The Dragon Institute

Innovation for Social Change

SPECIAL POPULATIONS

Hayden McRobbie
Clinical Director The Dragon Institute
Professor of Public Health Interventions Wolfson Institute
of Preventive Medicine, Queen Mary University of London
Disclosure
I am Professor of Public Health
Interventions at Queen Mary University of
London
I am the Clinical Director of The Dragon
Institute for Innovation
In the past 5 years have received honoraria
for speaking at smoking cessation meetings
that have been organized by J&J and Pfizer.
I have no links with any tobacco or e-
cigarette manufacturers.
CARING FOR PEOPLE WITH
MENTAL ILLNESS WHO SMOKE
 Smoking and mental health

Accepted part of the culture

in many psychiatric treatment
facilities
Many misconceptions
One illness at a time
Quitting is bad for mental
health
Clients dont want to quit
Treatment does not work

Williams et al. Addict Behav. 2004;29:1067-1083;

Smoking prevalence and mental health

People with (any)

mental disorder are
more likely to smoke
than people who do
not.

Smoking prevalence is
even higher in people
with any substance
abuse
Smoking and Socio-economic group (SEG)

Higher degree of
tobacco
dependence
Social norms and
their lived realities
Higher levels of
stress, which may
make relapse
Compared to smokers from higher more likely
SEGs, those from lower SEGs are Difficulty coping
Just as likely to try to quit with stress
Less likely to succeed
Why the higher prevalence?

Self medication
Psychosocial or environmental
factors
Smoking causes mental health
problems
Common genetic vulnerability
(genes that are related to both
smoking and mental illness)
Problems associated with smoking

Psychiatric patients who smoke

have

1. Higher incidence of illicit drug

use
2. Poorer treatment compliance
3. Lower Global Assessment
Functioning (GAF) score
4. More hospitalisations
5. Higher medication doses

Williams et al. Addict Behav. 2004;29:1067-1083; Dalack et al. Am J Psychiatry. 1998;155:1490-1501; Montoya et al. Am J Addict.
2005;14(5):441-454.
Coronary Heart Disease (CHD)

Compared with the general population,

people with schizophrenia

Have a 20% shorter life expectancy

2-fold higher risk of CHD
Twice as likely to die of CHD
Major risk factors for CHD are more
commonsmoking,
hypercholesterolemia, hypertension,
obesity, and diabetes

50% to 75% of patients with

schizophrenia have CHD

Hennekens et al. Am Heart J. 2005;150:1115-1121;

Nicotine Withdrawal Syndrome

Irritability,
frustration,
Insomnia/sleep
disturbance
or anger
Anxiety
Increased appetite
(may increase
or weight gain
or decrease
with quitting)

Restlessness Dysphoric or
or impatience depressed mood

Difficulty concentrating
Importance of managing nicotine withdrawal

People will mental illness

may be more likely to
experience nicotine
withdrawal symptoms
Both dependence and
withdrawal appear to be
independent predictors of
treatment failure in this
population

Am J Public Health. 2014 Feb;104(2):e127-33. doi: 10.2105/AJPH.2013.301502. Epub 2013 Dec 12.
Cigarette smoking and mental illness: a study of nicotine withdrawal.
Smith PH1, Homish GG, Giovino GA, Kozlowski LT.
Benefits of Quitting Smoking

Gain in life expectancy

Improved health and functioning
Greater happiness and life satisfaction
Less financial stress
Improvements in mental health
Reduce inequalities in health
E.g. people with mental illness die earlier than people without
77.7% of excess deaths were attributed to physical health conditions (e.g. CVD
cancer); suicide was the cause of 13.9% of excess deaths.*
To give people back control (smoking is a behaviour
over which people have lost control)

*Lawrence et al BMJ 2013;346:f2539 (Published 22 May 2013)

Stopping Smoking and Mental Health
Anxiety
Depression
Anxiety and Depression
Stress
Effects of Bans

Some studies show a worsening of psychiatric

symptoms post-ban with an increase in incidents
and medication use to control these symptoms
in the first few months following the ban
A retrospective study 3 of 119 psychiatric
patients in a maximum-security unit and in an
open ward showed:
smokers were less likely to be in a good mood after the
ban
an increase in aggression towards staff in open wards
no increase in adverse reactions in the maximum security
section
1. Cole et al. Journal of Psychiatric Practice 2010;16(2):75-81.
2. Velasco et al Psychiatric Services (Washington 1996;47(8):869-71.
3. Harris et al The Journal of Behavioral Health Services & Research 2007;34(1):43-55.
Effects of Bans

