David W. Blodgett
Tobacco use, primarily in the form of chronic cigarette smoking, is the greatest single cause of illness, disability, and death in the United States. Smoking is estimated to cause more than 440,000 deaths annually—almost 20% of all deaths.
The perniciousness of the habit relates largely to its long history of social acceptability and to the failure by society and by health professionals to recognize and respond to smoking as a health-damaging behavior. This situation has been changing, and it continues to change. Within the United States and many other countries, both society and health professionals are now acting to proscribe, prevent, restrict, and treat smoking. Still, much remains to be done. The prevalence and acceptability of smoking remain high in many subgroups and in many countries. The World Health Organization (WHO) estimates that worldwide tobacco-related deaths will increase from 3 million annually in 1990 to more than 8 million annually in 2020.
Prevalence of Tobacco Use
The decline of smoking prevalence in the United States in recent decades represents an impressive success of public health and prevention efforts. Beginning in 1965, adult smoking prevalence declined by 0.5% to 1.0% per year, from 42% in 1965 to 25% in 1993. The rate of decline has now slowed; total prevalence fell only two and a half more percentage points over the next 9 years, to 22.5% in 2002. Smoking is becoming concentrated in more resistant individuals. Table 27.1 summarizes the prevalence of adult cigarette smoking in relation to demographic characteristics for the 2002 National Health Interview Survey. There are substantial differences among demographic subgroups. Smoking is more common in poor communities and least common among the highly educated.
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TABLE 27.1 Percentage of Adults (Age, ≥18 yr) Who Smoke Cigarettes, United States, 2002 |
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Smoking prevalence has been fairly constant in recent years among U.S. adults and adolescents. Prior to 2002, smoking rates had increased among high school students. That trend has since stabilized. Currently 22.9% of high school students in the United States are cigarette smokers.
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Each day nearly 4,000 young people between the ages of 12 and 17 years initiate cigarette smoking in the United States. Of these 2,000 will become daily cigarette smokers. Adult smoking prevalence is highest among Native Americans, fairly similar among African Americans and whites, somewhat lower among Hispanics (especially Hispanic women), and lowest in Asian/Pacific Americans. In contrast, adolescent prevalence is appreciably lower among African Americans than whites, with Hispanics intermediate; daily smoking prevalence for high school students in 2003 were 25.5% of whites, 20.5% of Hispanics, 14.3% of African Americans, and 12.8% of Asian Americans. Other forms of tobacco use occur predominantly in males: pipe and cigar use in approximately 3% and 5%, respectively, and use of smokeless products (snuff, chewing tobacco) in approximately 6%. However, in some locales and subgroups (e.g., young men in rural or southern areas), the prevalence of smokeless tobacco use may approximate that of smoking.
Causes and Risk Factors
The development of tobacco dependence can be viewed as a pediatric disorder. Smoking typically begins in the preteen or teenage years; initiation after 22 years of age is rare. The habit is so widespread that it is not limited to any specific environmental, physiologic, or psychological circumstances. Social influences, such as peer pressures or efforts to display independence and to appear mature and self-confident, are major factors in promoting and sustaining initial smoking experiences. Aversive experiences (e.g., coughing, nausea, dysphoria) are described during the initiation phases of smoking, even by those who proceed to lifelong dependence. Nicotine is the causative pharmacologic agent responsible for establishing and maintaining tobacco use and addiction. The continued easy availability of nicotine-delivering tobacco products, combined with strong learned behavioral habits, memories, and associations, make tobacco use a truly addictive disorder—with characteristic resistance to change (1).
About half of individuals who smoke for 1 month become chronically dependent (2). Certain risk factors are associated with an increased likelihood of becoming a chronic cigarette smoker. Smoking runs in families. An individual with parents and siblings who smoke is four times as likely to become a smoker as is an individual from a nonsmoking family. The familial association results from both genetic and environmental factors. Twin studies indicate an approximately 50% heritability of smoking (3). Other studies suggest that genetic variations in cytochrome P-450, dopamine receptor and transporter, and serotonin transporter genes influence the propensity toward smoking (4). Smoking is also significantly associated with adverse childhood experiences; violence in the family, childhood abuse, and stressful life events are each associated with a two- to fourfold increase in the probability of being a smoker (5,6). In the past, males were more much likely to smoke than females, but this is no longer the case. Alarmingly, it has been well documented that female smokers have a more difficult time quitting smoking than males, perhaps related to differences in reasons for smoking initiation, psychological addiction, and self image (weight gain) (7). There is no distinct personality type that is characteristic of smokers, but on average they tend to be somewhat more extroverted than nonsmokers, more adventuresome or risk taking, and more likely to deviate from social norms or rules. These latter characteristics may, in adolescence, increase the probability of experimentation with smoking, with a consequent increased risk of chronic dependence. Smoking is often referred to as a “gateway drug.” Smoking is more prevalent in individuals with other substance use disorders (e.g., 70% to 90% prevalence in alcoholics and other drug abusers). Smoking adolescents are also more likely to have unplanned pregnancies, participate in violent acts, to be involved in automobile accidents or other high-risk activities.
