Tailoring strategies to high-risk groups 36 BPJ Issue 64

Smoking rates are declining in New Zealand as more and more people are successfully quitting. However, rates remain unacceptably high among deprived communities, Māori and Pacific peoples and in people with mental health disorders. It is often helpful to think of smoking as a chronic relapsing disease, thereby acknowledging the difficulties of smoking cessation and the likelihood of relapse. Ideally, health professionals should be providing smoking cessation support in the ABC format to every patient who smokes, at every consultation. It is also important to individualise cessation support by understanding why a patient's previous quit attempts have failed and encouraging a wave of social support for future attempts, particularly in groups with high rates of smoking. Health professionals who are able to do this increase the chances that patients will be able to stop smoking long-term. Identifying groups with high rates of
number of people who attempt to stop smoking by 40 – 60%.4 This means that one extra person can be expected to attempt to give up smoking for every seven people who are advised to In New Zealand, smoking rates are falling; daily smoking do so and offered support in their attempt.4 among all adults was 18.3% in 2006/07, 16.4% in 2011/12 and most recently, 15.5% in 2012/13.1 However, smoking is Tailoring support to patients by understanding their quit- analogous to a chronic disease with frequent relapses, and history and circumstances means that health professionals can ongoing work is required to continue this downward trend in increase the chances of the patient's next attempt succeeding. the number of people who smoke. It is important to let patients who are quitting know that it is likely that they will lapse. However, behavioural support, e.g. Smoking rates are substantially higher than the national Quitline, and pharmacological smoking cessation aids, do help average, and particularly concerning in: prevent a lapse in abstinence becoming a return to regular People who live in highly deprived areas Māori and Pacific peoples Current smoking is associated with poverty
People with mental health disorders Deprivation is strongly associated with smoking in New Zealand (Figure 1, over page). After adjusting for age, sex and The good news is that many people who smoke also frequently ethnicity, a person from one of the most deprived communities think about quitting, regardless of their background. When in New Zealand (Decile 10) is over three time more likely to surveyed, approximately 40% of people who smoke reported be a current smoker, compared with a person from one of attempting to quit in the previous 12 months.2 However, most the least deprived communities (Decile 1).1 Women who live attempts to quit do not succeed, and long-term success, e.g. in lower socioeconomic areas are also more likely to smoke remaining smokefree for at least six months, is only achieved during pregnancy (17%) compared with pregnant women in in 3 – 5% of attempts without the support of a health the general population (11%).5 Smoking rates in Māori and Pacific peoples must be
There are two strategies that health professionals can pursue in order to increase the number of people who quit smoking Almost one-third (32.7%) of Māori smoke, a rate more than twice as high as New Zealanders of European descent, and more 1. Increase the number of people who attempt to quit than one-third of Māori women smoke during pregnancy.5, 7 Death rates due to lung cancer and smoking-related diseases 2. Increase the success rate of quit attempts are three times higher in Māori than non-Māori.7 However, it is encouraging to know that most Māori who smoke do want Brief advice to stop smoking and, most importantly, an offer to quit. During the five-year period between 2006 and 2011, of cessation support by a health professional can increase the it was estimated that almost two-thirds (62%) of Māori who BPJ Issue 64 37
smoked made at least one quit attempt.7 It is important that reported that 32% of Tokelauan and 30% of Cook Island people these previously unsuccessful attempts be acknowledged and were classified as regular smokers in the 2013/14 New Zealand lessons learnt when future attempts to quit smoking are made. census, while 13% of people who identified as Fijian were It is also good news that the number of Māori youth who have regular smokers.9 Encouragingly, rates of smoking are reported never smoked is increasing: for boys from 58% in 2006/07 to to be declining among Pacific youth. Regular smoking among 75% in 2013/14, and for girls from 52% in 2006/07 to 72% in Pacific boys aged 15 – 19 years dropped to 13.6% in 2013/14 2013/14.7 Relative to their population size, Māori also tend to (from 20.1% in 2006/07), and regular smoking among Pacific use smoking cessation support services more than non-Māori; girls of the same age fel to 10.3% in 2013/14 (from 21.4% in from April to June 2014 Māori accounted for almost one in five Quitline caller registrations.8 Māori who do not smoke are exposed to second-hand smoke Smoking prevalence increases with severity of mental
more (11.4%) than non-Māori who do not smoke (6.4%).7 This increases the severity of the negative health effects of smoking People with a mental health disorder are approximately twice on Māori children. More than 20% of Māori households with as likely to smoke as people who do not have a mental health one or more child have at least one person who smokes inside disorder and generally, the level of nicotine dependence the home, compared to under 8% in non-Māori households.7 increases with the severity of the illness.10 Many people with mental health disorders who smoke will require additional The overall rate of smoking among Pacific peoples is 23%, support from health professionals to achieve long-term although this varies greatly depending on sub-ethnicity; it is Current sm
Figure 1: Proportion of people living in New Zealand communities, by deprivation status, who are current smokers,
adapted from NZDep20136
38 BPJ Issue 64
Adapting the ABC to different patient groups
Why does quitting smoking improve
General practitioners are encouraged to Ask about smoking,
mental health?
