Smoking Cessation


Article Author:
Tiffani Sealock


Article Editor:
Sandeep Sharma


Editors In Chief:
Alexandra Caley
Sameh Boktor


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
2/17/2019 9:14:42 AM

Introduction

Tobacco use, primarily as cigarette smoking, is the leading cause of preventable disease and death in the United States. It is well established that smoking increases the risk of different forms of cancer, including lung, liver, and colorectal. Eighty-five percent of lung cancers occur in smokers. Also, smoking increases the risk of respiratory diseases (such as chronic obstructive pulmonary disease) and cardiovascular disease. During pregnancy, smoking increases the rate of complications, some of which include miscarriage, stillbirth, preterm birth, fetal growth restriction, and congenital anomalies. Neonatal and pediatric complications of exposure to cigarette smoking include sudden infant death syndrome and abnormal lung function in children, such as asthma. Despite the magnitude of disease burden related to smoking, 42.1 million adults in the United States smoke cigarettes, according to the National Health Interview Survey data from 2013. This makes quitting smoking one of the most important, yet challenging steps a person can take to improve his or her health, and most smokers make several attempts to quit before achieving abstinence from smoking.[1][2][3]

Assisting patients with smoking cessation is one of the most important tasks of the primary care physician, and the benefits of assessing patients’ smoking behavior are well established. The US Preventive Services Task Force (USPSTF) recommends using the 5 As:

  • Ask about smoking

Office systems should ensure that smoking status is documented at every visit.

  • Advise to quit

Use clear, personalized messages.  Even brief advice from a physician can improve quit rates compared with patients who receive no advice.

  • Assess willingness to quit

Patients assessed as not yet willing to quit should receive the motivational intervention.

  • Assist in quitting

Ask patients who are willing to set a quit date.

  • Arrange follow-up and support

There is substantial evidence that behavioral interventions alone or in combination with pharmacotherapy improve the achievement of smoking cessation. Both behavioral interventions and pharmacotherapy are effective and recommended, and combinations of interventions are most effective. The best and most effective interventions are those that are feasible for the individual.[4][5]

Issues of Concern

Behavioral Interventions

Behavioral interventions found to be effective in aiding adults in smoking cessation include in-person counseling, telephone counseling, and self-help materials. These interventions may increase rates of smoking cessation from a baseline of 5% to 11% in control groups to 7% to 13% in intervention groups. Both minor and intensive in-person interventions increase the proportion of persons who successfully quit smoking and remain abstinent. However, more or longer sessions improve cessation rates. According to the Public Health Service guidelines, individuals should undergo at least 4 in-person counseling sessions.  Interventions delivered by various types of providers, including physicians, nurses, psychologists, social workers, and cessation counselors can be effective.  Effective telephone counseling interventions should provide at least 3 telephone calls and can be provided by trained professional counselors or health care providers. Self-help material shown to be effective are ones that are tailored to the individual patient and are primarily print-based.[6]

Pharmacotherapy

Pharmacotherapy interventions approved by the FDA for the treatment of tobacco dependence in adults include bupropion SR, varenicline, and NRT (nicotine replacement therapy).[7][8]

Nicotine Replacement Therapy (NRT)

Nicotine in itself is not carcinogenic. It acts on the reward pathway as in all addicting substances. The goal of nicotine replacement is to relieve cravings and reduce nicotine withdrawal symptoms. Rates of smoking cessation may increase from 10% in control groups to 17% in persons using any form of NRT, and using 2 types of NRT has been found to be more effective than using a single type. There is evidence that combining a nicotine patch (slow nicotine-releasing) with a rapid-delivery form of NRT (for example, chewing gums, lozenges, nasal spray, and inhalers) is more effective than using a single type.

Buproprion SR

Smoking cessation may increase from 11% in control groups to 19% in those using bupropion SR. Buproprion was first developed as an antidepressant; however, it has been shown to be effective as a smoking cessation aid. Some studies show that NRT in combination with bupropion SR may be more effective than bupropion alone, but not necessarily NRT alone.

Varenicline

Varenicline (Chantix) is a selective alpha4-beta2 nicotinic receptor partial agonist. It works by reducing cravings and withdrawal symptoms while blocking the binding of smoked nicotine. Smoking cessation rates have been shown to increase from 12% in control groups to 28% in those using varenicline. In 2009, a black-box warning was applied by the FDA to varenicline because of safety reports of an association between the drug and adverse psychiatric events including depressed mood, agitation, and suicidal behavior. Pfizer (the manufacturer of Chantix) was required by the FDA to conduct a clinical trial to evaluate the risk of psychiatric events. The risk of these events was found to be lower than previously suspected, and therefore, the FDA removed the black-box warning for serious mental health side effects from the Chantix drug label in December 2016. In 2011, the FDA advised that varenicline may slightly increase the rate of cardiovascular events in persons with cardiovascular disease. Results are still pending from a large trial conducted to address this issue.