Primary Prevention
Primary prevention efforts must be directed to preadolescents and adolescents. An important element is changing societal norms about the acceptability of tobacco use. Formal preventive interventions should begin in elementary grades and continue for several years. Effective interventions are not simple fact-based health education, but instead teach specific skills for resisting social pressure and rejecting enticing tobacco advertising messages. They include explicit instructions and rehearsals with peers in vignettes about resisting offers to use cigarettes, alcohol products, and illegal drugs. Children who receive such training have reduced rates of smoking onset (8). As community health leaders, physicians should encourage and support preventive interventions, including bans on tobacco use in public areas, enforcement of prohibitions on tobacco sales to minors, increasing the price of tobacco, and restrictions on advertising that glamorizes smoking or appeals to youth.
Course of the Habit
The health hazards of smoking are now widely recognized, and the social acceptability of smoking has declined. Consequently, most smokers vacillate between defending and justifying their habit and trying to end it. Seventy percent of smokers report wanting to quit, and about half attempt to stop in a given year. Adverse health events and advice from physicians are potent forces in promoting increased
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cessation efforts by patients. In the United States there are now about twice as many former smokers as there are current smokers.
Patterns of Quitting and Relapse
Approximately 60% to 80% of smokers who attempt to quit achieve at least a minimal period of abstinence. However, the relapse rate is high, most occurring very quickly after quitting (9). Approximately two thirds of quitters resume smoking within 3 to 6 months, many within only a few days. Only 15% to 20% of untreated quitters remain cigarette-free for 6 months or longer. Treatment approximately doubles the long-term success rate, but relapse, repeat quit attempts, and repeat treatments are commonplace. Cessation should not be considered successful until abstinence has been sustained for at least 6 months. The probability of relapse after 6 months of abstinence is reduced but still present.
Approximately 95% of smoking cessation occurs as the result of smokers’ self-directed personal efforts, without formal treatment. Abrupt (“cold turkey”) cessation is more likely to be successful than is gradual reduction. Most successful quitters require more than one attempt before becoming permanent ex-smokers. Repeated quitting and relapsing are characteristic of the normal, successful cessation process. Success should be applauded with each quit attempt, as each attempt brings a greater likelihood that the next attempt will be successful. The risk of relapse is increased when patients are under emotional stress (e.g., anger, frustration, anxiety, depression), when ex-smokers are exposed to cues associated with prior smoking (e.g., after meals, when consuming alcoholic beverages), and in people whose spouse or friends continue to smoke (10).
Health Consequences
Risk of Disease
Although smoking dramatically increases overall population morbidity and mortality, its effects on individual smokers are unpredictable, and some smokers escape major health consequences. Age-adjusted mortality rates for smokers are 70% greater than those for nonsmokers. Smoking significantly shortens life expectancy (e.g., 8.1 years less for the 30-year-old two-pack-a-day smoker than for a comparable nonsmoker). Risk is dose related; mortality increases with increasing number of cigarettes smoked, with increasing number of years as a smoker, and with depth of inhalation.
Smoking is associated with an astounding list of health related effects. Most notably, it has been linked to increased risk of cancer (especially of the respiratory tract); cardiovascular disease; chronic obstructive pulmonary disease (COPD); gastric ulcer; breast; prostate and cervix; postmenopausal osteoporosis, diabetes, and macular degeneration. Smoking by pregnant women reduces fetal growth and birth weight and increases the risk of fetal death; smoking interacts with the use of oral contraceptives by women and increases the risk of myocardial infarction (MI), subarachnoid hemorrhage, and thromboembolic disease.
The risks of cancer and chronic pulmonary disease in smokers are ten times those in nonsmokers (30% of all cancers have been linked to tobacco use). The percentage of oral, throat, and lung cancer deaths attributable to smoking exceeds 80%. The risk of atherosclerotic cardiovascular disease is approximately doubled in smokers. The percentage of cardiovascular disease deaths attributable to smoking is 20%. In sum, tobacco smoking is the single largest underlying cause of death. The morbidity and mortality as well as the economic toll brought on by the use of tobacco present at once a perplexing problem, as well as a golden opportunity to improve health.
Benefits of Cessation
The greatest immediate benefit of smoking cessation is the reduction of cardiovascular risk. Within hours after smoking cessation, both carbon monoxide and nicotine are dissipated from the body, with a consequent reduction in cardiac work requirement and a concurrent increase in oxygenation. There is also prompt reduction in the risk of upper respiratory tract infection (URTI). Slower to accrue are a reduction in the rate of decline of pulmonary function and a reduction in cancer risk; benefits of cessation are measurable in these domains within 3 and 10 years, respectively, after smoking cessation. The risk of coronary artery disease (CAD) and death 15 to 20 years after quitting is similar to that of the nonsmoker.
