Counselling patients about smoking cessation

The popularity of nicotine vaping products is on the rise in Australia. But a legislative change that came into effect on 1 October, making the products prescription-only, has essentially made GPs their gatekeepers.
 
But what do these changes mean for GPs and practice staff, and how can they best navigate these conversations with patients?
 
An upcoming webinar, ‘Counselling smoking cessation in a changing world’, aims to give GPs the information they need.
 
Taking place on Wednesday 10 November, the online session will explore the latest smoking-cessation recommendations and what to do if a patient asks for an e-cigarette script.
 
It will also delve into other options that exist to aide smoking cessation, and how to identify the risks and benefits associated with the different options on offer.
 
Addiction medicine specialist and Sydney GP Dr Hester Wilson will be presenting the webinar.
 
She says many GPs have concerns about the legislative changes and their role in prescribing nicotine vaping products, particularly given the lacking evidence around their safety and effectiveness as a smoking-cessation tool.
 
‘They’re experimental, we really don’t know,’ Dr Wilson said.
 
‘The pharmacological therapies, including nicotine-replacement therapy (NRT) and varenicline, are first line and those [that] in conjunction with support give you the best chance of actually changing smoking.
 
‘But we do acknowledge that nicotine addiction or dependency is a chronic relapsing condition … and it’s possible that for some people nicotine-based e-cigarettes may well be part of that smoking cessation story.
 
‘But [while] there’s clearly a place to offer that as an option as a time-limited smoking cessation tool – not as an ongoing maintenance tool – we don’t want e-cigarettes to become the next big thing after cigarettes and to have a generation of people addicted to it.’
 
According to the RACGP’s Smoking cessation guidelines, nicotine vaping products, accompanied by behavioural support, are only recommended as a second-line treatment ‘for people who have tried to achieve smoking cessation with first-line therapy (combination of behavioural support and TGA-approved pharmacotherapy) but failed and are still motivated to quit smoking’.
 
But Dr Wilson emphasises that, with the appropriate support systems in place, first-line therapies such as NRT, varenicline or bupropion, can be very successful.
 
‘People do stop and it does make an extraordinary difference to their health, there’s no doubt about it. We’ve had smoking rates drop from about 35% down to about 15% in the last few years,’ she said.
 
‘But the reality is … they’re the people that were going to find it easier to stop and we’re left now with a group of people who are more highly dependent.’
 
Dr Wilson says if a patient has demonstrated their attempt at first-line therapies and is at particularly high risk of coming to harm from smoking cigarettes, nicotine vaping products may have a place.
 
But she says understanding their role and having a plan in place is vital to cutting down use and, eventually, ceasing it altogether.
 
‘There are a group of people who have decided this is their thing that they do and this is their right,’ Dr Wilson said. ‘But there’s really very little place for long-term use of e-cigarettes.
 
‘My approach to that would be, “Well, I understand that that’s what you have decided to do, but … I don’t think I can continue to prescribe for you long-term at the moment because we just don’t have the evidence that the long-term use of this is safe”.
 
‘Each of us, as prescribers, need to think through it for ourselves and make the decision that’s right for us, but also for our patients as well.’
 
The webinar will also explore how to manage refusing a prescription for nicotine vaping products when deemed an inappropriate option.
 
The session will run for up to 50 minutes, with an additional 10–15 minutes set aside for participants to ask questions.
 
Dr Wilson says while she understands that the legislative changes regarding nicotine vaping products are controversial, she does think the decision to restrict access is the right step. 
 
‘We do want to be able to access this as a novel, potential and experimental treatment to see if we can assist our patients if it’s appropriate for them,’ she said. ‘But to have it generally available, that’s not the place that I come to by reviewing the literature.’
 
For GPs still unsure of whether they plan on becoming prescribers, Dr Wilson hopes the webinar will help them to make that decision.
 
‘One of the reasons we’re doing the webinar is that there isn’t an easy answer to this,’ she said.
 
‘I suppose your easy answer is to go to your patient … “I’m not in a position to do that, you’re going to have to seek that elsewhere”. Whereas there will be other GPs who having assessed the evidence for themselves and the patient group that they see, and will be more than happy to prescribe and to work with their patients.
 
‘That’s an individual decision.’
 
The webinar ‘Counselling smoking cessation in a changing world’ is taking place on Wednesday 10 November at 7.00 pm (AEDT) and will attract 2 CPD points. Visit the RACGP website to register.
 
The webinar is sponsored by Johnson & Johnson.
 
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