Smoking Cessation
Nancy A. Rigotti
Cigarette smoking is the major preventable cause of death in the United States. Compared to nonsmokers, current smokers sacrifice at least 10 years of life expectancy. Nonetheless, even those who have smoked for many years, are elderly, or already have a chronic tobacco-related disease can benefit from cessation. The health risks of smoking are widely recognized, and the prevalence of smoking has fallen dramatically in the last five decades, but 45 million Americans continue to smoke, and one third to one half of them will die of a tobacco-related illness. Most smokers say that they want to quit. Multiple studies have shown that a physician’s actions can help a patient to stop smoking and have identified effective smoking cessation therapies. Addressing tobacco use in primary care is highly cost-effective and is acceptable to smokers, even those who are not ready to quit. The primary care physician needs routinely to identify patients’ smoking status and motivate smokers to quit, advise them about treatment options, refer them as needed to additional resources, and monitor their progress. This requires knowledge about smoking cessation techniques and an appreciation of how and when to use them. It also requires understanding that tobacco use is a chronic relapsing condition that requires a long-term management approach.
Since 1964, when the Surgeon General’s Report first publicized the health risks of smoking, the prevalence of cigarette smoking by adults in the United States has decreased from more than 40% to 19.3%, and the male predominance in smoking prevalence has narrowed, so that at present, 21.5% of men and 17.3% of women smoke. Smoking is now most prevalent in populations that have less education and a lower socioeconomic status.
Most smokers know that cigarette smoking is harmful to health, although they may not be aware of the full range of smoking-related illnesses and may not be convinced that these apply to them. Nonetheless, in 2010, 69% of smokers in a national survey said that they would like to quit, and 52% of smokers had made an attempt to quit in the past year, but only 6% of them had succeeded in quitting for 1 year. Although the success rate for any single attempt at quitting is low, smokers who repeatedly try to quit increase their likelihood of success, especially if they learn from their past experience. More than half of adult Americans who have ever smoked have now quit. Lighter smokers are more successful than heavier smokers. Smokers most likely to quit are those who have confidence that their attempt will succeed, have a strong belief in their personal control over events, and have strong social support for nonsmoking from a nonsmoking spouse and friends. Smokers with depression or alcohol or other substance abuse have a lower success rate than smokers without these problems and require more-intensive interventions.
Health concerns are the most common reasons given by former smokers for quitting. However, a smoker is less likely to cite the future risk of lung cancer and heart disease than to cite a current smoking-related symptom, such as cough or dyspnea. Actual symptoms may successfully motivate a smoker to quit by making personally salient the more serious health risks of smoking. The likelihood that a smoker will quit increases with the severity of the symptom or diagnosis. Although 6% of smokers in the general population quit each year, approximately one third of smokers quit after a first myocardial infarction. Between 25% and 40% of pregnant women smokers quit during pregnancy, but 70% of them resume smoking in the year after delivery. Other reasons for quitting cited by former smokers include a desire to exert self-control over one’s life, concern about the cost and social unacceptability of smoking, aesthetic objections to the smoking habit, and fear of setting a bad example for others.
Two thirds of smokers who try to quit do so without assistance from physicians, medications, or formal treatment programs, and only 6% of these quit attempts succeed. In contrast, long-term cessation rates with state-of-the-art treatment programs that combine medication and psychosocial counseling are 25% to 30%. Many more smokers entering a program will quit initially, but many of those who attain short-term cessation resume smoking before 1 year has passed. Smokers sometimes switch to a cigarette brand that is lower in tar and nicotine delivery in the hope of reducing their health risk, but doing so provides no actual risk reduction and is not an acceptable alternative to cessation.
Smoking is a complex behavior that is initiated and maintained for different reasons. External factors such as the influence of peers, parents, and the media appear to be most important in the initiation of smoking. Adolescents whose parents and friends smoke are more likely to begin smoking. Once the smoking habit is established, it is sustained by both biologic and psychosocial factors.