Health benefits of smoking cessation are greater for smokers who quit before the development of symptoms; however, the benefits of cessation also extend to those who have already experienced symptoms of smoking-related disease. For example, individuals who stop smoking after MI have improved survival rates compared with those who continue smoking. Similarly, there are pulmonary benefits to smoking cessation even late in life (11).
Low-Yield Cigarettes
Because the risks of smoking are dose related, it is tempting to believe that substantial health benefits might be achieved by switching to low-yield cigarettes. This is not the case; the variations in currently marketed tobacco yields have little health impact, and there are negligible correlations between the stated yield values and blood levels of nicotine and its major metabolite, cotinine (12). Biologic yield may differ substantially from stated yield
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because of behavioral variations in the way the cigarettes are smoked. When nominal yields change, smokers tend to change their behavior so as to keep biologic delivery unchanged (e.g., by smoking more cigarettes, inhaling more smoke). The primary manufacturing technique for producing current low-yield cigarettes is to place ventilation holes in the sides of the filter to dilute the smoke stream with air. With these low-yield brands it is especially likely that biologic delivery will significantly exceed assay delivery, because the smoker's fingers and lips tend to block these ventilation holes (13). Smokers should be cautioned that so-called low-yield cigarettes will not decrease the health-related risks of smoking.
Physical Dependence and Craving
Chronic tobacco use produces physical dependence on nicotine. On cessation of use, an abstinence syndrome typically occurs (14, 15, 16). The subjective aspects of the syndrome can be very distressing and include irritability, restlessness, sleep disturbances, difficulty in concentrating, anxiety, gastrointestinal (GI) disturbances, hunger, weight gain, and, most important, craving for cigarettes. Most patients feel normal again within approximately 2 weeks of abstinence, except that the craving for tobacco may persist for months or years. Nicotine substitution treatment is effective in reducing the abstinence syndrome. The physiologic aspects of the tobacco abstinence syndrome are generally inconsequential, consisting of a slight and gradual decline in heart rate and blood pressure.
Craving for tobacco is an extraordinarily persistent obstacle to sustained abstinence. Many ex-smokers report cravings years after cessation. The duration of craving is highly variable, but it should be expected to persist for at least 3 to 6 months, with its frequency and urgency diminishing over that interval. Craving may be a learned phenomenon rather than part of an abstinence syndrome, because it is high even among smokers making no attempt to quit or reduce their smoking.
Passive Smoking
Passive smoking exposure of nonsmokers to air contaminated by the smoking of others is not only an irritant to many nonsmokers; it has definite adverse health effects. There are significant health risks associated with passive smoking (17, 18, 19, 20). Passive exposure to the smoke of spouses is associated with impaired pulmonary function, increased lung cancer risk, and increased coronary heart disease risk. Children passively exposed to smoke by parents have increased rates of respiratory infections, slower developmental increases in pulmonary function, and an increased incidence of asthma attacks. Maternal smoking contributes to reduced birth weight, and smokers who stop the habit during pregnancy have significantly heavier babies than do those who continue smoking (21).
Physicians should try to protect nonsmokers from cigarette smoke and should recognize that most indoor ventilation systems simply diffuse and redistribute smoke rather than remove it. Smoking (including employee smoking) should be emphatically prohibited in physicians’ offices, and physicians should support similar efforts in all public settings, especially in health care facilities. Legal prohibition of indoor smoking in public or commercial facilities is now common.
Recognition and Diagnosis
Nicotine dependence is a diagnosable substance use disorder in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV). The diagnostic criteria are identical to those for other substance-related disorders (see Chapter 29), reflecting the growing recognition of extensive commonalities among alcoholism, drug abuse, and tobacco dependence.
There is widespread failure of health professionals to recognize and diagnose tobacco dependence and to maintain it on an active problem list. Tobacco use status should be considered at every visit at the office reception point (22). There should be a clear and prominent chart cue to prompt attention at subsequent visits.
Assessment of smoking status is normally via practitioner questioning and patient self-report. Smoking status can be assessed by measuring carbon monoxide concentrations in expired breath (concentrations greater than 5 to 8 ppm normally indicate smoking). Urine and saliva test-strips for detection of nicotine or its metabolites have been developed.
Treatment
Substantial evidence, assistive materials, and pharmacologic modalities are now available for the rational planning and implementation of smoking cessation interventions with patients. They are summarized here.