Briefly advise to quit and offer Cessation support (ABC), to
all patients who smoke, at every consultation.11 Some health
A meta-analysis of 26 studies found consistent evidence professionals may be reluctant to persistently advise people that smoking cessation is associated with improvements to quit smoking due to concerns that their relationship with in depression, anxiety, stress, quality of life and positive patients may be damaged. However, it should be remembered affect.14 This benefit was similar for people in the general that most people who smoke are open to the idea of quitting;12 population and for those with mental health disorders.14 80% of current smokers report that they would not smoke if they had their life over again.11 The fallacy that smoking improves mental health can be understood when the neural changes that long-term "When was the last time you smoked a cigarette?" is a
smoking causes are considered. Over time, smoking non-judgemental way of enquiring about smoking status in results in modification to cholinergic pathways in patients who are known to be smokers.
the brain, resulting in the onset of depressed mood, agitation and anxiety during short-term abstinence from tobacco, as levels of nicotine in the blood drop.14 When Understand the barriers before you start
a person who has been smoking long-term has another Understanding why the patient relapsed into smoking cigarette their depressed mood, agitation and anxiety is following attempts to quit allows health professionals to relieved. However, as a person continues to abstain from provide individual strategies, e.g. encouraging the patient's smoking the cholinergic pathways in the brain remodel partner to also take part in the quit attempt if the partner is and the nicotine withdrawal symptoms of depressed influencing the patient's smoking status. Having a partner mood, agitation and anxiety are reduced through who continues to smoke during pregnancy is said to "almost abstinence from nicotine. The process whereby people universally predict" a return to smoking among women who relieve withdrawal symptoms with a drug, i.e. nicotine, which then reinforces these symptoms is referred to as a withdrawal cycle and it may also be associated with a Fear of consequences can encourage smoking
decline in mental health.14 For people whose social life is restricted to family/whanau and neighbours, a fear that quitting smoking can result in being "left-out" socially is a barrier to quitting.12 Concerns that giving up smoking will cause illness are also not uncommon, e.g. coughing or chest infections following quitting. Other barriers The effects of smoking cessation on
to quitting smoking that are frequently reported include: fear patients with mental health disorders
of weight gain, boredom and the timing of a quit attempt being problematic.12 A patient's individual concerns about Hydrocarbons and tar-like products in tobacco smoke quitting need to be addressed when discussing smoking are known to induce the cytochrome P450 enzyme CYP1A2.15 When patients taking other medicines that are metabolised by this enzyme stop smoking there Viewing smoking as a stress-reliever can be a barrier to
may be an initial rise in medicine levels in their blood as enzymatic activity falls to normal levels. There may People who smoke often view it as a stress-relieving activity, be some instances where stopping smoking in a patient therefore do not want to quit.12, 14 There may also be concern taking certain antipsychotics (e.g. clozapine, olanzapine, that quitting smoking will worsen mood in people with a chlorpromazine, haloperidol) or insulin causes clinically mental health disorder.14 In fact the opposite is more likely significant changes in serum concentrations.15 Patients to be the case: smoking cessation has been shown to have with insulin-dependent diabetes who stop smoking beneficial effects on mood disorders, with an effect size equal should be alert to the symptoms of hypoglycaemia and to, or larger than, treatment with antidepressants.14 Health increase their frequency of blood glucose monitoring.16 professionals should acknowledge that a patient's mood may improve in the minutes after smoking a cigarette. However, this is an opportunity to explain to the patient that the reason BPJ Issue 64 39

