Consider what happens when someone lights up a cigarette, said smoking cessation specialist Michael C. Fiore, MD: After entering the alveoli bed of the lungs, the smoke hits the brain within 10 seconds, bathing it with pleasure-inducing dopamine.
At the same time, the brain is being washed with nicotine, which one former U.S. Surgeon General characterized as the world's most addictive drug. The average patient who has smoked more than 20 years has inhaled more than a million times, said Dr. Fiore, an internist who chaired the U.S. Public Health Service panel that produced a tobacco use and dependence treatment guideline in 2000.
"That has a powerfully reinforcing effect that often starts in adolescence," he pointed out. "About 80% of smokers start before age 18."
For patients, smoking represents not only a physical but also a psychological dependence, one used as a coping device or as a habitual accompaniment to daily life. For physicians, Dr. Fiore said, smoking cessation is frequently a source of frustration.
"A lot of physicians think, 'The success rate is so low—why should I spend my precious time on this?' " said Dr. Fiore, who directs the University of Wisconsin Center for Tobacco Research and Intervention in Madison, Wis. "I always counter with: Tobacco dependence is an often lifelong chronic illness and exhibits many of the characteristics of chronic disease, including periods of relapse and remission."
Physicians have to change their mindset, he added, and stop viewing cessation as a one-time event. And they need to "institutionalize" their efforts to get patients to quit.
"Use your support staff, as you do with diabetes and cholesterol education, to develop expertise in more detailed counseling and cessation messages," Dr. Fiore said. As with other chronic illnesses, physicians need to use a team approach as well as rely on treatment extenders and community resources that include "quit lines," state-sponsored telephone centers that provide one-on-one cessation counseling.
To boost your rate of success, Dr. Fiore said, practices should also designate one staff person as a cessation coordinator and implement a tobacco-user identification system so every patient is asked about smoking status at each visit.
Cessation coordinators should provide physicians feedback about their intervention efforts. And doctors should promote hospital policies to provide inpatient cessation counseling—and strongly advocate for insurance coverage of all available cessation therapies.
"Victories in smoking cessation come in small steps," Dr. Fiore said. "It's time well invested—and what we have to do to be good doctors." (Also see "Smoking cessation treatments and barriers.")
This edition of ACP Observer Special Focus is designed to help optimize your ability to help manage patients who smoke, with recommendations for cessation counseling and therapies.
Five-step intervention to promote cessation
Smoking-cessation guidelines developed by the U.S. Surgeon General include five intervention steps—dubbed "the five As"—for the willing-to-quit smoker:
Ask about tobacco use
Advise to quit
Assess willingness to make a quit attempt
Assist in quit attempt
For patients unwilling to quit:
- Encourage them to think of relevance of quitting smoking to their lives.
- Help them identify smoking risks and cessation rewards.
- Discuss roadblocks or barriers to quitting.
- Repeat the motivational intervention at each visit.
SCREENING AND INTERVENTIONS
Ask all patients if they smoke, regardless of age or sex. A meta-analysis of nine studies found that clinicians who asked patients about smoking status were three times more likely to introduce a smoking cessation intervention that convinced patients to quit. A 1998 smoking cessation guideline from the American College of Preventive Medicine urged physicians to include smoking status as a vital sign and to flag those who smoke with a stamp on their patient record.
Determine smokers' willingness to quit and tell them they are at increased risk of dying sooner than nonsmokers and of developing ischemic heart disease, myocardial infarction, stroke, peripheral vascular disease and chronic obstructive lung disease. Smoking also increases patients' risk of lung, esophageal, oral, bladder, cervical and pancreatic cancers.
Provide all smokers with a brief counseling intervention to encourage quitting, but stress cessation particularly to the following populations:
Patients with established coronary artery and chronic obstructive lung disease. These patients have higher morbidity due to smoking. A cohort study of patients post-myocardial infarction found that mortality among those who quit smoking approached that of nonsmokers within three years.
Pregnant women. Cessation reduces the incidence of both low-birth-weight babies and preterm labor. A systematic review found that the efficacy of smoking cessation counseling was greatest in pregnant patients and in people with established coronary artery disease. One randomized controlled trial of a nurse-managed intervention with phone follow-up showed an absolute increase in cessation of 26% of patients at one year.
Parents. Studies have found that children exposed to adult smoking had significantly higher rates of otitis media, tympanostomy, tonsillectomy, adenoidectomy, asthma, cough and lower respiratory tract illness. Secondhand smoke exposure is also associated with an increased risk of sudden infant death syndrome—and with raising children who grow up to be smokers.