Nicotine is the constituent of tobacco smoke that is responsible for causing physiologic dependence on cigarettes. Chronic nicotine exposure produces changes in the brain, such as the upregulation of nicotinic acetylcholine receptors, which lead to tolerance and a craving for cigarettes when smoking stops. Smokers smoke to maintain a constant level of nicotine to avert the nicotine withdrawal syndrome, symptoms of which include restlessness, irritability, impatience, difficulty concentrating, an anxious or depressed mood, and an increased appetite. Nicotine withdrawal symptoms begin within a few hours of smoking cessation, peak 48 to 72 hours later, and gradually wane over weeks. The duration and the severity of nicotine withdrawal are highly variable, representing different degrees of nicotine addiction among
smokers. No biochemical test can measure nicotine addiction, but heavily addicted smokers tend to have their first cigarette shortly after arising (i.e., within 30 minutes), smoke more cigarettes per day, and have difficulty when forced to abstain from cigarettes for even a few hours. This model of pharmacologic dependence can explain the initial difficulties that smokers have when they stop smoking but cannot alone explain why smokers have difficulty remaining abstinent after the first few weeks.
smokers. No biochemical test can measure nicotine addiction, but heavily addicted smokers tend to have their first cigarette shortly after arising (i.e., within 30 minutes), smoke more cigarettes per day, and have difficulty when forced to abstain from cigarettes for even a few hours. This model of pharmacologic dependence can explain the initial difficulties that smokers have when they stop smoking but cannot alone explain why smokers have difficulty remaining abstinent after the first few weeks.
Cigarette smoking is also a habit, a learned behavior that continues because it is rewarding to the smoker. Certain repeated situations, such as finishing a meal, become strongly associated with smoking and trigger the urge to smoke. Cravings for cigarettes, which are produced by a combination of learned associations and physical changes in the brain, last longer than nicotine withdrawal symptoms and can trigger both early and late relapses in smokers who stop smoking. Smokers also use cigarettes to handle environmental stress and regulate emotions, especially strong negative emotions like anger or frustration. There is a strong epidemiologic association between depression and smoking. Smokers are much more likely than are nonsmokers to have a current or past history of depression. Nicotine withdrawal symptoms are more intense in smokers with comorbid depression or depressive symptoms, and stopping smoking can trigger or worsen depressive symptoms in smokers with a depression history. This may explain the observation that smokers with depression are less likely to succeed at quitting.
The evidence in support of smoking cessation therapies was reviewed systematically for the U.S. Public Health Service’s (USPHS) clinical practice guideline Treatment of Tobacco Use and Dependence, which was updated in 2008. This document concluded that two methods had the strongest evidence of efficacy: psychosocial counseling and pharmacotherapy. Combinations of the two were more effective than either method alone, as might be expected because they target different factors that maintain smoking behavior (e.g., psychological dependence and physiologic nicotine addiction). Maintaining long-term tobacco abstinence remains the challenge in smoking cessation treatment. Short-term cessation rates of 60% to 70% are common after a treatment program. However, a predictable and rapid return to smoking follows initial cessation, such that about half of individuals who initially quit resume smoking within 1 year. An effective smoking cessation program should have a 1-year cessation rate of 25% to 30%.
Pharmacotherapy (2,3,8,10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27 and 28)
Meta-analyses conducted for the 2008 USPHS guideline panel identified several drugs with efficacy for smoking cessation. Using any of them relieves nicotine withdrawal symptoms to make quitting less difficult and increases smoking cessation rates compared to placebo, but these products do not obviate the commitment and effort needed to stop smoking. The cessation rates achieved by all of them are higher when they are used in combination with smoking cessation counseling.
Three of these drugs—nicotine replacement, the antidepressant bupropion, and varenicline, a partial agonist at the α4β2 nicotine receptor—were designated as first-line treatment. Each of them at least doubles the success rate of a quit attempt compared to placebo, and all are approved by the U.S. Food and Drug Administration (FDA) for this indication. Two other agents—the tricyclic antidepressant nortriptyline and the antihypertensive clonidine—were designated as second-line agents because a smaller body of clinical evidence supported their efficacy and neither is FDA approved for smoking cessation. Because of the demonstrated efficacy of pharmacotherapy, the USPHS guideline panel recommended that all smokers willing to quit be offered one of these drugs, unless they are medically contraindicated (Table 54-1).
