Chapter 72

Smoking Cessation

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Class	Generic Name	Trade Name	Formulation
Nicotine replacement therapy	nicotine polacrilex	Nicorette	Gum
	nicotine	NicoDerm CQ	Transdermal
		Habitrol	Transdermal
		Nicotrol	Transdermal
		ProStep	Transdermal
		Nicotrol NS	Nasal spray
		Nicotrol inhaler	Oral inhaler
		Commit	Lozenge
Antidepressants	bupropion	Zyban, Wellbutrin	Tablet
Nicotine receptor agonists	varenicline	Chantix	Tablet

INDICATIONS

• All products useful in smoking cessation.

• Varenciline off-label may also reduce cravings in alcohol use.

Many pharmacologic approaches have been used to help people stop smoking. In current use are the nicotine replacement therapy (NRT) products and bupropion (Zyban, GlaxoSmithKline; Wellbutrin, GlaxoSmithKline). This chapter discusses methods for assisting the patient to stop smoking. The only drugs that are discussed in detail in this chapter are the NRT products because bupropion is discussed in Chapter 47. Many NRTs are now available OTC, but the patient still benefits from professional guidance on how to use these products.

Therapeutic Overview

Results of a 2012 national survey show that about 1 in 5 U.S. adults smoke cigarettes, a number unchanged since 2004, making it the leading preventable cause of disease and death in the nation. This contrasts with the decline in smoking seen between 1997 and 2004. Smoking is strongly correlated with age, with a new epidemic among school-age children, where almost 1 in 5 high school seniors reporting they regularly smoke, and nearly 90% of adult smokers reporting they started smoking by age 18. Currently an estimated 27.9% of those aged 18 to 24 smoke, followed by 27.3% of those aged 25 to 44, 23.3% of those aged 45 to 64, and only 10.5% of people who are 65 or older. (The relatively low number of older smokers may be due to the fact that many smokers die prematurely as a result of their smoking.) There is an inverse relationship with increased years of education.

Smoking has been associated with more than 420,000 deaths annually, causing risk for cancer of the lung, larynx, esophagus, and others. Cigarette smoking is associated with coronary artery disease/myocardial infarction, COPD, peripheral artery disease, and cerebrovascular disease. The combination of smoking, diabetes, and obesity is associated in many patients with actual shrinking of brain mass and dementia. Cancer and respiratory diseases have also been associated with passive (environmental) smoking. Women smokers have a higher risk of not only heart disease, but of some types of skin cancer. Early morning smokers seem to have the highest cancer risk for some reason. Nicotine and other tobacco-related components (e.g., tar and aromatic hydrocarbons) are probable causative factors for the psychologic and pathologic sequelae of smoking. For mothers who smoke while pregnant, their children were more likely to have problems with eczema and to end up on medications such as antidepressants, stimulants, and drugs for addiction. New research suggests that smoking may affect a baby’s developing brain. Individuals, especially children, who are subjected to passive smoke have a higher risk of developing asthma and childhood leukemia. Current research suggests that children already in danger of developing heart disease because of high cholesterol blood levels face a triple jeopardy if they live in smoke-filled homes, because the passive smoke lowers by about 10% the level of the child’s HDL, or the good cholesterol that protects against heart attacks.

Primary care is an ideal setting in which to institute smoking cessation measures. Most smokers see a primary care provider each year. The provider should screen all patients for smoking behaviors and should recommend that all patients stop smoking. In fact, some third-party payers or insurance companies now require preferred providers to ask about tobacco use and to document recommendations to quit. Some companies are starting to raise health insurance premiums if the purchaser is a smoker, and most life insurance companies already have higher rates for smokers.

Research suggests that many health care providers fail to take advantage of opportunities to recommend that the patient stop smoking. Primary care clinicians especially should be knowledgeable about the components of successful smoking cessation programs.

Although most smoking cessation therapy is aimed at cigarette smokers, cigars and chewing tobacco also contain nicotine and place the patient at risk. These smoking cessation products are helpful in patients who get nicotine from these other products.

Mechanism of Action

Nicotine is rapidly absorbed across the pulmonary capillary membrane and is delivered to the brain in high concentration within seconds of inhalation. The typical smoker (10 to 15 cigarettes/day) delivers 200 to 300 boluses of the addictive drug nicotine to the brain each day.

Nicotine increases heart rate, elevates blood pressure, causes peripheral vasoconstriction, enhances platelet aggregation and fibrinogen levels, decreases nitric oxide, and blunts its vasodilatory effects. It also increases carbon monoxide levels, and this reduces oxygen delivery to the myocardium. Nicotine activates the sympathetic nervous system and can induce coronary vasospasm. A risk of blood clots has been documented for young women on hormonal contraception and who smoke. Research has demonstrated that smokers may lose their cognitive abilities, such as remembering, thinking, or perceiving, more rapidly than elderly nonsmokers.