Some studies have demonstrated an

improvement in health with significant
reductions in the following:
disruptive behaviour;
referrals for the assessment of physical illness;
instances of verbal aggression
instances of physical aggression
smoking related health conditions
coercion or threat incidents
There is evidence of general improvements in
psychiatric scores after imposition of a smoking
ban 1. Hempel et al. Behavioral Sciences and the Law 2002;20(5):507-22.
2. Quinn et al. Administration and Policy in Mental Health 2000;27(6):451-53.
3. Hollen et al. Psychiatric Services 2010;61(9):899-904.
4. Smith et al. Psychiatric Services 1999;50(1):91-94.
Effects of Bans

A prospective cohort study 1 audited data

from 289 patients that were admitted to a
secure psychiatric unit over an 8-month
period (4-months pre and 4-months post
smoking ban).
There was no significant change in incidence
of:
self-harm
physical aggression
verbal abuse
property damage.

1. Cormac et al. The Psychiatrist 2010;34(10):413-17

Full ban is better

Partial bans, where smoking is allowed on grounds,

or on outings, generally demonstrate poorer
outcomes with greater disturbances in behaviour

1. Cormac et al. The Psychiatrist 2010;34(10):413-17.

2. Hempel et al. Behavioral Sciences and the Law 2002;20(5):507-22.
3. Hollen et al. Psychiatric Services 2010;61(9):899-904.
4. Resnick et al. Hospital & Community Psychiatry 1989;40(5):525-27.
5. Shetty et al. The Psychiatrist 2010;34(7):287-89.
6. Smith et al. Psychiatric Services 1999;50(1):91-94.
7. Quinn et al. Administration and Policy in Mental Health 2000;27(6):451-53.
RCP report recommendations

Smoke-free policy is crucial

to promoting smoking
cessation in mental health
setting
All healthcare settings used
by people with mental
disorders should therefore
be completely smoke free
There is no justification for
healthcare staff to facilitate
smoking
Royal College of Physicians, Royal
College of Psychiatrists. Smoking and
mental health. London: RCP, 2013.
Cessation Treatment for People with Mental
Illness
Brief counselling without medication does not appear to be
effective in helping smokers with mental illness to stop

Best to provide multi-session behavioural support plus

pharmacotherapy

People with mental illness and other substance misuse will

benefit most from intensive treatment and they should be
referred to face-to-face services
European Psychiatric Association

European Psychiatry 29 (2014) 6582

NRT

NRT is likely to be
Quit rates in people with depression
effective in people with
mental illness.
It has been studied
specifically in people
with
Depression
Schizophrenia
Substance use
disorder Nicotine Gum Placebo

. [Kinnunen T, Doherty K, Militello FS, Garvey AJ. Depression and smoking cessation: characteristics of depressed smokers and effects of nicotine repla- cement. J Consult Clin Psychol 1996;64:7918.

. [Kinnunen T, Korhonen T, Garvey AJ. Role of nicotine gum and pretreatment depressive symptoms in smoking cessation: twelve-month results of a randomized placebo controlled trial. Int J Psychiatry Med 2008;38:37389
 Bupropion

Bupropion has been used in people schizophrenia who were

motivated to quit

Cochrane meta-analysis combined the results of 5 trials (n = 214)

and showing that it was effective at helping people to quit
smoking for at least 6 months (risk ratio 2.78; 95% CI:1.027.58)

Smoking cessation treatment did not jeopardise mental state

Bupropion is also effective for smoking cessation in patients with

a history of depression or alcoholism

yford KE, Patten CA, Rummans TA, Schroeder DR, Offord KP, Croghan IT, et al. Efficacy of bupropion for smoking cessation in smokers with a former history of major depression or alcoholism. Br J Psychiatry 1999;174: 1738.
Bupropion + NRT in people with schizophrenia

