Smoking - final completed modulelphn.lshtm.ac.uk/files/learning-resources/smoking.pdf · Capital...

Title of Module: Smoking

Type of resource: Tutor’s Notes

Author: Edith Okola with Holly Halstead

Subject expert: Ann Wylie

Date last updated: 12/10/08 By: Helen Barratt

These resources are freely available to be copied and used for teaching and public health studies. Please acknowledge author and LTPHN for publication. ©LTPHN 2008

Smoking – Tutor’s Notes

©LTPHN 2008 Original Author: Edith Okola with Holly Halstead Last Updated: 12/10/08

SMOKING Why is smoking important? Approximately 10 million adults currently smoke in the UK.1 In London a person is admitted to hospital every 10 minutes due to causes related to smoking, around 55,000 people each year. It is estimated that approximately 12,000 people in the Capital are killed by tobacco annually - 18% of all deaths.2 Smoking impacts on health within every clinical specialty, and is the responsibility of every healthcare professional. Identifying people who smoke and offering them help to stop will reduce premature morbidity and mortality, and is also important in reducing health inequalities. The Public Health white paper published in 2004 Choosing Health: Making Healthier Choices states that ‘every member of the NHS staff has the potential to increase their role in raising people’s awareness of the benefits of healthy living – as part of the NHS responsibility to patients to improve health, not just provide healthcare for the sick.’3 Epidemiology Nationally Smoking prevalence has decreased over the last 20 years in both men and women. (51% to 26% of men and 41% to 23% of women in Great Britain from 1974 to 2004.3) The General Household Survey in 2004 demonstrated that 25% of adults smoked. Figure 1 shows the highest prevalence was in the 20-24 age group and the lowest in the 60 years and over group. The prevalence is thought to be lowest in the over 60 group because many people stop smoking in middle age, whilst a quarter of smokers die before their 70 birthday.1,4

Figure 1: Prevalence of smokers in Great Britain in 2004 5

0

5

10

15

20

25

30

35

40

16-19 20-24 25-34 35-49 50-59 60 andover

Age

Perc

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Male %Female %



Figure 2: Cigarette smoking status of men in Great Britain in 2004 5

26%

28%

46%

All current smokers

Ex-regular smokers

Never or only occasionallysmoked

Figure 3: Cigarette smoking status of women in Great Britain in 2004 5

23%

20%

57%

All current smokers

Ex-regular smokers

Never or only occasionallysmoked

The survey found that 31% of people in manual socio-economic groups smoked compared to 18% in non-manual groups. Men had a higher prevalence for smoking than women in all socio-economic classifications as shown in figure 4.



Figure 4: Prevalence of smoking among adults aged 16+ years by National Statistics Socio-economic classification (NS-SEC) in Great Britain in 2004 5

20

26

32

17

22

30

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15

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35

Managerial andprofessional

Intermediate Routine andmanual

Socio-economic classification

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MaleFemale

The managerial and professional group had a higher percentage of smokers wanting to quit than the routine and manual group, which is shown in the chart below.5

Figure 5: The percentage of adult smokers who would like to stop by gender and socio-economic classification 5

70

64

67

72 72

68

60

62

64

66

68

70

72

74

Managerial andprofessional

Intermediate Routine andmanual

Socio-economic classification

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MenWomen

In 1974 the mean number of cigarettes smoked daily by men was 18 and women 13. In 2004 it had decreased to 15 for men and stayed at 13 for women.5

In 1999 the Health Survey for England found that self reported smoking was higher in Bangladeshi, Irish and Black Caribbean men and Irish women than for the general population as shown in table 1.6 However, the survey did not include the African population. It also should be noted that in some cultures it is more common to chew tobacco rather than smoke.