Children exposed to secondhand smoke also die more often from fires caused by smoking materials. Environmental tobacco smoke-related illness kills between 136 and 212 children each year in the United States, while about 150 childhood deaths a year are caused by smoking-related fires.
Encourage patients to set a cessation date within two weeks after deciding to quit, and arrange follow-up visits to improve cessation rates and maintain patients' motivation.
Use specific behavioral therapies for smoking cessation, including dispensing clear advice to quit now, referral to cessation programs that provide cognitive-behavioral therapy and materials to those who want to quit on their own.
All smokers should receive at least one episode of smoking cessation advice per year. Brief physician instruction and encouragement can significantly reduce patients' smoking rates. (See "Estimating the odds."
Patients who receive between four and eight treatment sessions have been found to have twice the likelihood of quitting, compared to those receiving only one session or none.
In randomized trials, nicotine replacement therapy and bupropion each approximately double cessation rates. They are considered the first line agents for smoking cessation.
Nicotine replacement therapy: Nicotine replacement is safe in most patients. Despite the theoretical concern of using nicotine replacement therapy in patients with ischemic heart disease, it is safe in those with stable coronary disease. For those with unstable coronary disease, the safety factor is unknown because it is used selectively for patients with severe nicotine withdrawal symptoms.
Therapies include the nicotine patch, nasal spray, inhaler, gum, sublingual tablet and lozenge. Patients can use 16- to 24-hour patches containing up to 22 mg of nicotine per 24-hour period for eight to 16 weeks, either tapering off or abruptly discontinuing. They can also use nicotine gum in a fixed dose regimen or as needed. Use the 4-mg dose of gum for highly dependent smokers, and 2 mg to 4 mg for others.
Combination therapy with nicotine replacement products may increase cessation rates over monotherapy, although there is insufficient evidence to make a firm recommendation. One randomized controlled trial of combination therapy with nicotine patch and nasal spray found the regimen to be more effective than patch alone for cessation at one year. The combination also improved maintenance cessation at six years.
Antidepressants: Two large randomized trials studied the effectiveness of bupropion for quitting smoking. In one trial, bupropion produced a 15% absolute increase in smoking cessation compared with placebo and a 14% absolute increase in cessation compared with nicotine replacement therapy at one year.
A separate trial of sustained-release bupropion vs. placebo in black Americans demonstrated an absolute increase in smoking cessation of 7.3% at 26 weeks.
Administer 150 mg of sustained-release bupropion once daily for three days, followed by 150 mg twice daily for seven to 12 weeks—although a dose of 150 mg per day is effective if patients cannot tolerate the full dose. Have patients set a smoking cessation date for about one week after they start therapy.
Combining bupropion and nicotine replacement therapy increased one-year cessation rates by 5% over bupropion alone, which is not statistically significant. The study did indicate, however, that the combination was safe.
Because it lowers the seizure threshold, bupropion is contraindicated in patients with a history of seizures, bulimia or anorexia nervosa. Patients should not use the two forms of bupropion—Zyban and Wellbutrin—together, nor should patients use bupropion if they are currently using or have used a monoamine oxidase inhibitor within the past 14 days. (Zyban is FDA-approved for smoking cessation, while Wellbutrin is approved for depression.)
Anaphylaxis has been reported at a rate of one to three per 1,000 patients taking bupropion. The drug has been associated with hypertension requiring treatment, so patients taking the drug should have their blood pressure monitored.
Nortriptyline—a tricyclic antidepressant—and clonidine, used to treat hypertension, are also effective in smoking cessation but have not received FDA approval because they are already available in generic forms.
Other drugs: There's no evidence showing the effectiveness of anxiolytics for smoking cessation. The U.S. Public Health Service guideline issued in 2000 did not recommend lobeline, naltrexone, silver acetate or mecamylamine for smoking cessation.
SMOKING CESSATION STATISTICS
The upside …
Smoking cessation is associated with a dramatic reduction in mortality rates and other adverse outcomes. Researchers with the Lung Health Study, a longterm multi-centered series of clinical trials, found that patients in 10-week cessation programs maintained a higher rate of cessation: 21.7% vs. 5.4% among the control group. They also found that after 14.5 years, mortality rates from all causes, including lung cancer and cardiovascular disease, were higher in the nontreatment group.
Here are other good reasons to quit:
Smokers who quit have a 50% reduction in their risk of cardiac events after one or two years. However, it may take 10 to 15 years for the excess coronary heart disease risk to entirely disappear.