Evins et al 2007 George et al 2008

Bup + NRT

Evins AE, Cather C, Culhane MA, Birnbaum A, Horowitz J, Hsieh E, et al. A 12- week double-blind, placebo- . George TP, Vessicchio JC, Sacco KA, Weinberger AH, Dudas MM,
controlled study of bupropion sr added to high- dose dual nicotine replacement therapy for smoking cessation or Allen TM, et al. A placebo-controlled trial of bupropion combined with nicotine
reduction in schizophrenia. J Clin Psychopharmacol 2007;27:3806. patch for smoking cessation in schizophrenia. Biol Psychiatry 2008;63: 10926.
Varenicline - warning

Post marketing reports

exacerbations of symptoms of existing psychiatric disorders during
treatment
psychiatric side effects in patients without a diagnosis of mental illness

A warning was then applied highlighting the risk of serious

neuropsychiatric symptoms.
changes in behaviour
hostility
agitation
depressed mood
suicidal thoughts and behaviour, and attempted suicide
Smoking and suicide risk

There is a strong association between heavy

smoking and high suicide rate
Suicide rate

25

Doll R et al. BMJ 1994;309:901-911.

Systematic Review

Cochrane review concludes

that there is little evidence
from controlled studies of
any link between
varenicline and psychiatric
adverse events

However, this does not imply that

varenicline is risk free.

All medicines have an associated

risk and these have to be weighed-
up against the benefits

. Cahill K, Stead LF, Lancaster T. Nicotine receptor partial agonists for smoking
cessation. Cochrane Database Syst Rev 2012;4:CD006103.
Expert opinion (2010)

Although the risk of potential

neuropsychiatric events is evident through
voluntary reporting systems and reported
cases in the literature, multiple studies and
case reports support the use of varenicline
in the mental health population
Cautious treatment initiation, patient
education, and close follow-up, monitoring
for mood and behaviour changes during
therapy are recommended
Purvis TL, Nelson LA, Mambourg SE. Varenicline use in patients with mental
illness: an update of the evidence. Expert Opin Drug Saf. May 2010;9(3):471-
482.
More recent data (2012)

Varenicline (n = 19 933) and

NRT patch (n = 15 867)
users

Patients were followed for

neuropsychiatric
hospitalisations

There was no increase in the rate of neuropsychiatric hospitalisations

in patients treated with varenicline compared to NRT patch when followed
for 30 days (propensity-score matched HR = 1.14, 95% CI: 0.562.34).
Results were similar after 60 days of follow-up
Another meta-analysis (2013)

Varenicline
did not
increase the
17 placebo rates of
controlled suicidal
trials events,
(N=8027) depression,
or
aggression/a
gitation
Varenicline use in people with depression

There were no
clinically relevant
differences between
groups in suicidal
ideation or behaviour
and no overall
worsening of
depression or
anxiety in either
group.
 Varenicline use in people with schizophrenia

127 people with

schizophrenia
Abstinence Rates
84 received varenicline

43 received placebo

Total adverse event rates

were similar between groups,

No significant changes in
symptoms of schizophrenia
or in mood and anxiety
ratings. p=0.046

Rates of suicidal ideation p=0.09

adverse events were 6.0%
(varenicline) and 7.0%
(placebo) (P = 1.0).

nelli RM, Morris CD, Treadow J, Thompson JR, Yunis C, et al. A randomized, double-blind, placebo-controlled study evaluating the safety and efficacy of varenicline for smoking cessation in patients with schizophrenia or schizoaffective diso
Varenicline Maintenance in people with
schizophrenia
247 smokers with schizophrenia or bipolar disease received standard
treatment with varenicline
87 (35%) were abstinent at 12 weeks and were randomised to receive
varenicline or placebo up to 52 weeks

OR=4.6, (95% CI: 1.5-15.7)

OR=3.4, (95% CI: 1.02-13.6)

Evins et al . Maintenance treatment with varenicline for

smoking cessation in patients with schizophrenia and
bipolar disorder: a randomized clinical trial.
JAMA. 2014 Jan 8;311(2):145-54.
Varenicline + Bupropion

506 smokers were randomized to varenicline +

placebo or varenicline + bupropion

OR=1.49, 95% CI: 1.05-2.12)

OR=1.52, 95% CI: 1.04-2.22)

OR=1.39, 95% CI: 0.93-2.07

Varenicline + bupropion Varenicline + placebo

Ebbert et al JAMA 2014 311 (2)
In highly dependent smokers

506 smokers were randomized to varenicline +

placebo or varenicline + bupropion

OR=1.74 (95% CI: 1.04-2.93)

