. A patient consultation should be carried out to ensure the maximum benefit is being obtained from the NRT or varenicline (Champix®). If appropriate and verbal consent has been obtained, the pharmacist or pharmacy technician will refer the patient to North Yorkshire NHS Stop Smoking Service by calling 7359 (or external 0300 303 1603), providing the patient name, telephone number and GP practice.

Electronic cigarettes (e-cigs)

Electronic cigarettes are often designed to look and feel like cigarettes. They have been marketed as cheaper and healthier alternatives to cigarettes but are not currently licenced or regulated. There are concerns about e-cigarettes renormalizing smoking and counteracting smokefree policies and legislation. HDFT takes the view that only licenced Nicotine Replacement Therapy will be permitted on Hospital grounds. Electronic cigarettes are not currently licenced and are therefore not permitted to be sold or used on Trust premises. This position will be reviewed when developments are made in the regulation and or licencing of electronic cigarettes.

Appendix 1

Appendix 2

/ Very brief advice
to beoffered by Doctor and Pharmacist / Pharmacy technician
it only takes 30 seconds to change a smoker’s life
On admission
Ask
Are you a Smoker? How many do you smoke?
Advise
Stopping smoking is the best thing you can do for your health.
As you can’t smoke in Hospital we are offering you medication now to lessen your nicotine withdrawal and referral on discharge for support to remain stopped
Smokers are up to four times more likely to quit successfully with NHS support.
Act
Prescribe and gain consent for referral.
On discharge
If appropriate, Pharmacist / Pharmacy technician arrange two weeks medication and refer to North Yorkshire NHS stop smoking services. Tel: 7359
(external 0300 303 1603)
Referral details
Referrers name / ward / department
Patients name
Patients address
Patients phone number
Date of discharge

Appendix 3

Nicotine Replacement therapy treatment options

A combination of NRT patch and a faster-acting intermittent NRT product has been shown to give smokers an increased chance of success compared with using one product alone.

Additional information

Patch16 hour
25mg/15mg/10mg
Treatment period
12 weeks / >10 Cigarettes
Nicorette Invisi patch
25mg for 8 weeks, then 15mg for 2 weeks, then 10mg for 2 weeks / <10 Cigarettes
Nicorette Invisi patch
15mg for 8 weeks, then 10mg for 4 weeks / Easy to use; semi-transparent patch with excellent safety/tolerability profile
Disadvantages Not orally gratifying; local itching may occur but tends to be transient / How to use
Apply to clean, dry, hairless skin and use a different site every day. Wave the patch in the air before applying, to reduce the risk of skin irritation
Patch 24hour
21mg/14mg/7mg
Treatment period
8-12 weeks / >10 Cigarettes
NiQuitin
21mg for 6 weeks, then 14mg for 2 weeks, then 7mg for 2 weeks / <10 Cigarettes
NiQuitin
14mg for 6 weeks, then 7mg for 2 weeks / Easy to use; all brands have good tolerability profile
Disadvantages
24 hour patch may cause sleep disturbance; not orally gratifying; local itching may occur but tends to be transient / Apply to clean, dry, hairless skin and use a different site every day. Wave the patch in the air before applying, to reduce the risk of skin irritation. Niquitin patches can be used for up to 24 hours (less if appropriate)
Quick Mist mouth spray
1mg
Treatment period
12 weeks / Use 1 or 2 sprays every 30 minutes to 1 hour. Max 2 sprays per dosing episode. Max 4 sprays per hour / Relieves cravings in 60 seconds (the fastest acting of the intermittent NRT products); rapid absorption of nicotine
Disadvantages
Hiccups; gastric upset / ‘Prime’ spray by pointing it away from the face and pressing top until a fine spray appears. Hold close to mouth and press to release 1 spray into the mouth Avoid the lips. For best results, do not inhale, swallow, eat or drink straight after use
Inhalator
15mg
Treatment period
12 weeks / 6-12 cartridges per day for 8 weeks, then reduce the number of cartridges used by half over the next 2 weeks, then reduce use to zero by the last day. 1 cartridge = 20 minutes use / Helps to keep hands/mouth busy; could help to prevent overeating
Disadvantages
Coughing/throat irritation / Inhale through mouthpiece. Shallow puffing and deep inhalations are equally effective
Mini lozenge
Dosage
1.5mg
Treatment period
12 weeks / NiQuitin
1.5mg <20CPD. Max 15 per day
Reduce dose gradually after 12 weeks / Fast onset of action. Can be used discreetly; easy to adjust dose
Disadvantages
Gastric upset; stinging mouth; hiccups; localised irritation / Place lozenge in mouth and allow dissolving. Periodically move lozenge from one side of mouth to other until completely dissolved (about 10 minutes). Do not chew or swallow whole

General Cautions for NRT

Refer to individual SPC’s for more specific information

1.Skin disease / broken skin - avoid patches

2.Active peptic ulceration - avoid gum / lozenge

3.Unstable cardiovascular / cerebrovascular disease:

a)discuss with senior clinician

b)use short acting NRT

c)monitor carefully

These guidelines are for adult patients only. For advice in stopping smoking in paediatrics refer to North Yorkshire NHS Stop Smoking Service.

General Drug Interactions

Refer to individual SPCs for more specific information

Theophylline - tobacco smoking increases the metabolism of theophylline so stopping smoking may cause theophylline levels to rise. The hospital medical team and GP will need to be informed that NRT has been started so that theophylline levels can be monitored.

Smoking cessation may also cause other drug levels to rise, such as warfarin, insulin, benodiazepines, tricyclic antidepressants (such as imipramine), antipsychotic medication (including lithium), beta blockers, oestrogens and analgesics - check with a pharmacist before initiating NRT

Further information available UKMI Medicines Q&A 136.4.

Authors: Laura Henry and Frances Astin (North Yorkshire NHS Stop Smoking Service)

Approved by: APC

Date Approved: February 2014

Review Date: January 2016