Role of the Health Care Provider
Concern about health remains the most cited reason smokers quit, and smokers cite physicians as the people most able to influence their decisions to attempt to quit. The optimal role of a physician or other health care practitioner in the treatment of tobacco dependence is to advise and assist all smoking patients to stop. It is a mistake to rely heavily on referral to specialized smoking cessation programs. Results of referral are disappointing when compared with
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those obtained by devoting equal or less time to brief direct advice.
Brief advice can significantly increase rates of smoking cessation (23,24). A rigorous review of more than 39 studies (with more than 31,000 smokers) found that physician advice resulted in a small but significant increase in the odds of quitting. Although counseling effectiveness is not necessarily related to the intensity of advice, direct comparisons of minimal advice versus intensive counseling found a small advantage for intensive advice; direct comparisons also suggested additional benefit for followup visits. (25). Medical economic analyses have shown that smoking cessation advice is as cost-effective as other common interventions, such as treatment of hypercholesterolemia or mild hypertension. An increase in smoking cessation rates of between 3% and 5% can be expected if practitioners simply caution each smoker to quit during routine office visits for other problems. Addition of pharmacologic treatment further increases success. Among certain patients, advice alone can achieve impressive efficacy. For example, the smoking cessation rate after a first myocardial infarction is as high as 50% for patients given directive smoking cessation advice by their physician, compared with approximately 35% for patients receiving usual care. Similarly high rates of cessation are seen in prenatal care settings, where up to 20% to 30% of smokers may quit during a pregnancy (21).
Consistency of Counseling
Despite its known benefits, the frequency and consistency of physician counseling to quit smoking remain disappointing. Fewer than 50% of smokers report receiving smoking cessation advice from their physician (26,27). Patients who are younger, male, African American, uninsured, healthier, or lighter smokers are less likely to report receiving physician advice to quit smoking. This may be related to frequency of patient health care contacts, or physicians’ likelihood to counsel may be influenced by patient characteristics (26,28).
Absolute rates of smoking cessation in response to physician advice are likely to remain frustratingly low. But, it is important to recognize that the overall public health benefit may be very large because of the number of smokers counseled. Routine smoking cessation advice from physicians plays an important role in reducing overall societal smoking rates (29). Further, although patients may not immediately quit smoking as a result of direct physician advice, such counseling may play an important role in increasing readiness to quit smoking in the future (30).
Motivational Communication
The goal of effective doctor–patient communication is to provide advice that maximizes a smoker's motivation and decision to quit. A common error is to rely too much on fact-based health education that implicitly seeks to motivate through fear. Smokers are now well aware of the health risks of smoking and do not respond to that information alone. The five actions described later in this chapter (seeRecommended Office Approach) integrate what is known about motivational communication into a practical approach for helping smokers to quit. The approach includes many of the behavioral strategies described in Chapter 4. It focuses on one clear and simple message—“I strongly advise you to quit”—delivered in a manner free of blame or rancor. The advice should be personally relevant to patients, should describe in a positive way the benefits to be gained, and should prescribe a particular course of action. These three objectives can be attained by pointing out the association between smoking and the specific symptoms, illnesses, or health risks of the individual patient; by pointing out that smoking cessation can prevent, reverse, or stop the progression of disease (whichever is appropriate); and by stating clearly, simply, and directly the course of action to be taken: stop smoking. A general statement that “Smoking is bad for your health and you can kill yourself if you continue” fails on all three of these points. It is not specifically personal, it describes no benefit, and it is not sufficiently directive. More personalized and directive statements can be more persuasive (e.g., “I strongly advise you to stop smoking; both your coughing and your recurring colds and flus are caused in part by your smoking; I want you to try to quit smoking, and then we should see some improvement”).
Patients differ in their readiness and willingness to change their smoking habit. The goal is to move patients along the continuum depicted inFig. 4.1. When patients are ready to attempt cessation, the goal should be to agree on a cessation date and to provide therapeutic assistance. Patients not yet ready for cessation may become ready in response to repeated nonjudgmental encouragement and motivational advice.
Brochures and Self-Help Materials
Self-help smoking cessation brochures can provide useful motivational advice and specific helpful techniques for smokers. Local health departments have developed excellent resources to help patients quite smoking. Additionally, local offices of the American Cancer Society, the American Heart Association (AHA), or the American Lung Association can be contacted to obtain copies of their smoking cessation self-help brochures. An excellent product, You Can Quit Smoking, is available from the Agency for Healthcare Research and Qualtiy (AHRQ) online at http://www.surgeongeneral.gov/tobacco/consorder.pdf, or by calling 1-800-358-9295. Patients with Internet access can also be referred to a wide range of smoking cessation self-help aids, programs, and support groups available on the Internet (seehttp://www.hopkinsbayview.org/PAMreferences).