they feel better is because they are addicted to nicotine, and without assessing their readiness to stop smoking. Only that every puff continues this cycle (see: "Why does quitting offering cessation support to people with a stated desire to smoking improve mental health?", previous page). The patient quit smoking is a missed opportunity for positive change. Also can then be reassured that al people who break the cycle of see: "A review of pharmacological smoking cessation aids", smoking addiction will experience mental health benefits.14 N.B. The doses of antipsychotics used to treat some mental health disorders (and insulin) may need to be adjusted if A meta-analysis of the effect of cessation support found that abrupt cessation occurs in a person who is heavily dependent offers of cessation support by health professionals, e.g. "If you on cigarettes (see: "The effects of smoking cessation on would like to quit smoking I can help you do it", motivated patients with mental health disorders: previous page). an additional 40 – 60% of patients to stop smoking within six months of the consultation, compared to being advised to quit smoking on medical grounds alone.4 It is important to From talking to quitting
note that the motivation of patients to stop smoking was not Motivational interviewing can increase the likelihood that a assessed before offers of cessation support were made. patient will attempt to quit smoking and increase the chances of them succeeding.10 Referral to a smoking cessation service is recommended
Quitline is a smoking cessation service which offers phone-
The general techniques of motivational interviewing based support, six days a week (Monday – Friday 8 am – 9.30 pm, Sunday 10 am – 7.30 pm on 0800 778 778) to all people 1. Expressing empathy who want to quit smoking. People can self-refer to Quitline or they can be referred by a health professional. Patients can e.g. "So you've already tried to give up smoking a couple also be referred electronically if the relevant feature is enabled of times and now you're wondering if you will ever be on the practice management system. Txt2Quit support is available from Quitline directly to mobile phones.
2. Developing the discrepancy between the goal of being For further information go to:
smokefree and the behaviour of smoking e.g. "It's great that your health is important to you, but Aukati Kai Paipa is a free smoking cessation service that how does smoking fit with that for you?" delivers face-to-face coaching for Māori from over 30 centres around New Zealand. 3. Rolling with resistance e.g. "It can be hard to cope when you're worried about To find your closest provider go to the Aukati Kai Paipa your mother's health and I realise that smoking is one of website at:
the ways that you've used to give yourself a break. What other ways do you think you could use? " Smokefree Communities offers smoking cessation services to people living in the North Shore, Waitakere and Rodney 4. Encouraging self efficacy areas. Programmes focus on reducing rates of smoking among women who are pregnant and their whanau/family, Asian e.g. "Last time you didn't think you'd be able to manage people and their families, and al families with children aged without smoking at al – and you've actual y gone al week under 16 years. Smokefree Communities provides support in with only two cigarettes – what did you do differently this Chinese, Korean, Burmese and Hindi/Fiji Hindi languages. time to make that happen?" To find out more about Asian Smokefree services go to: A goal of care when consulting with patients who are current smokers is to negotiate a firm quit date and to agree on "not one puff" from that point onwards.10 Cessation support is the most important aspect of the
Preventing smoking relapses
ABC approach
Health professionals can discuss strategies with patients to It is important that cessation support, e.g. referral to smoking help manage triggers where there is extra pressure to smoke. cessation service, should be offered to all people who smoke For example, focus on something that is important to the 40 BPJ Issue 64

patient and incorporate it into a response that they use to decline an offer to smoke, e.g. "No thanks, my daughter has asthma – our home is now smokefree to help her breathing Incentives to smokefree pregnancies
get better".
