SMOKING CESSATION

Anju Mattoo, M.D.

Learning Objectives

• Appreciate the significance of smoking cessationcessation as a means of reducing a major threat to public health.

• Learn about the attitudes and policies that can have a major impact on smoking behavior.

• Review the various strategies available for smoking cessation.

• Role of drug therapy in achieving successful smoking cessation.

Introduction

• Cigarette smoking responsible for 5 million premature deaths worldwide (2000).

• In the US - the major preventable cause of disease; results in more than 400,000 deaths annually.

• Most important causes of smoking related mortality- atherosclerotic disease, lung cancer, and COPD.

• Smoking cessation - a major health care goal with clear benefits.

Benefits of cessation.

• CV disease - rapid decrease in the risk of new myocardial events ; reduced risk of complications of atherosclerotic vascular disease.

• COPD - reduces the decline of FEV1 in smokers; improved FEV1 and symptoms after quitting.

• Reduced risk of other pulmonary diseases.• Malignancy- reduced risk of cancers ( lung, liver,

kidney, pancreas, stomach, uterine cervix, and mesothelioma).

Benefits of cessation

• Reproductive disorders – cessation reduced the risk of premature menopause related to smoking. (smoking also associated with infertility, spontaneous abortion, and ectopic pregnancy).

• Osteoporosis – smoking related to accelerated bone loss and a risk factor for hip fracture ; reversal of risk with cessation after about 10 yr.

• PUD – cessation decreases the risk of developing peptic ulcer and also accelerates the healing of existing ulcers.

Social attitudes and policies

• Public debate – important in a democratic society; active participation by health care providers.

• Restriction of minors to tobacco products.

• Restriction of smoking in public places.

• Restriction on advertisement.

• Increase in price through taxation.

Role of PCP

• THE 5 A’s

• Ask, identify and document tobacco use status for every patient at every visit.

• Advise smokers to quit

• Assess readiness to quit

• Assist in smoking cessation effort

• Arrange for follow up visit.

Strategies for Cessation

• Behavioral approaches.

• Nicotine replacement therapy.

• Other pharmacological therapies.

• Combined approach.

Behavioral therapy

• 70 percent of patients who smoke say they would like to quit - only 7.9 percent are able to do so without help.

• Physician counseling : the advice of a physician alone can improve the smoking cessation rate to 10.2 percent.

• Group counseling : includes lectures, group interactions, self recognition, development of coping skills, and suggestions for relapse prevention. One year quit rates are approx 20%.

• Hypnosis and acupuncture – scientific evidence of support weak.

Pharmacological therapy.

• Drug therapy is designed to ameliorate symptoms due to loss of nicotine, while the smoker deals with the behavioral aspects of smoking cessation.

• Symptoms of nicotine withdrawal:

Depressed or dysmorphic mood

Insomnia

Irritability, anger, restlessness

Anxiety

Difficulty in concentration

Increased appetite, weight gain

Nicotine replacement

• Nicotine replacement is a safe intervention, even in out patients with known CV disease.

• Concurrent use of nicotine replacement with smoking is not recommended. However concerns about excess cardiac toxicity associated with nicotine appear to be unfounded.

Nicotine patch

• Easy dosing and available OTC • Nicoderm CQ : One patch per day ( 21 mg for 6

weeks, 14 mg for 2 weeks, 7 mg for 2 weeks).• Nicotrol : single dose patch (16 hrs/day for 6 weeks

with no tapering). • Local skin irritation ( upto 50% ) ; insomnia with 24 hr

dosing.• Caution : pregnant women, recent MI (4 wk ), serious

arrythmias.

Nicotine gum

• Available OTC.• Satisfies oral behavior• Nicorette gum : 2 mg and 4 mg strength.

<25 cigs/day use: 2 mg tab

>25 cigs /day use:4 mg tab

1 to 2 tab/hr for 6 weeks, taper over 6 weeks

• Multiple doses required each day.

Nicotine inhalers and spray

Inhaler (Nicotrol Inhaler) : • 6-16 cartridges/ day (4mg/ cartridge), initial Tx 6-12 wk

and taper over 6-12 wk. • Substitutes for behavioral aspect of smoking.• Frequent continuous puffing x 20 mts each cartridge.• Local irritation, cough, and bronchospasm.

Nasal spray (Nicotrol NS) :• 1-2 sprays each nostril Q hr (max 80 sprays/d).• Initial Tx 8 wk, taper over 4-6 wk.

Bupropion

• Provides therapy for depression. • Zyban or Wellbutrin: 150 mg qd for 1st 3 days then

150 mg bid..• Start 1-2 wk prior to quit date and continue 7-12 wk

after the quit date (questions remain on the optimal duration of treatment).

• Two trials of extended therapy with bupropion to prevent relapse after initial cessation, failed to detect a long-term benefit.

• Caution in smokers with seizures, head trauma, alcohol use, and anorexia.

Combination Therapy

• Bupropion (150 mg qd for 3 days followed by 150 mg bid for 60 days, starting one week before the quit date) and Transdermal nicotine ( 21 mg/day starting on the quit date and continued for 6 weeks, 14 mg/day for 1 week, and 7 mg/day for 1 week).

• In one trial the combination of bupropion and nicotine patch produced slightly higher quit rates than the patch alone, but this was not replicated in a second study.

Other agents

• Clonidine : initially promising, but now regarded as having limited efficacy.

• Nortriptyline : has shown benefit in some trials, but not FDA approved.

• Anxiolytic drugs : no significant effects on smoking cessation.

• Lobeline and Mecamylamine are currently being evaluated.

Treatment and follow up

• The process of quitting smoking begins with a “Quit date”.

• Patients should be prepared for withdrawal symptoms, even on nicotine or bupropion.

• Common suggestions to help smokers cope with early days of smoking cessation include chewing gum, increased physical activity, and avoidance of high risk situations.

• Follow up visit should be scheduled within 3 to 7 days of quit date.

Reimbursement issues

• Currently only 36 states provide Medicaid coverage for tobacco treatment and only 10 of these cover counseling.

• Most private health plans provide limited benefits for tobacco treatment.

Questions

How to manage patients who fail the first regimen?

• Advise patients not to think of themselves as failures.

• Most smokers make many attempts to quit before they achieve success.

• Figure out reasons for failure and explore solutions to use in the next attempt.

• Consider trying different cessation methods.

• Trial of hypnosis and acupuncture may encourage renewed attempts to stop smoking by patients who have failed with other techniques.

Is Group therapy helpful?

• Groups are better than self-help and other less intensive interventions. However, not enough evidence on their increased efficacy or cost-effectiveness compared to intensive individual counseling.

Does wellbutrin work?

• The antidepressant Bupropion can aid smoking cessation but selective serotonin reuptake inhibitors (e.g. fluoxetine) do not.

Does higher dose help?

• The potential for higher doses of bupropion to improve rates of abstinence from smoking was assessed in a prospective trial of over 1500 patients treated with bupropion 150 mg QD, bupropion 300 mg QD, or placebo for eight weeks

• Treatment with either dose improved abstinence rates, but the difference between these groups was not significant.

• Increased side effects : insomnia, tremor, difficulty concentrating, and gastrointestinal symptoms.

Resources

• Cochrane library

• UPSTF

• Uptodate

• American family physician.