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TABLE 27.2 Summary of Smoking Cessation Products |
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Pharmacologic Treatments
There have been substantial advances in recent years in the availability of pharmacologic treatments for tobacco dependence. Nicotine chewing gum, lozenge, and transdermal patch products are now available over the counter without prescription. Other types of nicotine replacement treatment products are available by prescription, including nicotine nasal spray and nicotine vapor inhaler. Also, bupropion, the first non-nicotine smoking cessation product, is available by prescription. Table 27.2 summarizes characteristics and 2005 costs of these products. Table 27.3 compares the costs of smoking and the costs of pharmacologic treatment with available products.
Mechanism and Indication
Smoking cessation medications are intended to aid patients who are making a serious attempt to stop tobacco use. They will not themselves induce such an attempt. They
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enhance the success of motivated behavior change efforts but do not cause or motivate such behavior change directly. Nicotine replacement products suppress the nicotine abstinence syndrome and reduce subjective desire or craving for tobacco. The mechanism of bupropion's efficacy is uncertain, although it also appears to suppress nicotine withdrawal and craving and to help treat comorbidities that might favor sustained smoking. Medications are to be used in conjunction with a complete cessation of tobacco use. If tobacco use persists beyond the first couple of weeks of treatment, the medication should probably be discontinued until some future renewed effort at total cessation is attempted.
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TABLE 27.3 Cost of Smoking versus Cost of Treatment |
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Efficacy
Strong data support the efficacy of all these marketed treatments, but none is clearly superior (31, 32, 33, 34). Meta-analyses quantifying their effectiveness are summarized in the recent clinical practice guideline released by the surgeon general (31). All have been shown to increase smoking cessation rates by approximately 50% to 100% over placebo comparison conditions. The absolute rates of smoking cessation depend on many factors: patient motivation and setting, intensity of concurrent behavioral counseling, definition of cessation, and time of assessment. Most clinical efficacy trials described in product labeling are conducted in patients sufficiently motivated to volunteer for smoking cessation treatment and in conjunction with individual or group counseling; success is generally defined as 4 weeks of smoking abstinence during active treatment. Under these conditions cessation success rates of 30% to 50% are often achieved in active medication groups, compared with rates of 10% to 30% in placebo groups. Success rates decline to half of these values when assessed 6 to 12 months after the end of treatment. Despite variations in the absolute rates of success, the relative efficacy of active pharmacologic treatment over placebo is robust and is preserved across different populations, settings, counseling levels, and followup periods.
Nicotine Patch
The nicotine transdermal patch is the treatment of choice at present. This preference relates primarily to its ease of use and relatively good patient compliance. Patches may be worn for either 24 or 16 hours per day with equivalent effectiveness. The rationale for 24-hour use is to minimize nicotine withdrawal on waking. The rationale for 16-hour (daytime only) use is to minimize sleep disturbances that may accompany 24-hour use. The most common side effect is skin irritation at the site of patch application. In a placebo-controlled trial, the nicotine patch was shown to be effective and safe for use in a wide spectrum of patients with chronic cardiac problems (32). While emerging evidence suggests that nicotine contributes to the elevated risk of heart disease among smokers, the benefits to cessation rates from short-term nicotine replacement therapy far outweigh the risks of continued smoking.
Nicotine Chewing Gum
A potential advantage of nicotine gum is the ability to adjust dosage individually and to schedule use as needed in response to situational variations in nicotine withdrawal and craving. Its major disadvantages are the extensive behavioral compliance required for effective use, relatively long periods of time required for onset of action, and the common failure of patients to use enough. Patients must be instructed in proper chewing technique; they must understand that the nicotine is absorbed primarily through the oral mucosa but very poorly if swallowed. Proper use involves a few chews until a peppery taste or tingling is felt, parking the gum inside the cheek to allow absorption, then repeating at intervals of about 1 minute. Nicotine absorption is not rapid, so a regularly timed dosing schedule of 1 gum every 1 to 2 hours is usually more successful than self-selected dosing. Acidic beverages (coffee, juices, soda, and wine) should be avoided before or during gum use because their pH reduces nicotine absorption. The 4-mg dosage form is intended for patients with higher levels of nicotine dependence. Convenient indices of dependence level are number of cigarettes smoked per day (25 or more is considered high dependence) and how soon after waking the first cigarette is smoked (smoking within just a few minutes of waking reflects high dependence).
Nicotine Lozenges
Nicotine lozenges deliver about 25% more nicotine than corresponding doses of the gum (33). The lozenge should be sucked slowly until the taste become strong, then kept between the gum and the cheek and slowly sucked again after the taste has faded. The recommended dose is 7 to 8 up to a maximum of 25 lozenges per day. Lozenges are easier to use than nicotine gum, requiring little instruction to use. Smoking cessation-related weight gain is reduced with 4-mg lozenges as opposed to placebo. Abrupt discontinuation may precipitate withdrawal symptoms.