Incentive programmes have recently been launched to encourage pregnant women to quit smoking in some Creating a wave of social support
North Island areas, including Waikato, Counties Manukau Encourage the person quitting to reach out for assistance and Northland DHBs. As part of the Waikato programme, from anyone they know who has previously quit smoking. vouchers to a total value of $250 are given to Māori or Peer support for people who are attempting to quit smoking Pacific women who are up to 28 weeks pregnant, at one, can take many forms. The rationale is that a person with similar four, eight and 12 weeks after they have quit smoking.19 life experiences to the person who wants to stop smoking Vouchers are intended to be spent on items such as can provide practical tips that fit with their lifestyle. A friend groceries or petrol; they cannot be exchanged for cash or family member is also more likely to have regular contact or spent on cigarettes or alcohol.19 The smokefree status with the person attempting to quit. Examples of peer support of the women participating is measured by testing might be having a coffee or tea together each morning to exhaled carbon monoxide levels. It was reported that this discuss any difficulties or temptations, or attending situations was a positive influence on quit attempts as it provided together where there may be a strong temptation to smoke, accountability.20 The Counties Manukau programme e.g. the pub.
resulted in a 65% quit rate at four weeks and a 60% rate at 12 weeks.20 There is some evidence that peer support may be more successful when people in deprived communities attempt to quit smoking, compared with people in the general population.17 Some maraes in New Zealand have also run competitions that both challenge people who are quitting smoking to stay smokefree while also supporting each other's quit attempts. The Quitline Blog is the most popular online smoking cessation peer support forum operating in New Zealand. People who are attempting to quit smoking can be encouraged to access this forum to receive support at any time of the day or night. Social networking platforms, e.g. Facebook, can also be used to provide a substitution for social situations where the person has previously found it difficult to resist the temptation to smoke. Social networking is more likely to be used by younger people who smoke and have regular access to the internet. The Aukati KaiPaipa Facebook page is available at: www.
Children are a positive and motivating influence
The health-related and financial benefits that the children of people who smoke gain when their parents quit smoking is a powerful motivating factor.12 In particular, prospective parenthood can provide additional motivation to stop smoking. Having a smokefree pregnancy and then maintaining a smokefree household means that children are less likely to develop middle ear infections, or to have lower respiratory illness, asthma or abnormal lung growth, and have a lower incidence of sudden unexplained death in infancy.11 BPJ Issue 64 41

The cost of smoking just keeps going up
A review of pharmacological
Cost increase is a recognised method for decreasing cigarette consumption. As part of the drive to create a smokefree New smoking cessation aids
Zealand by 2025, it is government policy that an average pack of 20 cigarettes will cost more than $20 by 2016, with Pharmacological aids for smoking cessation can reduce future price increases beyond this highly likely.18 This policy nicotine cravings and lessen withdrawal symptoms. An is supported by the Royal New Zealand College of General offer of medical assistance may embolden people who have Practitioners.11 previously attempted to quit smoking without support to try again. Pharmacological aids also reduce the likelihood of a At a cost of $20, a pack-a-day smoker would be spending lapse in abstinence becoming a return to long-term smoking. $140 a week, or more than $7000 per year on cigarettes. The money that a family/whanau can save by quitting smoking The important factors to consider when discussing smoking can, and should, be used to create goals that unite families in cessation treatment options are the patient's preferences and their desire to be smokefree. For example, as well as spending previous experience of smoking cessations aids, the patient's the extra money on essentials such as clothing, a small weekly likely adherence to treatment and the possibility of any treat such as going to the local swimming pool can provide adverse effects.
an ongoing and tangible incentive to being smokefree. Longer term goals such as saving for a family holiday can also create family "buy-in" and may help parents remain abstinent from Nicotine replacement therapy
smoking in the months following their quit date. The use of NRT approximately doubles the likelihood of a person being able to quit smoking long-term; one in 14 people who would not otherwise have stopped smoking will do so for What to do if the patient does have another cigarette?
