Clinical Effectiveness of Dual Nicotine Replacement Therapy in Planned Hospital Admissions to an Epilepsy Monitoring Unit: An Irish Perspective

In Ireland, where the overall prevalence of cigarette smoking is estimated at 19.5%,1 the standard of care for nicotine replacement therapy (NRT) has traditionally been monotherapy in the form of prolonged-release transdermal nicotine patches. In keeping with international evidence-based best practice,2–5 recent guidelines from the Irish Health Service Executive6 advise the use of dual NRT (ie, a nicotine patch combined with an immediaterelease nicotine preparation for relief from breakthrough cravings). The systematic implementation of these guidelines nationally has not yet occurred and it is widely acknowledged that the usual standard of prescribing NRT monotherapy prevails. Although the underlying reasons are not clear, and existing prevalence studies are difficult to compare for methodological reasons, smoking is believed to be more common among people with epilepsy than the general population.7,8 A study in French-speaking Switzerland, for example, found 32.1% of people with epilepsy in a selected cohort were daily smokers, while the prevalence of smoking in the general population in the same region was estimated at 19%.7 Hospitalization is recognized as a potential opportunity for smoking cessation interventions.9 In-patient video-electroencephalography (EEG) monitoring on an epilepsy monitoring unit (EMU) can be performed to distinguish epileptic seizures from seizure mimics, to better characterize epileptic seizures in cases of known epilepsy and as part of the evaluation process prior to respective epilepsy surgery. EMU admission involves continuous recording from scalp electrodes and video cameras for days at a time, with cumulative seizure-provocation measures employed to induce events in a closely observed, controlled and safe environment. All seizure data is highly valuable. Clinical practices vary between EMUs. In order to aid tolerability of the monitoring process, some EMUs permit patients to leave for smoking breaks during their hospital stay. However, this may lead to missed seizures or suboptimal recordings, and can be associated with increased length of EMU stay, as demonstrated by a study of smoking breaks on a Canadian EMU which found that those who smoked had almost four times more missed seizures and stayed on average 1.5 days longer than nonsmokers.10 Some EMUs which accommodate smoking breaks transfer patients temporarily to portable EEG equipment (without video recording) but such EEG traces tend to contain more muscle artifact that can obscure clinically useful information and, in the absence of video, render the captured seizure uninterpretable. Of greatest concern is that leaving the controlled and closely-observed environment of the EMU to smoke in an unsupervised area with multiple potential hazards in the context of drug withdrawal and sleep deprivation—methods routinely used to induce seizures—places patients at increased risk of injury and death.11 Cork University Hospital, a tertiary epilepsy centre in the Republic of Ireland serving a population of approximately 1.1 million people, opened its EMU in January 2015 and now provides two of the six national EMU beds. EMU admissions are typically planned months in advance and last for up to 7 days. To optimize patient safety and the diagnostic yield, the unit has a policy requiring all patients to remain on the EMU throughout the entire monitoring period, with direct nurse observation 24 hours per day. Accordingly, if a patient were to leave the EMU for any reason, including smoking, monitoring would be terminated and they would be discharged from hospital. As a consequence of these physical restrictions on patients, total abstinence from smoking is imposed until discharge. In order to aid patient concordance insofar as possible, the EMU team intentionally diverged from the NRT monotherapy approach employed elsewhere and—with the express authorization of the hospital pharmacy—adopted the use of dual NRT from the outset. We sought to assess the clinical effectiveness of dual NRT use in preventing smoking during planned admissions to the EMU for video-EEG monitoring.