Table 1: Percentage of self-reported smokers by ethnicity and gender

Ethnicity Male Female Bangladeshi 44 1 Black Caribbean 35 25 Chinese 17 9 Irish 39 33 Indian 23 6 Pakistani 26 5

Many people start smoking and become addicted to nicotine as teenagers. A series of surveys at secondary schools in 2004 showed 7% boys and 10% girls aged 11-15 smoked regularly. 7 Smoking regularly was defined as at least one cigarette a week. Figure 6 shows the prevalence of smoking by age and gender.

Figure 6: Prevalence of regular smokers among secondary school children in England in 2004 7

1 15

11

16

1 26

14

26

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20

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11 12 13 14 15

Age

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Male % Female %

The prevalence of smoking increases with age. A higher percentage of girls smoke than boys, from ages 12-15 with the percentage gap widening from 1% more girls at age 12 to 10% more at age 15. London 31% of men and 26% of women in London smoke, about 2 million people.8 The highest percentage of smokers is found amongst the 25-34 age group. Men have a higher prevalence of smoking in all ages under 75 years old, as shown in figure 7.



Figure 7: Prevalence of smoking in London between 1998-2001

05

10152025303540

16-24 25-34 35-44 45-54 55-64 65-74 75+

Age

Perc

enta

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Male Female

Smoking prevalence has had a larger decrease in London from 34% to 28% in men and 24% to 20% in women when compared with a fall nationally from 29% to 27% in men and 26% to 24% in women between 1998 and 2003.9 What’s in a cigarette?

Over 4000 chemicals are found in tobacco smoke, which include tar, nicotine, benzene, benzopyrene, carbon monoxide, ammonia, dimethylnitrosamine, formaldehyde, hydrogen cyanide, sulphur dioxide and acrolein.10,11 Of these, nearly 70 are known or suspected carcinogens and the World Health Organisation (WHO) has classified secondhand smoke as a carcinogen.8, 12

Why do people smoke? Nicotine is contained in the moisture of tobacco leaf and is an addictive substance.13,14 It is a stimulant, entering the blood via several routes including the lungs and mucous membranes, and quickly crosses the blood-brain barrier to reach the brain within 15 seconds. Nicotine enhances the release of neurotransmitters including dopamine, acetycholine, norepinephrine and serotonin.15 This experience for smokers is pleasurable, and when repeated becomes physically and psychologically addictive.15

Evidence shows the effect on the dopamine system in the brain is similar to that of heroin and cocaine.16 A study in the late 1980s showed people who had alcohol, cocaine or heroin dependence found cigarettes as hard to give up as their other drugs.17,18 Further information about the physiology of smoking can be found in ‘Nicotine Addiction in Britain’ at http://www.rcplondon.ac.uk/pubs/books/nicotine/index.htm



Smoking and health It has been estimated that 1000 people a day are admitted to an NHS hospital with a smoking related problem.15 Each year approximately 114,000 smokers die from a smoking related illness in the UK,19 and smoking related diseases cost the NHS £1.5 billion annually.20 Ref 20 onwards In London between 1998-2002 the percentage of smoking related deaths ranged from under 14% in Barnet and Kingston, more affluent areas, to 23% in Tower Hamlets. Further information on London boroughs can be found from the London Health Observatory. 7

Below are examples of the effects smoking has on most clinical specialties. 21 The WHO has also produced a poster called The Smoker’s Body, which demonstrates some of the effects of smoking.22 The relevance of smoking to different clinical specialties 15

Smoking is relevant to most clinical specialties: it both causes disease and makes treatment more difficult. The examples here are not intended as an exhaustive list. • Surgery – all sub-specialties

Smoking up to 8 weeks pre-operatively: − increases the risk of postoperative complications, including respiratory,

cardiac and vascular problems − increases the risk of poor wound healing − increases average lengths of stay − increases the likelihood of admission to an intensive care unit

postoperatively − increases the risk of postoperative death

Smoking also damages skin flaps used in reconstructive and cosmetic surgery often causing failure or subsequent breakdown