at least six months following a course of NRT.15 Several studies If a patient who is attempting to quit reports that they have suggest that in people who are unmotivated to quit within the had a brief smoking lapse then it is important that they do not next month, the use of NRT results in an increased number of see this as a failure. Support is required to help them avoid quit attempts and marginally higher rates of abstinence.21 NRT feelings of guilt and loss of control that can undermine their may therefore act as a quit catalyst for patients who smoke quit attempt. Remind patients that many people who quit and who report that they are not yet ready to stop.21 Offering experience lapses. Encourage the patient to continue to use patients who smoke the opportunity to trial different forms of NRT and any other smoking cessation medicines that have NRT before they attempt to quit may also improve their choice been prescribed. Ask the patient to again commit to "not of NRT and result in better treatment adherence. one puff" onwards and to ensure that cigarettes, lighters and ashtrays have been discarded. Most people who are attempting to quit smoking do not use enough NRT.22 Patients who are heavily dependent on cigarettes may gain benefit from increasing the dose of nicotine, e.g. wearing two patches, to replicate the levels of nicotine that reach the brain when they are smoking. Combining NRT products, e.g. using a nicotine patch and nicotine gum, is more effective than using a single NRT product.15 If patients begin to feel nauseous when using NRT they can be advised to reduce the frequency or dose of the product.22 Subsidised NRT can be prescribed by general practitioners and registered Quit Card Providers. Subsidised supplies of NRT may also be obtained by general practices using a Practitioner Supply Order. Pharmacists can supply subsidised NRT that is prescribed on a normal prescription (maximum quantity 12 weeks) or a Quit Card (maximum quantity 8 weeks) at a cost of $5; these wil be dispensed in four-week quantities. Pharmacists are not able to prescribe subsidised NRT unless they are part of a special regional programme, e.g. Canterbury DHB.
42 BPJ Issue 64
Nicotine replacement therapy should be continued for at is indicated for people who are highly dependent on tobacco, least eight weeks; the normal treatment course is 12 weeks.23 i.e. smoking within an hour of waking. The gum should be Patients who feel they are still gaining benefit from treatment bitten to liberate a peppery flavour. The gum should not be can continue to use NRT for longer periods.23 If patients wish chewed continuously as swallowed nicotine can result in to use NRT as a way of reducing cigarette consumption, prior gastrointestinal disturbance. It can be placed between the to quitting, then cigarette use should be reduced to half at six cheek and gum and chewed again when the taste fades, and weeks and completely stopped at six months.23 disposed of after 30 minutes.22, 23 In order to determine an appropriate NRT regimen, New Nicotine lozenges are available in 1 mg and 2 mg formulations.
Zealand guidelines recommend combining the time until the It is recommended that lozenges be used regularly when first cigarette with the total number of cigarettes a person nicotine cravings occur.22 The 2 mg formulation is indicated smokes each day (Figure 2). The amount of time that passes for people who are highly dependent on tobacco, i.e. smoking after waking until a person smokes their first cigarette is a within an hour of waking.
useful guide when assessing nicotine dependence; New Zealand guidelines use smoking within an hour of waking All people who wish to quit smoking can use NRT, including
as a sign of high tobacco dependence,22 smoking within five people with cardiovascular disease and women who are minutes of waking is a sign of severe dependence.10 pregnant or breastfeeding, if they would otherwise continue to smoke.22 When discussing the use of NRT with a woman Nicotine patches are fully subsidised in New Zealand and
who is pregnant or breastfeeding perform a risk assessment available in 7mg, 14 mg and 21 mg patches. These should be and consider "Can she quit without NRT?" If not, NRT is safer pressed in place on dry, clean and hairless skin, and replaced than smoking. A study involving over 1700 pregnant women daily.22 Patches may cause some dermal erythema.22 If patients who used NRT found no significant association between NRT report disturbed sleep while using nicotine patches then they use and decreased infant birth weight.24 Pregnant women who should be removed at night. are using nicotine patches should remove them overnight.22 Adolescents aged 12 years or over can also be prescribed Nicotine gum is available in 2 mg and 4 mg formulations. It is