Combination Behavioral and Pharmacotherapy

Combining behavioral and pharmacotherapy may increase smoking cessation rates from 8% to 14% when compared with minimal behavioral interventions such as brief advice on quitting. Combination interventions usually include behavioral components delivered by specialized smoking cessation counselors combined with NRT. Combination interventions are made up of several sessions (more than 4) and are more successful with more sessions. Adding behavioral interventions to pharmacotherapy also increased cessation rates from 18% in persons receiving pharmacotherapy alone to 21% in patients using a mix of pharmacotherapy and behavioral support.

Electronic Cigarettes for Smoking Cessation

In a Cochran review, electronic cigarettes with nicotine increased smoking cessation rates compared with placebo, with cessation rates similar to that of nicotine patches. The most common reason given for using electronic cigarettes has been to quit or reduce cigarette smoking. However, little is known about the ingredients or long-term effects of electronic cigarettes, and to date, no electronic cigarette manufacturer has applied for or received FDA approval to market its product for smoking cessation. Initial studies show that electronic cigarettes contain nicotine and also made add other harmful chemicals, including carcinogens and lung irritants. The USPSTF found insufficient evidence of the use of electronic cigarettes as a smoking cessation tool in adults.

Pregnant Women

Smoking during pregnancy contributes to preterm deliveries, low-birthweight term deliveries, sudden infant death syndrome and preterm-related deaths. Approximately 23% of women smoked during the three months before conception and data from 2011 showed that 10% of women smoke during the last 3 months of pregnancy. According to the U.S. Preventive Services Task Force (USPSTF), behavioral interventions substantially improve the achievement of tobacco smoking abstinence is pregnant women, increase infant birthweight, and reduce the risk of preterm birth. There is not enough evidence regarding the benefits of NRT during pregnancy and no evidence on the benefits of bupropion SR, varenicline, or electronic cigarettes for smoking cessation in pregnant women. Although a few studies suggest a potential benefit of NRT on perinatal outcomes in pregnancy, it is a pregnancy category D medication, meaning there is evidence of fetal risk. Both Buproprion SR and varenicline are pregnancy class C medications.[9]

Clinical Significance

Physicians should make it a priority to help patients stop smoking. Smoking even a few cigarettes a day or only smoking occasionally increases a person's chance of developing lung cancer. There are immediate benefits to smoking cessation which occur only hours, weeks, and months after a person stops smoking. These primary benefits included lowering of blood pressure, decreased cough and phlegm production, increased lung capacity. In the long-term, quitting smoking reduces a patient's risk of developing cancer, heart disease, and chronic lung disease. The earlier a person stops smoking, the more their risk of developing lung cancer is reduced. However, stopping smoking at any age is beneficial, and the benefits of smoking cessation are cumulative over time. When a person stops smoking before the age of 40, they reduce their chances of dying from smoking-related disease by 90%. Even people already diagnosed with cancer benefit from smoking cessation. In some forms of cancer, quitting smoking at the time of diagnosis can reduce the chances of dying from cancer by as much as 40%.[10][11]

Enhancing Healthcare Team Outcomes

There is no longer any question that nicotine is harmful and affects almost every organ in the body. It is estimated that smoking accounts for 20% of deaths in the US and the healthcare costs exceed $300 billion. Nicotine has been linked to many cancers and even second-hand exposure to nicotine can increase the risk of lung and heart disease. Despite four decades of urging the public to stop smoking, people continue to smoke in large numbers. There is no magic pill that can help people quit smoking. All the currently available medications to help people quit smoking are no better than a placebo. The big problem is that while many people can cease smoking for a few days, the urge to smoke is overwhelming and relapse rates are high. Clinicians, pharmacists, and nurses should assist in educating patients about the adverse effects of smoking. Today both family- and school-based smoking prevention programs are in operation, but scientific evidence reveals that their benefits are limited. The majority of patients simply quit smoking on their own but why they succeed in quitting smoking and others can't is not well understood. All healthcare workers should continue to insist that patients not smoke- even if only a few percentage stop smoking; with nicotine addiction even 1% of quitters is considered a success. [12][13](Level V)


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Smoking Cessation - Questions

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Smoking cessation is vital in preventing multiple disorders. Which of the following is the key to successful smoking cessation?



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What is the best indicator for success in a smoking cessation program?



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There are five stages in the transtheoretical model. A patient who is engaged in a smoking cessation program is in the preparation stage. In what stage of change should the patient be classified?



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After discontinuation of smoking, what will the lipid profile of a 50-year-old show?



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What percentage of those who smoke gain weight after smoking cessation?



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How many pieces of nicotine gum should be chewed per day by individuals actively pursuing smoking cessation?



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A patient who is a smoker expresses a desire to quit at an appointment with his medical provider. What stage of change does this represent?