• Obstetrics and gynaecology Antepartum bleeding and abruptio placentae has been linked directly with smoking23 Smoking during pregnancy induces fetal hypoxia and, because of the vasoconstrictive effect of nicotine, also causes uteroplacental underperfusion – both contribute to prematurity and low birth weight (maternal smoking cessation in the first trimester eliminates the excess risk of low birth weight)24,25,26,27,28,29,30,31,32,33 Smoking has been associated with a 29% increase in fetal malformations, including hare lip, cleft palate and abnormalities of the central nervous system, heart and digestive system



• Orthopaedics Smoking is associated with delayed bone healing: the average length of time for a non-smoker to form 1 cm of new bone is 69.6 days, but it takes 89.4 days in a smoker.34,35

Women who smoke have a lower bone mass and are more likely to have a premature menopause – in combination, these two factors significantly increase the risk of osteoporosis and fracture.36

Men who smoke are also at increased risk of osteoporosis because smoking affects the production of bone cells.14

• ENT Smokers are 70% more likely than non-smokers to suffer hearing loss.37,38

Non-smokers living with smokers are twice as likely to have hearing problems.29,30

• Orthopaedics

Smoking increase the risk of developing age-related macular degeneration and smokers are up to four times more likely to go blind in old age.39,40,41

Cataracts are more common in smokers.42

• Dentistry There is a direct relationship between smoking and bone resorbtion – smokers are more likely to lose their teeth, and have a high risk of dental implant failure.43,44,45,46,47 Periodontal disease is 2-3 times commoner in smokers.48

• Gastroenterology Smokers are twice as likely to develop peptic ulcers, and gastroesophageal reflux is more common in smokers.49,50,51,52

Smokers are more likely to develop Crohn’s Disease.53

Current and former smokers have been found to have more hepatic inflammation and scarring than non-smokers and, independent of the effect of alcohol, smoking can aggravate the effects of hepatitis C infection.54,55

Smoking increases the risk of developing alcoholic liver cirrhosis – smoking 20 cigarettes a day trebles the risk compared to that of a lifelong non-smoker.56

Smoking increases the hepatotoxicity of some drugs, e.g. paracetamol.57

• Cardiovascular medicine Smoking causes coronary heart disease.

Smoking causes peripheral vascular disease.

Stroke is commoner amongst smokers.



• Respiratory medicine Smoking causes chronic obstructive pulmonary disease.

People with chronic obstructive pulmonary disease who give up smoking halve their likelihood of hospital admission because of an exacerbation, whilst merely cutting down has no benefit at all.

People with cystic fibrosis who smoke (actively or passively) have much poorer respiratory function.

• Endocrinology Smoking affects pituitary, thyroid, adrenal, testicular and ovarian function, calcium metabolism and the action of insulin. Smokers are more likely to develop:58,59

− insulin resistance − Grave’s Disease (thyroid eye disease is also commoner) − and irregular menstrual cycle and a premature menopause (in women) − osteoporosis (in men and women)

Smoking is an independent risk factor for diabetes.60,61,62

Smoking increases the risk of complications and premature death in people with diabetes.63,64

Nephropathy is commoner in people with diabetes who smoke.65,66

Smoking is an independent risk factor for pancreatitis.67,68

• Renal medicine Smoking is nephrotoxic in people with renal disease.69,70

Smokers have a higher risk of end-stage renal failure.71

• Dermatology Smoking leads to premature ageing of the skin – the effects are permanent.72,73,74

There is a significant relationship between smoking and hair loss and baldness.75

• Neurology Older people who smoke are at greater risk of developing dementia.76

Smoking is a risk factor for multiple sclerosis and its progression (smokers are three times more likely to have rapid progression of MS than non smokers).77,78

• Haematology Chronic exposure to cigarette smoke or nicotine causes T cell unresponsiveness – smoking reduces the effectiveness of the body’ immune system.79