Patients who are smoke-free for five years have half the risk for cancers of the oral cavity and esophagus than those who continue to smoke. Quitting smoking also cuts patients' risk of bladder cancer in half.
The risk of lung cancer in former smokers may be 30% to 50% less than that of current smokers.
Former smokers have a reduced risk of cervical cancer within a few years of quitting—and lower risk of pancreatic cancer after 10 smoke-free years.
Patients with established obstructive lung disease who quit have slower deterioration of lung function than those who continue to smoke.
... and the downside
For many patients, quitting smoking can lead to other problems. Cessation is associated with a mean weight gain of 11 pounds, with at least one study finding that women who quit tend to put on more weight than men.
And quitting may produce depressive symptoms severe enough to warrant treatment, particularly in patients with a history of major depression. Neither potential weight gain nor depression should stop physicians from initiating cessation interventions, but they should monitor for both.
|Access to PIER's smoking cessation module online.|
The information included herein should never be used as a substitute of clinical judgment and does not represent an official position of ACP.
The following estimated odds ratios for tobacco abstinence for different smoking cessation interventions are based on the U.S. Public Health Service guideline issued in 2000. In the guideline, the comparison group was no intervention.
|Clinical intervention||Odds ratio (95% CI)|
|Physician advice to quit||1.3 (1.1, 1.6)|
|Physician counseling||2.2 (1.5, 3.2)|
|Smoking cessation counseling|
|Individual||1.7 (1.4, 2.0)|
|Group||1.3 (1.1, 1.6)|
|By telephone (proactive)||1.2 (1.1, 1.4)|
|Self-help material||1.2 (1.02, 1.3)|
|Gum||1.5 (1.3, 1.8)|
|Transdermal patch||1.9 (1.7, 2.2)|
|Vapor inhaler||2.5 (1.7, 3.6)|
|Nasal spray||2.7 (1.8, 4.1)|
|Bupropion SR*||2.1 (1.5, 3.0)|
|Nortriptyline**||3.2 (1.8, 5.7)|
|Clonidine**||2.1 (1.4, 3.2)|
**Unlike the other pharmacotherapies listed, nortriptyline and clonidine are not approved by the Food and Drug Administration for smoking cessation.
Source: U.S. Public Health Service, June 2000.
Physicians frustrated with patients who still smoke should keep in mind that half of all Americans who have ever smoked have kicked the habit. According to figures from the Centers for Disease Control and Prevention, 45.4 million American adults in 2003 were still active smokers—but 45.9 million had quit.
Nancy A. Rigotti, FACP, an associate professor at Harvard Medical School, directs the Tobacco Research and Treatment Center at Boston's Massachusetts General Hospital. She founded the center in 1992 and spoke with ACP Observer about cessation efforts:
On how many patients want to quit:
Survey data show that 70% of smokers say they want to quit and 40% will make an attempt in any one year. Only 5% of people who try to quit without any help are successful; that figure rises to about 30% for those who have the best available treatment. Most people have to try between three and five times before they are successful.
On treating different patient populations:
Certain groups, such as those with mood disorders, have a much lower success rate of quitting. Both men and women who are depressed or have substance abuse problems have more trouble, as do people with little social support. These groups need extra help.
On what treatments are most effective:
Research tells us that a combination of counseling and drug treatment produces the highest cessation rates. All too often smokers tell me that they have tried everything, but in fact they have never gotten any cessation counseling support and need to be encouraged to access it.
Physicians should think about combinations, such as bupropion with nicotine replacement therapy or combining the patch, which is a long-acting form of nicotine replacement, with a shorter-acting form, such as gum, lozenge or inhaler. It's like treating hypertension patients: We commonly have to use three different drugs in combination and recommend lifestyle changes.
On treatment and counseling barriers:
Smoking is the leading preventable cause of death, yet smoking cessation is very poorly covered by health plans, which is an outrage, and cost remains a barrier for many people. Medicare recently started reimbursing for smoking cessation treatment, but only for counseling face-to-face, not in groups or over the telephone. By and large, private insurers don't cover counseling treatment and vary in their coverage of prescription-only drugs, while few cover over-the-counter therapies, like the patch.
On upcoming drug therapies:
One or more new drugs for smoking cessation may become available in the next year or two. New drugs will probably also bring more smokers into doctors' offices. In the past, when a new drug appeared, smokers initially flooded doctors' offices, so we should be prepared.
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