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A patient who has been smoking for 20 years presents with a cough of viral etiology. When asked, the patient reveals no intent to quit smoking. What stage of change is represented here?



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Which of the following is the best option for smoking cessation in a patient who cannot tolerate nicotine replacement therapy?



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Which of the following is true about switching to low nicotine and low tar cigarettes?



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Which of the following is true regarding smoking cessation?



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What percentage of people who stop smoking will relapse within three months?



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What is not true about quitting smoking in pregnancy?



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After how many years of smoking cessation is the risk of cardiovascular disease equal to the nonsmoking population?



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A heavy smoker has come to your clinic and is asking for advice on how to quit smoking. He has tried almost every type of health supplement and prescription drug to no avail. He wants to know what is the best way to stop smoking. What should he be told?



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A 33-year-old who smokes tobacco would like to quit smoking. He has heard that electronic cigarettes (e-cigarettes) can help quit smoking. What is the current status of e-cigarettes in helping consumers stop smoking?



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A 65-year-old patient who is obese and is a chronic smoker has tried many times to quit smoking but has been unsuccessful. Other than eczema, she has no health problems. What is the best way to counsel the patient for smoking cessation?



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A 65-year-old male patient who underwent percutaneous coronary intervention (PCI) 7 days ago presents for a follow-up appointment. During the interaction with the patient, he admits that he smokes a pack per day. In counseling the patient, why should smoking cessation be recommended?



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Smoking Cessation - References

References

Dinh PC,Schrader LA,Svensson CJ,Margolis KL,Silver B,Luo J, Smoking cessation, weight gain, and risk of stroke among postmenopausal women. Preventive medicine. 2018 Oct 22     [PubMed]
Daoud N,Jung YE,Sheikh Muhammad A,Weinstein R,Qaadny A,Ghattas F,Khatib M,Grotto I, Facilitators and barriers to smoking cessation among minority men using the behavioral-ecological model and Behavior Change Wheel: A concept mapping study. PloS one. 2018     [PubMed]
Baskerville NB,Struik LL,Guindon GE,Norman CD,Whittaker R,Burns C,Hammond D,Dash D,Brown KS, Effect of a Mobile Phone Intervention on Quitting Smoking in a Young Adult Population of Smokers: Randomized Controlled Trial. JMIR mHealth and uHealth. 2018 Oct 23     [PubMed]
York NL,Kane C,Beaton K,Keown B,Mcmahan S, Identifying Barriers to Hospitalized Patients' Participation in a Free Smoking Cessation Support Program. Medsurg nursing : official journal of the Academy of Medical-Surgical Nurses. 2017 Jan     [PubMed]
Richardson S,McNeill A,Brose LS, Smoking and quitting behaviours by mental health conditions in Great Britain (1993-2014). Addictive behaviors. 2018 Oct 10     [PubMed]
Sweet L,Brasky TM,Cooper S,Doogan N,Hinton A,Klein EG,Nagaraja H,Quisenberry A,Xi W,Wewers ME, Quitting Behaviors among Dual Cigarette/E-cigarette Users and Cigarette Smokers Enrolled in the Tobacco User Adult Cohort (TUAC). Nicotine     [PubMed]
Halpern SD,Volpp KG, E-Cigarettes, Incentives, and Drugs for Smoking Cessation. The New England journal of medicine. 2018 Sep 6     [PubMed]
Varenicline null. 2006     [PubMed]
Barboza J, Current and emerging pharmaceutical strategies for smoking cessation during pregnancy. Expert opinion on pharmacotherapy. 2018 Oct 17     [PubMed]
Holla N,Brantley E,Ku L, Physicians' Recommendations to Medicaid Patients About Tobacco Cessation. American journal of preventive medicine. 2018 Oct 18     [PubMed]
Komiyama M,Ozaki Y,Wada H,Yamakage H,Satoh-Asahara N,Morimoto T,Shimatsu A,Takahashi Y,Hasegawa K, The effects of dietary instruction on cardiovascular risk markers after smoking cessation: study protocol for a multicenter randomized controlled trial in Japan. Trials. 2018 Oct 4     [PubMed]
Zawertailo L,Mansoursadeghi-Gilan T,Zhang H,Hussain S,Le Foll B,Selby P, Varenicline and Bupropion for Long-Term Smoking Cessation (the MATCH Study): Protocol for a Real-World, Pragmatic, Randomized Controlled Trial. JMIR research protocols. 2018 Oct 18     [PubMed]
Johnson L,Ma Y,Fisher SL,Ramsey AT,Chen LS,Hartz SM,Culverhouse RC,Grucza RA,Saccone NL,Baker TB,Bierut LJ, E-cigarette Usage Is Associated With Increased Past-12-Month Quit Attempts and Successful Smoking Cessation in Two US Population-Based Surveys. Nicotine     [PubMed]

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