Nicotine Nasal Spray
The nicotine nasal spray more closely simulates the pharmacokinetics of nicotine delivery via tobacco smoking than the other nicotine substitution medications do. It produces a larger and more rapid increase in blood nicotine levels, although still less than that achieved with smoking. The nasal spray may be especially beneficial to highly dependent smokers, who may need more rapid and more substantial nicotine delivery. The nasal spray's more rapid onset makes as-needed dosing more practical than with gum,
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but regularly scheduled dosing is still the recommended procedure.
Nicotine Vapor Inhaler
The nicotine vapor inhaler is similar in appearance to a cigarette and may be especially useful to patients who desire the physical manipulation and sensory aspects of smoking. There is no heat or combustion; puffs on the inhaler draw air over an internal nicotine-laden plug. Each puff delivers a very small dose of nicotine vapor (approximately 0.013 mg) to the mouth, where the nicotine is absorbed through the oral mucosa.
Nicotine Vaccine
One potential future approach to smoking cessation is the ongoing development of a nicotine-specific vaccine that removes the rewarding effects of cigarette smoke (34). The vaccine stimulates antibody formation that has a high affinity and specificity for nicotine. These antibodies sequester nicotine in blood, preventing entry into the brain. Theoretically, this would significantly increase cessation success rates. Human studies are in process to elucidate the safety and efficacy of such a vaccine, but initial results are encouraging.
Bupropion
Zyban is a sustained-release tablet formulation containing 150 mg of the antidepressant drug bupropion. The mechanism of action of bupropion in promoting smoking cessation is unknown, but it probably relates to its inhibition of norepinephrine and dopamine uptake. This is the only marketed non-nicotine smoking cessation medication. It is effective as a sole treatment, but its efficacy can perhaps be further enhanced by combination use with a nicotine replacement product (35). In a controlled trial in patients who were not depressed, bupropion, 300 mg (150 mg twice daily), yielded a 1-year cessation rate of 23.1%, compared with 12.4% in patients treated with placebo (36). Treatment was initiated 1 week before each patient's quit date and discontinued after 7 weeks. For the first 3 days, patients took 150 mg/day, then 150 mg twice daily. All patients received simple smoking cessation counseling.
Bupropion is also marketed as an antidepressant under the brand name Wellbutrin (see Chapter 24); patients should not use the two preparations simultaneously.
Chronic Treatment
Current recommendations are for nicotine replacement medications to be used for no longer than 2 to 3 months, during which time they are tapered gradually and discontinued. However, some patients who succeed at stopping smoking continue to use nicotine replacement products for longer periods and may be at risk for smoking relapse if the medication substitution is stopped. There is no consensus on the appropriate response to this circumstance. However, the health risks of chronic nicotine maintenance are certainly much lower than the risks of smoking.
Potential Medication Interactions
Nicotine substitution treatment typically yields nicotine blood levels well below those achieved during tobacco use. Therefore, potential medication interactions relate primarily to the cessation of tobacco use rather than to the administration of smoking cessation medications. After tobacco cessation, a dosage decrease may be required for acetaminophen, adrenergic antagonists (e.g., prazosin, labetalol), caffeine, imipramine, insulin, oxazepam, pentazocine, propranolol and other β-blockers, and theophylline. After tobacco cessation a dosage increasemay be required for adrenergic agonists such as isoproterenol or phenylephrine. Bupropion is contraindicated within 14 days of monoamine oxidase inhibitor (MAOI) use.
Weight Gain
Weight gain is a common, distressing consequence of smoking cessation. Weight gain results both from dietary changes (increased snacking and selection of high-calorie foods) and from discontinuation of the metabolic effects of nicotine (37). Weight gain of patients remaining abstinent for 1 year averages 5 to 15 lb. This magnitude of weight gain is medically insignificant relative to the health benefits of smoking cessation. Unfortunately, the anticipated social, cosmetic, and economic (e.g., wardrobe cost) consequences of weight gain deter some smokers from quitting and contribute to relapse in others. Nicotine replacement treatment and bupropion both significantly attenuate weight gain after smoking cessation (38). Recent research suggests that, among women concerned about weight gain, cognitive behavioral therapy can improve smoking cessation outcomes and decrease weight concerns (39). The goals of the cognitive behavioral therapy were to reduce concerns about, and promote acceptance of, modest weight gain; to discourage dietary restraint, dieting, and active resistance to weight gain; and to encourage moderate consumption of healthy foods in between-meal snacks. The important message for patients concerned about possible postcessation weight gain is perhaps counterintuitive: focusing on weight control concurrent with smoking cessation leads to worse outcomes on both smoking and weight.
