A middle aged man presents his prescription at the Update Pharmacy and asks to speak to the pharmacist. Pharmacist David Spencer comes to see him in the consultation area.

As he hands over his prescription, the man says: “My GP and the practice nurse say you run a stop smoking programme with a high success rate that can help me.”
David nods. “Can you tell me a bit about your situation? Have you tried giving up before?”

“Several times, I just can’t do it. But I have managed to cut down.”

“So, how many do you smoke?” asks David.

“On a good day, 10 cigarettes, on a bad one up to 20. But I was up to 40 a day at one time. I know it’s killing me – I’ve had a heart attack and had to have a by-pass operation, and I’ve also got diabetes. But the doctor says there’s still time to improve my health and my life expectancy – as long as I give up now, before it really is too late.”

David looks at the man’s prescription. It reads: Humalog insulin mdu; lisinopril 10mg tablets

i od; aspirin 75mg i om; simvastatin 40mg tablets i on.

“We’ll do our very best to help you,” David says, “and once you actually stop smoking I’ll give you some advice connected with your medicines.”

Questions

1. What advice will David give?

2. Aside from any on this prescription, which other medications may be affected by stopping smoking?

3. Which NRT presentation/s are most suitable for which type of smoker?

Answers

1. To monitor blood glucose levels carefully, as insulin absorption may be increased by stopping smoking. Insulin dose may need to be reduced.

2. Anti-psychotics: blood levels of several increased, effect with clozapine potentially most serious.

• Beta-blockers: effects can be enhanced, increasing blood pressure and heart rate.

• Theophylline/aminophylline: plasma levels may be increased; important as theophylline has a narrow therapeutic index and toxic effects may ensue.

• Warfarin: possible increase in INR. • Zolpidem: clearance reduced, possible increased sedation.

3. Low dependency (less than 10 cigarettes/day): lozenges, sublingual tablets or 2mg gum (Low dependency and high motivation to quit: encouragement and advice only). Moderate dependency (10-20 cigarettes/day), with low behavioural component* and normal or heavy build: patch**, starting with highest strength.

Moderate dependency, low behavioural component, slight build: patch, starting with middle strength (where available). Moderate dependency, high behavioural component: inhaler, sublingual tablets or 2mg gum (switching to 4mg if necessary); High dependency (more than 20 cigarettes/day): 4mg gum or lozenges or nasal spray. Very high dependency: nasal spray.

*Behavioural component: where part of the addiction is ritual behaviour associated with lighting, holding and inhaling a cigarette.

** 24-hour patch is better for smokers who crave a cigarette within 20 minutes of waking up.

16-hour patch should be used if sleep disturbances occur.