Nicotine Replacement Therapy
Five nicotine replacement products are sold in the United States (transdermal patch, gum, lozenge, oral inhaler, and nasal spray). Three are sold without a prescription (patch, gum, and lozenge), and two are available by prescription only (inhaler and nasal spray). To use any of these products, smokers are instructed in the product label to pick a day to stop smoking cigarettes and immediately begin using the nicotine replacement product. All of them relieve the symptoms of nicotine withdrawal by delivering nicotine to the bloodstream, but none of them produces the rapid peaks of blood nicotine produced by inhaling tobacco smoke. With nicotine withdrawal relieved, the smoker can focus on breaking the behavioral or “habit” aspects of tobacco use. Smokers often worry that they will remain dependent on nicotine if they use these products when stopping smoking. This rarely occurs because the dose of nicotine delivered and the pattern of nicotine delivery differ so much from inhaled tobacco smoke that a smoker using nicotine replacement is already being weaned from nicotine dependence. The smoker using nicotine replacement also avoids exposure to other harmful constituents of tobacco smoke, such as carbon monoxide and cancer-causing tars.
Nicotine can be delivered transdermally with a nicotine patch, through the oral mucosa with a nicotine chewing gum, lozenge, or inhaler, or via the nasal mucosa with a nasal spray. All nicotine replacement products are superior to placebos in randomized controlled trials, but they have rarely been compared with one another. One study that compared the patch, gum, inhaler, and nasal spray found no difference in efficacy among methods. All products are effective individually but produce higher cessation rates when used with a behavioral smoking counseling program. Combining the nicotine patch with a shorter-duration nicotine product produces better results than does using individual products and is the most effective way to use these products. In several trials, the nicotine patch produced better results when combined with the gum, inhaler, lozenge, or nasal spray used as needed to control cravings than it did when used individually. The FDA labeling warns against combining nicotine replacement products but does not reflect current data that show combinations to be both safe and more effective. The drugs can be combined safely, largely because each agent produces lower blood nicotine levels than does smoking and because smokers can control the dosing of these agents and do not use them at levels that produce nicotine toxicity.
Transdermal Nicotine
The nicotine transdermal patch provides the most continuous delivery of nicotine of all nicotine replacement products, and it is easiest for a smoker to use, but it does not offer a smoker the option of adjusting nicotine exposure over the course of the day. It approximately doubles the success of a quit attempt compared to a placebo patch. Nicotine patches are sold without prescription in the United States.
Starting on the quit day, a nicotine patch is applied each morning to any nonhairy skin site on the upper torso. It is removed and replaced the next morning. The patch site should be rotated daily to avoid skin irritation, the most common side effect. Insomnia and vivid dreams are also reported and can be managed by removing the patch at bedtime. An 8- to 12-week course is typically recommended. Smokers start with the strongest dose (21 mg/d) for 4 to 6 weeks, then gradually taper to lower-dose patches (14 and 7 mg/d) over 2 to 4 weeks. Those
who smoke fewer than 10 cigarettes (one half pack) per day are advised to begin with the 14-mg/d strength. The nicotine patch has been shown to be safe for use in patients with stable angina. Because of the vasoconstrictive action of nicotine, the risks and benefits of patch use must be weighed carefully in patients with unstable angina, recent (e.g., last 2 weeks) myocardial infarction, or serious ventricular arrhythmia. No data about safety in these situations are available, but the nicotine patch, unlike cigarette smoking, is not thrombogenic and therefore has little theoretical risk of triggering acute cardiovascular events. The benefits of nicotine replacement likely outweigh potential risks even in smokers with acute coronary syndromes who are having nicotine withdrawal. A similar argument can be made for its use in pregnant or breast-feeding women who cannot quit with nonpharmacologic methods.
who smoke fewer than 10 cigarettes (one half pack) per day are advised to begin with the 14-mg/d strength. The nicotine patch has been shown to be safe for use in patients with stable angina. Because of the vasoconstrictive action of nicotine, the risks and benefits of patch use must be weighed carefully in patients with unstable angina, recent (e.g., last 2 weeks) myocardial infarction, or serious ventricular arrhythmia. No data about safety in these situations are available, but the nicotine patch, unlike cigarette smoking, is not thrombogenic and therefore has little theoretical risk of triggering acute cardiovascular events. The benefits of nicotine replacement likely outweigh potential risks even in smokers with acute coronary syndromes who are having nicotine withdrawal. A similar argument can be made for its use in pregnant or breast-feeding women who cannot quit with nonpharmacologic methods.
TABLE 54-1 Drugs Used to Treat Tobacco Use | |||||||||||||||||||||||||||||||||||||||||||||||||
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