Organized Treatment
Health care practitioners often would like to refer smokers to formal cessation programs. For the small minority
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of smokers who attend them, organized programs at little or no cost are often available through local voluntary service organizations such as the American Lung Association or AHA. There are also available in some communities self-help peer-counseling programs (e.g., Nicotine Anonymous) modeled after the 12-step approaches used with other addictions. Commercial programs offer no clear advantages. Most organized programs incorporate standard behavioral principles of self-monitoring, control of environmental cues, and scheduling of rewards. These principles are also well represented in various self-help guides and in the patient education materials packaged with cessation medications. Patients often express interest in using alternative strategies for smoking cessation, such as acupuncture, hypnosis, or herbal aids. Although research has found no significant benefit of these often costly approaches, patients who are highly motivated to use such alternative strategies may benefit.
Relapse Prevention
As with most addictive disorders, the likelihood of relapse after cessation is high. Most relapses occur within the first few days or weeks of cessation, although patients are at some risk for relapse even after months of abstinence. New quitters face many urges to smoke again. Anticipation and advance planning can prevent relapse. Self-help educational brochures are useful for this purpose. They provide warnings about relapse risk circumstances and suggest coping strategies. Additionally, they help patients recognize the normality of “slips” and the importance of continued commitment to cessation. Slips or brief episodes of relapse are strong predictors of full relapse to smoking; therefore, patients should be carefully counseled that even one cigarette might jeopardize their smoking cessation attempt.
Recommended Office Approach
Most health care practitioners advise smoking cessation for patients with obvious smoking-related illnesses, such as the patient with COPD or the inpatient recovering from a MI. However, too often physicians neglect to give smoking cessation advice in routine office care. Patients with smoking-related diseases obviously require strong smoking cessation interventions, but it is the smoking patient who has not yet experienced negative health consequences of smoking who stands to benefit most from smoking cessation. This section describes the primary care smoking cessation practice developed and recommended in the 2000 Treating Tobacco Use and Dependence clinical practice guideline published by the U.S. Public Health Service (http://www.surgeongeneral.gov/tobacco).
Although health care practitioners agree that it is appropriate and important for them to counsel patients to stop smoking, they are inconsistent in providing such advice. Reported barriers to counseling include a belief that such advice is ineffectual, a belief that most smoking patients are uninterested in counseling, a perceived lack of skills, and time constraints. However, studies have repeatedly found that brief, directive smoking interventions delivered during routine care are cost-effective and have the potential for significant public health benefit. A routine office visit for the treatment of eczema, flu, or indigestion can be used successfully to change smoking behavior, in the same way that it may also be used to screen for hypertension. These office-based smoking cessation practices are most effective when the smoking cessation interventions are viewed as essential components of good care. Just as measuring blood pressure at each office visit is now standard practice, so also should smoking status assessment and smoking cessation interventions be systematically integrated into standard office practice (22).
Motivating Smokers to Quit Smoking
Effective motivational counseling for smoking cessation recognizes that smokers cycle through several levels of readiness before attempting smoking cessation (see Fig. 4.1 in Chapter 4). Many factors can influence a smoker's progress through the stages of a change process. Life events, health symptoms, workplace smoking restrictions, and the price of a pack of cigarettes can all move a smoker closer to cessation. Alternatively, stress, weight gain, family problems, and smoking peers can act as barriers to change. The strong, directive advice smokers receive from their health care practitioner regarding the personal importance of quitting smoking is often one of the significant forces that move smokers closer to quitting.
Health concern is one of the most common reasons smokers cite as a motivation for quitting. Physicians and other practitioners can increase overall motivation for cessation by underscoring the personal relevance of quitting for that individual patient. The risks of smoking to both the smoker and his or her family can be highlighted, as well as the rewards of quitting, such as better health, saving money, improved vitality, and fewer wrinkles. And finally, because developing sufficient motivation for change may take a smoker months or years, the effort to motivate patients should be repeated at every clinical contact. Practitioners who consistently and repeatedly use these 4 Rs—Relevance, Risks, Rewards, and Repetition (Fig. 27.1)—and provide smoking patients with advice and encouragement to quit smoking over the course of their medical care are most likely to see success. This 4 Rs strategy should be used in conjunction with the actions outlined in Figures 27.2to 27.6.
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FIGURE 27.1. The 4 Rs Strategy: Components of clinical interventions to enhance motivations to quit smoking. (From the Agency for Health Care Policy and Research. Smoking cessation: clinical practice guideline, no. 18. [USDHHS] AHCPR Publication No. 96-0692. Washington, DC: US Government Printing Office, 1996. ) |
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FIGURE 27.2. ASK—Systematically identify all tobacco users at every visit. (From Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence: clinical practice guideline. Rockville, MD: US Department of Health and Human Services, Public Health Service, June 2000. ) |
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FIGURE 27.3. ADVISE—Strongly urge all tobacco users to quit. (From Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence: clinical practice guideline. Rockville, MD: US Department of Health and Human Services, Public Health Service, June 2000 .) |
After advising cessation, the clinician should assess the smoker's motivation, identify those patients who are willing to make a quit attempt, and determine the type of treatment they will accept (Fig. 27.4). For the unmotivated smoker, the clinician can attempt to enhance motivation for future cessation.