OR=2.76 (95% CI: 1.47-5.21)

Varenicline
OR=2.77 (95% CI: 1.44-5.30) + bupropion
Varenicline + placebo

Ebbert et al JAMA 2014 311 (2)

Varenicline 2nd time round

Subjects were randomly assigned varenicline (N=249) or placebo (N=245)

Both groups received brief counselling (10 minutes)

OR=7.08; 95% CI: 4.34 -11.55

OR=5.83; 95% CI: 3.25 - 10.44

OR=9.00; 95% CI: 3.97- 20.41

Varenicline
Placebo

Gonzales et al. VARENICLINE RE-TREATMENT FOR SMOKING CESSATION IN SMOKERS WHO HAVE PREVIOUSLY TAKEN VARENICLINE: A RANDOMIZED, PLACEBO-CONTROLLED
Effects of smoking cessation on other medicines

Medicine Use Clinical relevance Action to take

High
Monitor blood clozapine levels
There is evidence to show that blood levels of clozapine
Clozapine is closely after the person has
can increase after stopping smoking.
antipsychotic stopped smoking. Advise the
Some experts have recommended the dose of clozapine
medicine that people person to watch for an increase
Clozapine needs to be reduced by approximately 35% when people
with schizophrenia in side effects associated with
stop smoking.
might be using. clozapine.
A reduction in cigarette consumption does not require
Adjust clozapine dose as
dosage adjustment.
necessary.

High Advise the person to watch for

Olanzapine is There is evidence that blood levels of olanzapine can an increase in side effects
antipsychotic increase after stopping smoking. associated with olanzapine (eg,
medicine that people Some experts have recommended the dose of olanzapine dizziness, sedation,
Olanzapine
with schizophrenia needs to be reduced by approximately 35 % when people hypotension).
might be using. stop smoking. A reduction in cigarette consumption does If an increase in side effects is
not require dosage adjustment. reported, the dose should be
decreased accordingly.

Advise the person to watch for

Chlorpromazine is
Moderate an increase in side effects
antipsychotic
Blood levels of chlorpromazine have been found to be associated with chlorpromazine
medicine that people
Chlorpromazine lower in smokers compared with non-smokers and there is (eg, dizziness, sedation). If an
with schizophrenia
some evidence to suggest that chlorpromazine plasma increase in side effects is
might be using.
levels can increase when people stop smoking. reported, the dose should be
decreased accordingly.
Effects of smoking cessation on other medicines

Medicine Use Clinical relevance Action to take

Theophylline is a drug
High
that is used for the
Smoking and quitting smoking affect theophylline Advise the person to tell their
treatment of respiratory
levels. Smoking speeds up the metabolism of doctor they are stopping smoking.
disease such as asthma.
Theophylline theophylline and stopping smoking has the opposite Blood theophylline levels should
It acts to dilate the
effect; meaning that theophylline levels could rise and be monitored and dose adjusted
airways, making
clients may start experiencing adverse effects. as necessary.
breathing easier.

High
There is evidence that stopping smoking can lead to
Warfarin is an anti- an increase in the blood level of warfarin, with an Advise the person to tell their
coagulant medicine and associated increase in international normalised ratio doctor they are stopping smoking.
Warfarin used for thinning the (INR). The INR should be monitored and
blood. The INR is a test of blood clotting, which is used to warfarin dose adjusted as
monitor warfarin therapy. If the INR rises too much, necessary.
there is a risk of bleeding and haemorrhage.

Moderatelow
Advise people who use insulin to
There are inconsistent data regarding the interaction
monitor their blood glucose levels
Some people with between subcutaneous insulin and smoking. Some
closely when they stop smoking
Insulin diabetes may be using data suggest that smokers may need a reduction in
and to be aware of signs of
insulin. insulin when they quit, but this may be balanced by
hypoglycaemia (low blood
the increase in appetite and food consumption when
glucose).
people quit.
Recommendations

1. Provide brief advice to stop smoking to all users of mental

health services who smoke.
2. Offer effective interventions (such as those identified in
the previous sections) to people with mental health
disorders who smoke.
3. Carefully monitor people with mental health disorders
who stop smoking while still using medication for their
mental health disorder, as the dosage of their medication
may need to be reduced.
PRE-OPERATIVE SMOKING
CESSATION
Hayden McRobbie
MB ChB (Otago) PhD (London)
Postoperative pulmonary complications