NRT,22 however, the use of NRT alone is unlikely to address recommended that nicotine gum be used regularly by people the reasons why an adolescent has begun, and continues to who are attempting to quit smoking.22 The 4 mg formulation Smokes after one
Smokes within one
hour of waking
hour of waking
Smokes fewer
Smokes fewer
more a day
more a day
either 2 mg gum or either 2 mg gum or either 4 mg gum or Figure 2: Nicotine dependence assessment algorithm for determining an appropriate NRT treatment regimen, adapted
from "Guide to prescribing nicotine replacement therapy (NRT)"22
BPJ Issue 64 43
Table 1: Comparison of smoking cessation medicines that are subsidised in New Zealand23
Funding status* Fully subsidised
Fully subsidised with Special Authority approval for people who have tried previously to quit smoking with other medicines† Efficacy Almost doubles a patient's
Almost doubles a patient's Approximately triples a chances of quitting smoking chances of quitting smoking patient's chances of quitting Mechanism of action Atypical antidepressant
Tricyclic antidepressant Stimulates nicotine receptors which aids smoking cessation which aids smoking cessation less than nicotine, i.e. is a independently of its independently of its partial agonist, thereby antidepressant action15 antidepressant action15 reducing cravings, and, at the same time, reduces the rewarding sensation of smoking, i.e. antagonist effect.10 Contraindications Lowers seizure threshold
Should not be taken by None, however, patients and and should not be taken by patients: who are acutely their family/whanau should patients with acute alcohol or recovering from a myocardial be vigilant for changes in benzodiazepine withdrawal, infarction, with arrhythmias, behaviour, thinking or mood, CNS tumour, eating disorders, during manic phases of bipolar in particular depression and bipolar disorder, use of disorder, with acute porphyria, suicidal ideation. If this occurs monoamine oxidase inhibitors who are breast feeding, or cease taking the medicine (MAOI) in the last 14 days, and who have used a MAOI in the and seek medical advice in patients with severe hepatic Adverse effects In general, bupropion is
Has the potential to cause Nausea may occur in considered to be a safer more harm than bupropion approximately one-third of medicine than nortriptyline. and can be fatal in overdose.15 patients, but this is generally One in a thousand patients Adverse effects include: dry mild and will only be are expected to have a seizure mouth, constipation, nausea, intolerable in a few patients.10 over the course of treatment.25 sedation (which can affect Use with caution in patients driving ability) and headaches. taking antipsychotics due to Advise patients to avoid increased seizure risk. Skilled alcohol as sedation may be tasks, such as driving, may be Women who are Avoid during pregnancy
Should only be taken during Avoid during pregnancy pregnancy when the benefits outweigh the risks 44 BPJ Issue 64
Patients with mental May cause levels of citalopram
In general, nortriptyline See contraindications health issues to be raised in some patients
should be used with caution in patients thought to be at an increased risk of suicide, or who have a history of psychosis. Levels of nortriptyline can be increased by two to four-fold, or occasionally more, by the concurrent use of fluoxetine; in this situation nortriptyline dose reductions of 75% have been suggested.
Dosing Initiate one to two weeks
Initiate ten to 28 days before Initiate one to two weeks before quit date with one 150 the agreed quit date with before the quit date, at 500 mg bupropion tablet, daily, for nortriptyline 25 mg, daily, micrograms varenicline, daily, three days, then 150 mg, twice gradually increase over ten for three days, increased to daily. The maximum single days to five weeks to 75 – 100 500 micrograms varenicline, dose is 150 mg bupropion, mg nortriptyline daily, for up twice daily, for four days, then and the maximum daily dose is to three to six months. The 1 mg twice daily for 11 weeks. 300 mg bupropion. Treatment dose should be slowly tapered The 1 mg dose can be reduced is usually for seven weeks. For while treatment is withdrawn. to 500 micrograms if it is not people with risk factors for tolerated. This course can be seizures or in elderly patients repeated to reduce the risk of the maximum daily dose is 150 mg bupropion.
* Subsidy status correct at the time of printing. Check the New Zealand Formulary for latest information.