Smoking is thrombogenic – it increases platelet stickiness

Smoking reduces the oxygen carrying capacity of red blood cells.80



• Paediatrics Children living with smokers are more likely to develop meningitis.81

Babies living with two or more smokers are 30 per cent more likely to need hospital treatment than those who live in smoke-free homes.82

Babies of mothers who smoke have five times the risk of dying of sudden infant death syndrome.83,84,85

Passive smoking by children has been shown to cause bronchitis, pneumonia, coughing and wheezing, asthma attacks and middle ear infections.86

• Genitourinary medicine Smoking causes erectile dysfunction – 40% of male smokers are affected compared with 28% of the general population.87

Smoking reduces the total sperm count and sperm motility – it is a significant cause of male infertility.88,89,90,91

Smoking has been directly linked with infertility in women.92,93,94,95,96

• Oncology Active and passive smoking causes cancer of the respiratory tract.

Smoking increases the risk of pancreatic cancer by 70%.

Smoking causes nasal, sinus and throat cancer.

Smoking is also associated with cancers of the oesophagus, stomach, kidney, bladder and cervix, and with myeloid leukaemia.

• Psychiatry People with mental health problems are much more likely to smoke – their general health is poorer and they are more likely to die prematurely (this likelihood is in addition to an increased risk of death from suicide).

People with mental health problems are much more likely to smoke – people with schizophrenia are ten times more likely to die of respiratory disease.

People with mental health problems who smoke are much more likely to require higher doses of neuroleptic drugs because of enzyme induction by nicotine.

Passive smoking Passive smokers inhale sidestream and mainstream smoke. Mainstream smoke has been inhaled and exhaled from a smoker. Sidestream smoke is emitted from the burning tip of a cigarette, contains higher concentration of potential toxic gases and composes 85% of a smoke-filled room.97,98 It was first recognised that passive smoking damaged health in 1981, and there is now plenty of evidence to support this.99 In November 2004 the Scientific Committee on Tobacco and Health, which advises the Government, showed that the risk of lung cancer and heart disease was increased by one quarter in adult non-smokers exposed to passive smoke.100 Within 30 minutes of exposure to passive smoke there is a



reduction in coronary blood flow.101 A non smoker has a 23% increased risk of heart disease when living with a smoker.102 Other recent reviews of the effects of passive smoking have been carried out by the International Agency for Research on Cancer (IARC), the California Environmental Protection Agency and the WHO. The impact of passive smoking on children103 Cotinine is a metabolite of nicotine. It is excreted in urine, saliva, and blood and can be found in hair. It is specific to nicotine and is a measure of the persons’ intake of tobacco smoke.104,105,106 Its half-life is approximately 24 hours. Studies have found cotinine in the urine and saliva of children exposed to passive smoking.107,108 From this it is reasonable to infer that children exposed to passive smoking are at risk of all smoking related illnesses. As many as up to half the children in Britain are exposed to passive smoke.109 • Dental

A cross sectional survey of 3531 children aged 4-11 years old showed an association between exposure to passive smoke and risk of dental caries.110

• Ear nose and throat (ENT)

A systematic quantitative review shows a likely a causal relationship between passive smoking and acute and chronic otitis media in children.111

• Infection

Passive smoking increases the risk of children developing invasive meningococcal disease.112

• Respiratory diseases

Passive smoking is a contributor to chronic cough in children113 and increases the risk of children succumbing to acute lower respiratory tract infections.114 A systematic quantitative review showed passive smoking:115

- Is a co factor for provoking wheezing attacks in 5 year olds and under

- Increases the symptom score of patients with asthma

- Is associated with more severe disease in established asthma

Prevalence surveys conducted amongst school-age children suggest wheeze and diagnosed asthma are more common in those exposed to passive smoke.116 It has also been demonstrate that children whose mothers smoke have a decrease in their lung function.117 Children with cystic fibrosis exposed to passive smoke have an increased number of hospital admissions compared with those who are not.118

