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Quitting smoking and clozapine - practical guidelines
Julie Luscombe, Health Promotion Officer, Smoking Cessation Health Promotion Department, St Saviour

Abstract
Cigarette smoke can induce enzymes which are responsible for metabolising many drugs. Patients who are stable on any drug metabolised by enzymes affected by tobacco smoke, who then stop smoking, may develop toxic side effects as a result of increased drug plasma levels. This is significant if the interaction is clinically important. Changes in drug plasma levels can occur quickly and may require a reduction in the amount of drug prescribed.

Clozapine is one of these medications. Locally, the Smoking Cessation Service and the Community Mental Health Team were aware of at least one individual who had stopped smoking, without informing anybody, and whose drug plasma levels had subsequently increased very quickly after the initiation of the quit attempt, resulting in him becoming physically unwell from the increased effects of the drug. The concern was that there was a lack of awareness and knowledge of the potential effects on drug plasma levels, and the subsequent effects on physical and mental health, both among the individuals being prescribed Clozapine and the professionals who were supporting them.

The Smoking Cessation Advisor, representatives from the Community Mental Health Team and the Hospital Pharmacists formed a working group to formulate practical guidelines for staff to follow in order for the individual's quit attempt to be monitored in conjunction with monitoring of their mental state and medication to maximise the chances of that individual staying quit and remaining mentally stable. It was also necessary to emphasize the importance of staff being aware of the need for continued monitoring as the medication would need to be reviewed again if the individual started smoking again.

The guidelines have now been communicated to all Mental Health Staff. Information is now routinely given to all patients prescribed Clozapine about the potential effects of stopping smoking on their medication together with information on support available to them. An example of the guidelines being used in practice is an individual who has since successfully quit and is now maintained on a much lower dose of Clozapine, experiences fewer side effects from the medication and is feeling the physical benefits of quitting.

The guidelines are due to be reviewed in spring 2007.

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Biography
Julie Luscombe is the Health Promotion Officer for Smoking Cessation. She was the sole worker in the Jersey Smoking Cessation Service until the beginning of 2007. Since the legislation banning smoking in enclosed workplaces came into effect in January in Jersey, a new team of advisors have been appointed and Julie's role is now focusing on delivery of the wider aims and objectives of the Jersey Tobacco Strategy.

Julie Luscombe
Smoking CessationHealth Promotion Department
Gloucester Lodge,
79 Stopford Road
St Saviour
JE2 7LB
Jersey, Channel Islands

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