Cigarette smoking has been found to be particularly hazardous for those who already have some pathologic condition. The risk of vasospasm following subarachnoid hemorrhage is increased in smokers. Cigarette smoking exaggerates risk factors for cardiovascular disease by significantly increasing a protein known as thromboglobulin, which increases the activity and clotting functions of platelets in hypertensive smoking patients. Smoking also increases epinephrine, stimulating the heart and blood pressure in hypertensive patients who smoke.

Even patients who suffer from the results of smoking continue to engage in the behavior. Among smokers who undergo angioplasty or coronary artery bypass surgery, almost three in five continue to smoke after their procedure.

Nicotine, the chief alkaloid in tobacco products, binds stereoselectively to acetylcholine receptors at the autonomic ganglia, in the adrenal medulla, at neuromuscular junctions, and in the brain. Two types of CNS effects are believed to form the basis of nicotine’s positively reinforcing properties: (1) a simulating effect (exerted mainly in the cortex via the locus coeruleus), which increases alertness and cognitive performance, and (2) a reward effect via the “pleasure system” in the brain in the limbic system. At low doses, the stimulant effects predominate, whereas at high doses, the reward effects predominate.

Regular nicotine consumption through smoking is associated with neuroadaptation of nicotinic receptors, which results in increasing numbers of receptors and the development of tolerance and drug dependence. Symptoms from abrupt withdrawal include irritability, restlessness, anxiety, difficulty concentrating, lethargy, depression, increased appetite, weight gain, and minor somatic complaints (e.g., headache, myalgia, constipation, fatigue). These symptoms may be reduced through the use of nicotine-containing smoking deterrents, which produce lower nicotine plasma concentrations (approximately 3 to 17 ng/ml) than those achieved through smoking (approximately 20 to 50 ng/ml).

When the drugs that are helpful in nicotine addiction are examined, the mechanism of action for bupropion cannot be identified. Bupropion is an inhibitor of the neuronal uptake of norepinephrine, serotonin, and dopamine. Another product, varenicline, partially stimulates nicotine receptors but to a lesser degree than nicotine does. It blocks the ability of nicotine to stimulate the dopamine system, which mediates the pleasurable effects of nicotine. It provides sufficient nicotine effects to decrease the urge to smoke and to ease withdrawal symptoms. If a patient restarts smoking while on varenicline, he or she will not experience the pleasurable effects of nicotine.

Treatment Principles

Nicotine replacement therapy does not improve relapse rate. Some patients will relapse regardless of whether they used nicotine replacement products with or without counseling. Table 72-1 lists actions and strategies for the primary care clinician from the Agency for Healthcare Research and Quality (AHRQ) guidelines. Research from the National Ambulatory Medical Care Surveys of 1991 through 1995 has documented that physicians reported counseling patients about smoking or prescribing nicotine replacement far less often than is called for by current practice guidelines, thus missing many opportunities to help their patients quit smoking.

TABLE 72-1

Actions and Strategies for the Primary Care Clinician to Use in Smoking Cessation