• Sudden infant death syndrome

A systematic quantitative review of the epidemiological evidence relating parental smoking to sudden infant death syndrome concluded that maternal smoking doubles the risk of sudden infant death syndrome.119



Along with evidence showing the detrimental effect passive smoking has on children’s health, there is also evidence to demonstrate that it adversely affects different treatment regimes. • Drug regimes

Tobacco smoke induces CYP1A2 enzymes found primarily in the liver.120 This speeds the metabolism of drugs induced by CYP1A2 leading to the patient requiring larger doses to obtain therapeutic levels. Drugs induced by this are: theophylline 121

olanzipine122 flecanide

Evidence also shows that insulin resistance increases with exposure to nicotine123, which leads to diabetics requiring more insulin.124

• Anaesthesia

Exposure to passive smoke affects children undergoing general anaesthesia. The risk of perioperative respiratory complications125 and incidence of postoperative hypoxaemia are both increased in children exposed to passive smoke.126 A retrospective cohort study showed there was a ten-fold increase risk of laryngospasm in children exposed to environmental tobacco smoke who underwent anaesthetic.127

• Ear nose and throat

The effects of passive smoking on ENT conditions have been discussed above. However, there is evidence to show that passive smoking effects the treatment of secretory otitis media. A prospective study of 606 children undergoing bilateral myringotomy with insertion of grommets showed passive smoking:128

- Increases the chance of an ear infection post grommet insertion - Adversely affects the length of time grommets are in situ post operatively. The

median survival rate of grommets in children exposed to passive smoking was 59 weeks compared to 86 weeks in non exposed children

- Increases the risk of myringosclerosis of the tympanic membrane after the

grommets were extruded

- Increases the risk of permanent perforation of the tympanic membrane

Endoscopic sinus surgery is used in children with chronic sinusitis in whom medical treatment has failed. Evidence shows that exposure to passive smoking predisposes children who are having endoscopic sinus surgery to a poorer outcome. At 12 months non exposed children had a success rate of 90% compared to 70% in children who were exposed to cigarette smoke.129



• Respiratory As discussed above passive smoking contributes to many respiratory problems in children. It also interferes in the treatment of many respiratory illnesses. Asthmatic children exposed to household smoke were more likely to have: - Increased attack frequency - Increased use of medication - Increased hospital attendance - Increased life threatening attacks

A prospective cohort study showed asthmatic children exposed to passive smoke were less likely to have good peak flow and symptom control than non exposed children.130

Tobacco Regulation Smoke Free Legislation Comprehensive legislation banning smoking in public places, including places of work and enclosed public areas such as pubs and clubs, was introduced in England in July 2007. Previously, it was estimated that 8% (2,182,000) of people employed in Great Britain worked in places with ‘no restrictions on smoking at all’ and 38% (10,366,000) in places where smoking occurs in ‘designated areas.’131 Smoke free legislation is a huge public health issue, because it is known that passive smoking is a risk to non-smokers. It is hoped that it will also reduce health inequalities by effectively decrease smoking rates, which are higher amongst people in manual work.132

Evidence from other countries demonstrates that a complete ban can decrease smoking prevalence by 4 %; this is assuming there are no smoking restrictions initially.133 New York went smoke free in 2003 and Ireland in 2004. In New York, an 85% drop in cotinine levels was seen in non-smoking staff working in restaurants and bars after the introduction legislation.134 In Ireland almost one in five smokers decided not to smoke whilst out socialising since the introduction of the ban there.135

Tobacco Advertising

The Tobacco Advertising and Promotion Act 2002 came into effect in the UK on 14th February 2003. This bans any advertising which has the purpose or effect of promoting a tobacco product, including:

• adverts in print and billboards; • internet; • direct mail; • promotions; • free gifts; and • sponsorship.136

Tobacco sponsorship was banned from domestic sport in 2003 and, at an international level, from World Snooker and Formula One in 2005. Exemptions from this ban include advertising at the point of sale.