Atelectasis and
pneumonia are
common following
abdominal and
gynaecological
surgery
Associated with
significant morbidity
and mortality
Smokers have been found to have a 6-fold
increase in risk of PPCs
Surgical wound

Cigarette smoking is associated with:

Delayed wound
healing
Concern with
reconstructive surgery
Risk of anastomotic
leakage with
colorectal surgery
Wound infection
Smoking related surgical complications

Effects of carbon monoxide

Decreased oxygen carrying capacity
Increase peripheral resistance
Increased airways secretions
Effects on metabolism of many
drugs
Hospital stay
Smokers are more likely to

Be admitted to
intensive care
Spend more time in
other departments
Have a longer stay in
hospital

A longer hospital stay incurs greater cost to both

the Health System and individual
Benefits of cessation

Immediate reductions in
carboxyhaemoglobin
Wound healing has been
shown to improve
Decreased risk of PPCs and
cardiovascular complications

Complete cessation is needed, simply reducing

cigarette consumption is of no benefit
Moller et al, Lancet, 2002

120 smokers
undergoing hip or knee joint replacement surgery

randomised

60 intervention 60 control
Intervention

Intervention
Weekly meeting with project nurse 6-8
weeks pre-op
Support, advice etc
NRT (free of charge)
Advised to stop completed, but could opt to
reduce their consumption by at least 50%
Control
Standard care (essentially nothing)
Results
*Significant Difference

The intervention group had

Higher quit rates (60% vs. 7%*)
Lower incidence of:
Total post-op complications (18% vs. 52%*)
Wound related complications (5% vs. 31%*)
Proportion of days spent in other departments
(0.3% vs. 6% of total hospital stay*)
Secondary surgery (4% vs. 15%)

Those who reduced cigarette consumption did

not differ from smokers
Cochrane review 2010

Included 8 trials (total of 1156 smokers)

Seven trials had smoking cessation interventions
Interventions were intensive or brief
Intensive = weekly counselling sessions over a period of 4-8
weeks
Brief = one face-to-face and/or telephone and/or interactive
computer counselling or one letter about the risks of smoking
in relation to surgery before surgery
NRT was offered or recommended to all
Five trials examined the effect of smoking
intervention on postoperative complications

Thomsen T, Villebro N, Mller AM. Interventions for preoperative smoking cessation. Cochrane Database of Systematic
Reviews 2010, Issue 7. Art. No.: CD002294.
Cessation at time of surgery
Risk of any complication
Risk of wound complications
Does timing matter?

In a sample of CABG patients

those who stopped smoking
less than 2 months before
surgery had a 4-fold increase in
PPCs compared to those who
had stopped for 2 months or
more
Those who stopped for more
than 6 months had a risk of
PPCs similar to non-smokers
Warner et al, Mayo Clin Proc. 1989. 64(6):609-16
Smokers vs. recent quitters
Never too late

There is no evidence at present that

stopping smoking shortly before
surgery has a negative impact on
post-surgery recovery
It provides less benefit than
extended abstinence, but seems to
pose no harm
A firm advice to stop smoking can
be provided to patients at any time
Quitting for good?
SMOKING CESSATION
PREGNANCY &
BREASTFEEDING
Effects of smoking in pregnancy
During pregnancy
Miscarriage, stillbrith, premature membrane rupture,
placental previa & abruption, fetal growth restriction
During the postnatal period
Premature babies, SIDS, increase BP, mental
retardation, & behavioural, psychiatric and cognitive
problems
During childhood
Respiratory illness, asthma, otitis media
Helping pregnant smokers
1. Self-help interventions

2. Interventions by midwives and other health care staff

during routine care

3. Interventions delivered by specialists at dedicated time

over multiple sessions
Self-Help

Self-help materials - booklets and leaflets

Often seen as an acceptable way to help a smoker quit
as they are quick, easy, and non-confrontational.
However in this group of smokers this method does not
work (Moore, Campbell et al. 2002).
Routine interventions

In view of difficulties in recruiting women to attend multi-

session treatments, this would have substantial potential
Three studies (Wisborg et al. 1998, Hajek et al. 2001,
Moore et al. 2001) found no effect of routine midwife
intervention. Another low-cost intervention study (Ershoff et
al. 99) has negative results as well
Likely barriers

Young age
Social disadvantage
High tobacco dependence (majority smoke within 30
minutes of waking up)
Social norms (up to 80% of partners of pregnant
smokers smoke)
Uncertain motivation - intrinsic in interventions actively
seeking clients
Specialist interventions

Cochrane meta-analysis identified 34 trials of variable

quality
There was a significant effect

Some negative findings

Low treatment attendance
Groups not feasible
No effect of relapse prevention (5 trials)
Can you use NRT in pregnancy?