Action	Strategies for Implementation
STEP 1. ASK: SYSTEMATICALLY IDENTIFY ALL TOBACCO USERS AT EVERY VISIT
Implement an office-wide system that ensures that for every patient at every clinic visit, tobacco-use status is queried and documented.^∗	This action should be implemented using preprinted progress note paper or, for computerized records, an item that assesses tobacco-use status. Alternatives are to place tobacco-use status stickers on all patients’ charts or to indicate smoking status via computerized reminder systems.
STEP 2. ADVISE: STRONGLY URGE ALL SMOKERS TO QUIT
In a clear, strong, and personalized manner, urge every smoker to quit.	Advice should be Clear: “I think it is important for you to quit smoking now, and I will help you.” “Cutting down while you are ill is not enough.” Strong: “As your clinician, I need you to know that quitting smoking is the most important thing you can do to protect your current and future health.” Personalized: Tie smoking to current health or illness and/or the social and economic costs of tobacco use, motivational level/readiness to quit, and the impact of smoking on children and others in household. Encourage clinic staff to reinforce the cessation message and support the patient’s attempt to quit.
STEP 3. ASSESS: IDENTIFY SMOKERS WILLING TO ATTEMPT TO QUIT
Ask every smoker if he or she is willing to make an attempt to quit at this time.	If the patient is willing to attempt to quit at this time, provide assistance (see Step 4). If the patient prefers more intensive treatment, or if the clinician believes that more intensive treatment is appropriate, refer the patient to interventions administered by a smoking cessation specialist, and follow up with the patient regarding quitting (see Step 5). If the patient clearly expresses an unwillingness to attempt to quit at this time, provide a motivational intervention.
STEP 4. ASSIST: AID THE PATIENT IN QUITTING
Help the patient to devise a plan for quitting.	Set a quit date: Ideally, the quit date should be within 2 weeks, with patient preference taken into account. Help the patient prepare for quitting: The patient must inform family, friends, and coworkers about quitting and must request understanding and support. Prepare the environment by removing cigarettes from it. Prior to quitting, the patient should avoid smoking in places where he spends a lot of time (e.g., home, car).
Encourage drug therapy except in special circumstances.	Review previous attempts at quitting. What helped? What led to the relapse? Anticipate challenges to the planned quit attempt, particularly during the critical first few weeks.
Give key advice on successful quitting.	Encourage drug therapy for smoking cessation. Abstinence: Total abstinence is essential. “Not even a single puff after the quit date.” Alcohol: Drinking alcohol is highly associated with relapse. Those who stop smoking should consider limiting or abstaining from alcohol use during the quit process. The presence of other smokers in the household, particularly a spouse, is associated with lower success rates. Patients should consider quitting with their significant others and/or developing specific plans to maintain abstinence in a household where others still smoke.
Provide supplementary materials.	Source: Federal agencies, including the National Cancer Institute and the Agency for Healthcare Research and Quality; nonprofit agencies (e.g., American Cancer Society, American Lung Association, American Heart Association); or local or state health departments Selection concerns: The material must be culturally, racially, educationally, and age appropriate for the patient. Location: Readily available in every clinic office
STEP 5. ARRANGE: SCHEDULE FOLLOW-UP CONTACT
Schedule follow-up contact, either in person or via telephone.	Timing: Follow-up contact should occur soon after the quit date, preferably during the first week. A second follow-up contact is recommended within the first month. Schedule additional follow-up contacts as indicated. Actions during follow-up: Congratulate success. If smoking occurred, review the circumstances and elicit a recommitment to total abstinence. Remind the patient that a lapse can be used as a learning experience and is not a sign of failure. Identify the problems already encountered, and anticipate challenges in the immediate future. Assess nicotine replacement therapy use and problems. Consider referral to a more intense or specialized program.

^∗Repeated assessment is not necessary in the case of the adult who has never smoked or has not smoked for many years, and for whom this information is clearly documented in the medical record.

From The Smoking Cessation Clinical Practice Guideline Panel and Staff: The Agency for Healthcare Research and Quality smoking cessation clinical practice guideline, JAMA 275:1270, 1996.

Prevention and Early Intervention

Research suggests that most smokers want to quit. With each visit to a health care provider, it is critical to ask patients if they smoke and to help them take the next step if they are ready. Smoking cessation programs have a high rate of success. Smoking cessation is a process. Relapsing is often part of the process. Sometimes patients have to try to quit several times but these efforts should be viewed as trials not as failure. If patients do not smoke, praise them for their wisdom and encourage them not to start. This is very important in children and adolescents and former smokers. Emphasize the immediate effects of tobacco, such as bad breath, stains on the fingers and teeth, reduced exercise performance, and dry skin and hair. Early research on addiction suggests that patients are not fully addicted for 3 years after starting to smoke, so this is the time to encourage them to stop.

Pharmacotherapy reduces the physical effects of nicotine withdrawal but does not address the psychologic aspects of smoking cessation. The highest rate of smoking cessation is seen in those individuals who are able to just stop smoking “cold turkey” and avoid replacement therapy. However, many are not able to do this. Pharmacotherapy should be used in conjunction with a behavioral modification program. Brief advice (i.e., 5 minutes) has been shown to be helpful. The five A’s model is recommended as a foundation for counseling (see Table 72-1). Also, a GETQUIT Support Plan is available to assist all patients who are taking varenicline.

Components of Smoking Cessation

For all patients who do smoke, the provider should assess their willingness to attempt to quit (Figure 72-1). If they are unwilling or unready to quit, the provider should focus on motivational issues. The negative consequences of smoking also should be emphasized. Patients are not influenced often by remote events such as COPD or lung cancer but may be motivated by immediate effects such as fewer and milder respiratory infections or asthma. They may particularly respond to suggestions that they are hurting their family, particularly small or unborn children. Discuss the positive consequences of smoking cessation, such as saving money, tasting food better, and feeling better physically.