Tobacco advertising increases tobacco consumption, and countries who have imposed a ban on advertising have also demonstrated a drop in consumption.137,138 A report by the US Surgeon General about tobacco advertising acknowledged the following points:

- Tobacco advertising increases the use of tobacco in children and young adults,

- It encourages ex smokers to re start - It increases the consumption of smokers - It lowers smokers’ motivation to stop smoking - It ensures tobacco remains acceptable and health warnings are

unheeded.139 Consumer Protection A European Union (EU) directive in 2001 regulated certain components of cigarettes, stating that any cigarettes sold in Europe can have a maximum 10mg tar, 10 mg carbon monoxide and 1 mg nicotine.140 The directive also regulates the health warnings on cigarette packets, which must cover 30% of the surface area on the front of the packet, and 40% of the back. Use of words such as ‘light’ or ‘mild’ in the brand name was also banned.141

Tobacco economics In 2004/2005 the treasury earned £8,013 million (excluding VAT) from tobacco duties.141 About 80% of the cost of a packet of cigarettes constitutes tax.142 The NHS spends approximately £1.5 billion a year on treating smoking related diseases, which does not include invalidity or sickness benefits.143 In England and Wales approximately 34 million days are lost each year due to absence because of a smoking related illness.144 Increasing the price of cigarettes does decrease consumption, but 16% of cigarettes consumed in the UK are smuggled, reducing the effect of the policy. 145



Smoking cessation At least 70% of adult smokers would like to quit smoking and one of the main reasons is for their health.146,147 The table below illustrates the benefits of stopping smoking.148

Table 2: Health benefits of stopping smoking Time since

quitting Beneficial health changes

20 mins Blood pressure and pulse rate return to normal.

8 hours Nicotine and carbon monoxide levels in blood reduce by half, oxygen levels return to normal.

24 hours Carbon monoxide will be eliminated from the body. Lungs start to clear out mucus and other smoking debris.

48 hours There is no nicotine left in the body. Ability to taste and smell is greatly improved.

72 hours Breathing becomes easier. Bronchial tubes begin to relax and energy levels increase.

2-12 weeks Circulation improves.

3-9 months Coughs, wheezing and breathing problems improve as lung function is increased by up to 10%.

1 year Risk of a heart attack falls to about half that of a smoker.

10 years Risk of lung cancer falls to half that of a smoker.

15 years Risk of heart attack falls to the same as someone who has never smoked

As nicotine is an addictive substance when smokers quit they experience withdrawal symptoms which are shown in table 3.149,150

Table 3: Withdrawal symptoms

Withdrawal symptom Duration Proportion of those trying to quit who are affected

Irritability / aggression < 4 weeks 50%

Depression < 4 weeks 60%

Restlessness < 4 weeks 60%

Poor concentration < 2 weeks 60%

Increased appetite > 10 weeks 70%

Light-headedness < 48 hours 10%

Night-time awakenings < 1 week 25%

Craving > 2 weeks 70%



NHS smoking cessation services NHS Stop Smoking Services were established in 1998 to offer support for smokers wanting to quit based on best available evidence. Behavioural support, nicotine replacement therapy (NRT) or bupropion are offered along with advice. There is evidence to show that providing smokers with help to quit is effective. Specialist intensive support quadruples the chance of quitting. 151 However, to stop one person smoking, twenty people need to be advised to quit. In 2004/2005 around 530,000 people in England set a quit date with NHS stop smoking services, and at four weeks follow up 56% were not smoking.152 There are three levels of intervention for stopping smoking and are outlined below. 153 • Level 1: Brief opportunistic advice to stop from a health care professional

The main aim of the intervention is to trigger an attempt to stop smoking. Brief advice to all smokers to encourage them to make an attempt to stop is effective in promoting smoking cessation.