NRT helps smokers to quit, roughly doubling their

chance of success
However your patient points out that the box of patches
says that these should not be used in pregnancy
Your gut instinct is that its better than smoking, but
what if something goes wrong?
The facts

There is no safe dose of nicotine during pregnancy

In animal studies nicotine has been linked to:
Reduced fetal growth
Abnormalities in CNS development
Behavioural changes in the infant
Changes in parts of the brain which may predispose
the infant to SIDS
But its not just nicotine
Carbon Monoxide affects

Placenta
Maternal fetal oxygen transport
Fetal physiology
Fetal growth
Brain development, neurochemistry & function
The effects of smoking in pregnancy

Are likely to be due to a number of

factors
Ideally, a pregnant smoker should be
both nicotine and tobacco free
However, most pregnant smokers we
see have difficulty becoming tobacco
free
SNAP Trial
1050 women who smoked at least 5 cigarettes per day
521 received 15 mg/16 hour patches
529 received 0 mg/16 hour patches
Research midwives provided a mix of telephone and
face-to-face support
NRT provided in 4-week supplies
Primary outcome validated abstinence between quit
date and delivery
Birth outcomes and assessment of infant impairment
(e.g. disability or behaviour and developmental
problem) assessed at 2-years

SNAP Smoking, Nicotine and Pregnancy Cooper et al (2014) HTA Assessment 18(54)
SNAP - results

Validated Abstinence Rates

OR=2.05 (95% CI: 1.46-2.88)

Nicotine Patch
OR=1.26 (95% CI: 0.82-1.96) Placebo Patch

SNAP Smoking, Nicotine and Pregnancy Cooper et al (2014) HTA Assessment 18(54)
SNAP infant outcomes at 2 years

Proportion surviving with no impairment

OR=1.40 (95% CI: 1.05-1.86)

SNAP Smoking, Nicotine and Pregnancy Cooper et al (2014) HTA Assessment 18(54)
SNIPP Trial
402 women who smoked at least 5 cigarettes per day
203 received nicotine 16 hour patches
199 received placebo 16 hour patches
Patch doses were adjusted to saliva cotinine levels
Daily dose range from 10 30 mg
Participants assessed monthly and provided with
behavioural support
Primary outcome validated abstinence between quit
date and delivery
Birth weights recorded

SNIPP Study of nicotine patch in pregnancy Berlin et al (2014) BMJ

SNIPP - results

Validated Abstinence Rates

OR=1.08 (95% CI: 0.45-2.60)

Nicotine Patch
Placebo Patch

SNIPP Study of nicotine patch in pregnancy Berlin et al (2014) BMJ

SNIPP - results

Outcome Nicotine Patch Placebo Patch Difference

Birth weight (g) 3065 3015 NS
Head circumference 33.7 33.9 NS
(cm)
Preterm birth 13.5% 13% NS
Transfer to NICU 7.1% 7.2% NS

SNIPP Study of nicotine patch in pregnancy Berlin et al (2014) BMJ

 Financial Incentives for Smoking Cessation in
Pregnancy

Myers-Smith, McRobbie & Hajek, National Institute of Health and Care Excellence
Recommendations

1. Use NRT in combination with support

2. Use the lowest dose of nicotine effective for
achieving cessation (oral products better)
3. If cannot tolerate oral products (e.g. due to nausea)
use a patch
4. If using a patch, use 16-hr only
5. Initiate treatment as early as possible
Breastfeeding
Serum concentrations of nicotine in breastfeeding infants
are low (1/50 of mothers level)

This is even lower in mothers using NRT

No risks of NRT at this stage, but ETS poses risks to the

infant
Conclusion
There is no doubt that NRT is safer than smoking and little
reason to think it would not work in pregnancy

The possible benefits of NRT outweigh any possible risks

WHAT DO
YOU
THINK?
THE END
hayden@thedragon.institute
www.thedragon.institute