† Varenicline is fully subsidised with Special Authority approval for people who have tried previously to quit smoking with other medicines and have not used varenicline in the preceding 12 months. In order to qualify for subsidy patients must: Indicate that they are ready to cease smoking; and Have enrolled, or about to enrol in a smoking cessation programme that includes prescriber or nurse monitoring; and Have trialled and failed to quit smoking previously using bupropion or nortriptyline; or tried but failed to quit smoking on at least two separate occasions using NRT, with at least one of these attempts including the patient receiving comprehensive advice on the use of NRT; and Not have used subsidised varenicline in the last 12 months; and Agree not to use varenicline in combination with other pharmacological cessation medicines; and Not be pregnant; and Not be prescribed more than three months funded varenicline BPJ Issue 64 45
Nicotine inhalators (15 mg nicotine cartridges) and
nicotine mouth spray (1 mg nicotine per dose) are available
Electronic-cigarettes – the jury is still out
as unsubsidised NRT products. Nicotine inhalators can be puffed on for 20 minutes every hour, and the cartridge Electronic-cigarettes are a topic in smoking cessation replaced after three hours.22 One cigarette puff is equivalent that is evolving rapidly, both in terms of device design to approximately ten inhalator puffs.22 Nicotine mouth sprays and evidence of effectiveness. The devices electronically are also recommended for regular use, or for when cravings vaporise a solution made up of propylene glycol and/ occur.22 After priming the pump, direct one spray to the inside or glycerol, nicotine and flavourings, that users inhale of each cheek. Advise patients to resist swallowing for several rather than burning tobacco leaves.26 The solution is held seconds after application to achieve best results.22 in cartridges that are inserted into the device.26 These devices are different to nicotine inhalators.
For further information see the "Guide to prescribing nicotine replacement therapy (NRT)" available from: The body of research on electronic-cigarettes is small, but growing quickly, and opinion is divided as to the potential harms or benefits to personal or public health.27 Currently, Medicines to aid smoking cessation
no electronic cigarette products have been approved under the Medicines Act for sale or supply in New Zealand Medicines for smoking cessation should be prescribed in and therefore it is illegal to sell an electronic-cigarette combination with behavioural support, e.g. Quitline, to that contains nicotine.26 It is also illegal for electronic- improve their effectiveness.10 Table 1 (previous page) provides cigarettes, with or without nicotine, to be sold as a comparison of smoking cessation medicines subsidised smoking cessation aids, or for an electronic-cigarette that in New Zealand. In general smoking cessation medicines resembles a tobacco product to be sold to a person under should not be used by women who are pregnant because the age of 18 years.26 However, electronic-cigarettes are the potential risk to foetal development cannot be balanced available on international websites as smoking cessation against the known benefits of smoking cessation.15 Some aids and many people who smoke are interested in using smoking cessation medicines may not be appropriate for them for that purpose.
patients with a history of mental disorders. Electronic-cigarettes are considered by experts to be less harmful than conventional cigarettes, however, short-term adverse effects have been attributed to exposure to propylene glycol including eye and respiratory irritation.28 The aerosol that electronic-cigarettes produce contains a number of cytotoxic and carcinogenic chemicals that may pose long-terms risks to women who are pregnant.28 These compounds are present at levels one to two orders of magnitude lower than is present in tobacco smoke, but at higher levels than is found in nicotine inhalers.28 Both the Ministry of Health and WHO recommend that people who smoke should be encouraged to quit using a combination of approved NRT products, i.e. patches, lozenges and gum.26 The Ministry of Health intends to assess new evidence as it arises regarding the safety and appropriateness of the use of electronic-cigarettes as smoking cessation aids.
46 BPJ Issue 64
Māori people to quit smoking. Quitline, 2014. Available from: www.
ACKNOWLEDGEMENT: Thank you to Dr Brent
Caldwell, Senior Research Fellow, Department of
2014website.pdf (Accessed Oct, 2014).
Medicine, University of Otago, Wellington, Dr Marewa
13. Mullen PD. How can more smoking suspension during pregnancy Glover, Director of the Centre for Tobacco Control
become lifelong abstinence? Lessons learned about predictors, Research, University of Auckland and Dr Hayden
interventions, and gaps in our accumulated knowledge. Nicotine Tob Res 2004;6 Suppl 2:S217–38.
McRobbie, Senior Lecturer, School of Public Health
and Psychosocial Studies, Auckland University of
14. Taylor G, McNeill A, Girling A, et al. Change in mental health after smoking cessation: systematic review and meta-analysis. BMJ Technology, Consultant, Inspiring Limited for expert guidance in developing this article.