Ask – if they are a smoker Advise – to stop smoking and reasons why Assist – explain different options for stop smoking services Arrange – to see a stop smoking advisor either level2 or 3

Recent NICE Public Health Intervention Guidance makes nine recommendations for brief interventions and referral for smoking cessation in primary care and other settings.154

The recording of smoking status should also be readily accessible in both primary and secondary care so that patients can be regularly asked and advice given is recorded.

• Level 2: Behavioural support to aid attempts to stop smoking

The main aim of the intervention is to respond to smokers requests for help with an attempt to stop smoking. The programme runs for 12 weeks with the clients being seen weekly for the first 4 weeks. Advice is given on the use of NRT or bupropion and behavioural advice and support is given.

• Level 3: Specialist services

This service provides intensive behavioural support in groups for smokers over a 6-7 week period. All healthcare professionals involved in smoking cessation to encourage the smokers to use bupropion or NRT where appropriate. Pregnant women and inpatients at hospital who smoke who wish to stop should have behavioural support provided by specialist counsellors.



Clients accessing Level 2 or 3 support will be asked the following questions to assess nicotine addiction and enable NRT to be tailored to their needs.

- What time do you have your first cigarette of the day? - Do you smoke more in the morning? - Do you smoke when you are ill? - Do you have difficulty not smoking in a non-smoking area? - Number of cigarettes smoked a day - Which cigarette would be the hardest to give up?

NICE Guidance on NRT and bupropion NRT and bupropion (Zyban) are recommended for smokers who want to quit smoking. It should normally be prescribed as part of an abstinent-contingent treatment which is when the client commits to stopping smoking on a certain date known as their quit date. Behavioural support is available from trained advisors to aid in the clients quit attempt. What is nicotine replacement therapy (NRT)? NRT works by reducing the severity of the withdrawal symptoms and reduces cravings and the desire to smoke. It provides a temporary nicotine substitution at a lower level (a third to a half) and slower delivery than nicotine from an inhaled cigarette. It helps smokers to quit in a two stage approach, firstly by behaviour change and then the drug. The nicotine replacement therapy is weaned during the programme and is available in a variety of preparations, such as gum, patches and inhalers. What is bupropion (Zyban)? Initially buproprion was used as an antidepressant in the US, known as Wellbutrin, but anecdotal reports demonstrated that it also aided people trying to stop smoking. The mechanism of action is not fully known. It may act as a nicotine acetylcholine receptor, inhibit dopamine reuptake or decrease activity of noradrenaline-releasing neurones. One 150mg tablet is taken daily for the first six days and the client still smokes. At day 7 the dose is increased to two tablets a day taken 8 hours apart. A quit date is set for between 8-14 days after starting bupropion. Contraindications include seizures, eating disorder, CNS tumours, bipolar disorder, severe hepatic cirrhosis, use of MAOIs. Common side effects include insomnia, headache, and a dry mouth; rarely it can cause seizures, severe allergic reactions, and hypertension.



For further information/Resources Action on Smoking and Health Fact sheets available covering:

• Smoking and health • Ethnic minorities • Passive smoking

• Tobacco advertising • Smoking in workplaces

www.ash.org.uk

NICE Guidance on smoking cessation, including bupropion and nicotine replacement therapy (No. 39), as well as brief interventions and referral for smoking cessation in primary care and other settings. www.nice.org.uk Department of Health Relevant online documents include:

• Smoking Kills: A White paper on tobacco 1998 • The NHS Plan: 2000 • Choosing Health: Making healthy choices easier 2004

www.dh.gov.uk World Health Organisation

• International consultation on environmental tobacco smoke (ETS) and child health

• The Smokers Body poster www.who.int/tobacco/en/ The Royal College of Physicians Information about nicotine addiction in Britain. http://www.rcplondon.ac.uk/pubs/books/nicotine/index.htm



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