Pharmacotherapies | Alternative Approaches | Special Groups | References
There are a number of special groups of patients for whom smoking cessation advice needs to be tailored.
See new May 2014 resources presented at our conference here
Smoking has substantial adverse effects on an unborn child, including growth retardation, pre-term birth, miscarriage and perinatal mortality. Smoking is linked to "cot death" or sudden infant death syndrome, the commonest cause of death between the ages of 1 month and 1 year.
Ideally, women should stop smoking before getting pregnant. In reality, most women who are planning to start a family don't stop smoking before they become pregnant, and it is pregnancy, itself, that is often the trigger for quitting. The greatest benefit for mother and baby results from cessation before, or as early as possible in pregnancy.
About 20-30% of smoking women quit when they become pregnant but about 70% of these relapse either during pregnancy or after their baby is born. One significant contributor to the relatively low success rates is the low rate of clinicians offering of effective smoking cessation strategies. Smoking cessation interventions are especially effective during pregnancy because mothers are usually aware of the benefit to them and their baby of quitting smoking. Post-partum follow up reduces relapse rates.
Smoking cessation programs are effective during pregnancy. As the dose of nicotine from NRT products is smaller than from smoking, the risk to the foetus is assumed to be lower than if a woman continues to smoke. However, there is, currently, a lack of evidence on the safety of pharmacotherapy in pregnancy, and so the benefits of using nicotine replacement therapy should be carefully balanced against the potential risks and discussed with the mother. Other pharmacotherapy (bupropion and varenicline) is not recommended in pregnancy.
AdolescentsEvery day, approximately 80,000 to 100,000 young people around the world become addicted to tobacco. If current trends continue, 250 million children alive today will die from tobacco-related disease. Around 80% of smokers start smoking as teenagers, though the reasons for starting are complex. There are some individual predictors:
- Parental smoking increases risk;
- Siblings or other family members who smoke increase the risk to adolescents;
- Adolescents with less connectedness to family, school and society are more likely to smoke;
- The ready availability of cigarettes increases adolescent risk;
- School-based policies around smoking education reduce the risk of teenage smoking;
- Social support reduces the risk of teenage smoking;
- Higher levels of physical activity may be protective against the onset of smoking.
Peer pressure, advertising, influence of media and concern over weight have also all been implicated in influencing adolescents to start smoking. The progression from never smoking to starting and then regular smoking occurs in a number of identified stages although recent evidence suggests that nicotine dependence develops very quickly in adolescents and may occur before daily smoking, suggesting that a period of experimentation before addiction is established may not be correct.
A new (July 2008) publication by the British Medical Association Forever cool: the influence of smoking imagery on young people explores effective ways of reducing young people¹s exposure to positive images of smoking and increasing their exposure to positive images of health.Things to say to teenagers to discourage smoking:
Teenagers care about the immediate benefits to their appearance, well being and financial status rather more than future health gains.
- Stopping smoking will improve your appearance;
- Stopping smoking will save you money. Calculate the financial cost of the adolescent's smoking in terms of the amount spent per year and feedback this information
- Stopping smoking will avoid bad breath and stained teeth;
- Stopping smoking may increase your potency
- Stopping smoking will expose you to less chemicals and toxins;
- Stopping smoking will give you back a feeling of control over your own behaviour;
- Stopping smoking will improve your long-term health.
- Brief advice or behavioural counselling is likely to be effective, but this has yet to be proved in teenagers. No randomised, placebo-controlled trials of NRT have been conducted among young smokers and these drugs are only licensed for use in adults.
Mental illness and smoking
People with mental health problems are more likely to smoke than those without mental illness. People with psychotic disorders are over three times more likely to be heavy smokers (20 cigarettes or more per day) compared with those without psychosis (35% compared with 9%). This may be due, in part, to the alleviation of some of the symptoms associated with psychiatric illness by nicotine.
Smoking and depression are related; around a third of people seeking smoking cessation treatment may have a history of depression. The antidepressants, bupropion and nortriptylin are effective in assisting smoking cessation in people with and without a history of depression. It is important to remember that bupropion can interact with a number of other antidepressant medicines by lowering seizure threshold.