15. Ministry of Health (MOH). New Zealand smoking cessation guidelines. MOH, 2007. Available from: (Accessed Oct, 16. UK Medicines Information. Which medicines need dose adjustment when a patient stops smoking? 2012. Available from: www.evidence.
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findings 2012/13. Wellington: Ministry of Health 2013. Available from: 17. Ford P, Clifford A, Gussy K, et al. A systematic review of peer-support update-key-findings-2012-13 (Accessed Oct, 2014).
programs for smoking cessation in disadvantaged groups. Int J Environ Res Public Health 2013;10:5507–22.
2. Borland R, Partos TR, Yong H-H, et al. How much unsuccessful quitting activity is going on among adult smokers? Data from the 18. Smokefree Coalition. Quitting tobacco would reduce poverty: media International Tobacco Control Four Country cohort survey. Addiction release. 2013. Available from: tobacco-would-reduce-poverty.pdf (Accessed Oct, 2014).
3. Hughes JR, Keely J, Naud S. Shape of the relapse curve and long-term 19. Waikato DHB. Waikato picks up incentive programme for smokefree abstinence among untreated smokers. Addiction 2004;99(1):29–38.
pregnancies. 2014. Available from: (Accessed Oct, 2014).
4. Aveyard P, Begh R, Parsons A, et al. Brief opportunistic smoking cessation interventions: a systematic review and meta-analysis 20. Auahi Kore. Counties Manukau smokefree pregnancy incentives to compare advice to quit and offer of assistance. Addiction pilot. Available from: smokefree-pregnancy-incentives-pilot (Accessed Oct, 2014).
5. Morton S, Atatoa C, Bandara D, et al. Growing up in New Zealand: A 21. Carpenter MJ, Jardin BF, Burris JL, et al. Clinical strategies to enhance longitudinal study of New Zealand children and their families. Report the efficacy of nicotine replacement therapy for smoking cessation: 1: Before we are born. 2010. Available from: https://researchspace.
a review of the literature. Drugs 2013;73:407–26. (Accessed Oct, 2014).
22. Ministry of Health (MOH). Guide to prescribing nicotine replacement 6. Atkinson J, Salmond C, Crampton P. NZDep 2013 Index of Deprivation. therapy. MOH, 2014. Available from: (Accessed 2014. Available from: (Accessed Oct, 2014).
23. New Zealand Formulary (NZF). NZF v28. 2014. Available from: www.
7. ASH: Action on smoking and health. Māori smoking: fact sheet. ASH, (Accessed Oct, 2014).
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report and associated article on electronic cigarettes. Addiction 11. The Royal New Zealand College of General Practitioners (RNZCGP). 2014;[Epub ahead of print].
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to encourage people living in high deprivation communities and/or BPJ Issue 64 47


Importancia del agua

Elementalwatson "la" revista ………………. Revista cuatrimestral de divulgación "En el conocimiento y la cultura no Año 4, número 11 sólo hay esfuerzo sino también placer. Llega un punto donde estudiar, o investigar, o Universidad de Buenos Aires Ciclo Básico Común (CBC) aprender, ya no es un esfuerzo y es puro

Microsoft word - schwaiger-ludescher_2003

Gabi Schwaiger-Ludescher Musiktherapie mit einer chronisch schizophrenen Frau – Beispiel einer Auseinandersetzung mit dem Modell der Affektlogik nach Luc Ciompi Luc Ciompis Affektlogik, erstmals herausgegeben 1982, wählte ich zur Grundlage meiner Diplomarbeit, wobei es mir ein Anliegen war, seine Theorie der Entstehung „Schizophrener Verrücktheit" sowie die daraus resultierenden Verständnis- und Behandlungskonsequenzen im Zusammenhang mit musiktherapeutischem Tun zu betrachten. Ich werde in einem ersten Schritt den Begriff Affektlogik sowie das dreiphasige Modell der Schizophrenen Verrücktheit vorstellen. Anschließend beleuchte ich die sich daraus ergebenden