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Actions: Ask, Advise, Assess, Assist, and Arrange
The surgeon general's clinical guidelines (see http://www.hopkinsbayview.org/PAMreferences) for treating tobacco use and dependence were derived from rigorous review of approximately 3,000 scientific reports. Those satisfying scientific quality criteria were analyzed by meta-analytic techniques. This permitted the authors to synthesize outcome data from different smoking cessation treatments and to identify effective treatment elements. Based on this review, the authors concluded that brief interventions are effective in promoting smoking cessation; therefore, “Every patient who uses tobacco should be offered at least brief treatment.” The resulting guidelines for brief counseling are based on sound scientific evidence, and they recognize the time constraints on practitioners. These recommended practices are designed to require 3 minutes or less. They consist of five actions that are described more fully in the following paragraphs: Ask, Advise, Assess, Assist, and Arrange.
Office-based practitioners should systematically ask about tobacco use at every visit (Fig. 27.2). Clinicians are more likely to intervene with smoking patients when office procedures are designed to identify smokers and document smoking status. Smoking status should be considered a vital sign that is automatically collected, updated, and integrated into the permanent medical record.
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FIGURE 27.4. ASSESS—Determine willingness to make a quit attempt. (From Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence: clinical practice guideline. Rockville, MD: US Department of Health and Human Services, Public Health Service, June 2000 .) |
The clinician should next advise every smoking patient in a strong, direct, personalized manner of the importance of quitting smoking (Fig. 27.3). Even brief advice to quit smoking (3 minutes or less) will increase smoking cessation rates.
For patients interested in quitting smoking, the clinician should assist in formalizing a quit plan by setting a quit date within 2 weeks (Fig. 27.5). Brief counseling can encourage the patient to inform his or her family of the quit date, remove cigarettes from the environment before quitting, review previous quit attempts, identify aids and barriers, and anticipate challenges (e.g., withdrawal symptoms). Nicotine replacement therapy should be encouraged for most patients. Patients should be advised that total abstinence is essential, that alcohol should be avoided, and that smoking friends and family members should either join the plan to quit or not smoke around the patient.
Finally, for patients who have set a quit date, a followup contact should be arranged, preferably within 2 weeks after the quit date (Fig. 27.6). This contact can be used to reinforce success, troubleshoot problems, monitor nicotine
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replacement therapy, and recommend more intensive smoking cessation assistance if necessary.
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FIGURE 27.5. ASSIST—Aid the patient in quitting. (From Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence: clinical practice guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, June 2000 .) |
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FIGURE 27.6. ARRANGE—Schedule followup contact. (From Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence: clinical practice guideline. Rockville, Md: US Department of Health and Human Services, Public Health Service, June 2000 .) |
Dealing with Relapse
Risk of relapse is very high for patients who slip and have even one cigarette. Drinking alcohol, socializing with smokers, and high-stress events can all trigger relapse episodes. Patients should be counseled in advance about factors associated with the risk of relapse and reinforced in the continuing challenge of staying abstinent. If relapse occurs, it is important to reassure the patient that relapse is not an indicator that they cannot quit smoking, but instead a common event that most former smokers have experienced before successful quitting. A relapse experience is discouraging for a patient, but it can provide information on the risks and barriers to be addressed in the next cessation effort. Patients should be encouraged to retry cessation as soon as they are ready, and they should be encouraged to use more intensive interventions (e.g., multisession group programs, longer-duration pharmacotherapy) if acceptable (40).
Other Forms of Tobacco Use
This chapter focuses on cigarette smoking because it is the most prevalent form of tobacco use and has the greatest health impact. Other forms of tobacco use—cigars, pipes, snuff, and chewing tobacco—also have deleterious health effects (41). Mortality rates associated for these other forms of tobacco use are intermediate between those of cigarette smokers and those of nonusers of tobacco; for example, the total mortality rate of cigar or pipe smokers is approximately 15% to 20% higher than that of comparable nonsmokers. Site-specific cancer rates in the oral-nasal cavity are five times as great as in nonusers of tobacco, and there is increased risk of cardiovascular disease. Treatment approaches for these other varieties of tobacco dependence are the same as for cigarette smoking.
Health Care Professionals and Public Policy
The likelihood of success in overcoming addiction to nicotine is increased not only by the personal motivation and willpower of the cigarette smoker but also by a social and legal environment that encourages nonsmoking, restricts access to tobacco, increases the price of tobacco, and reduces the social acceptability of smoking. An increasing body of evidence supports the value of increased taxation on tobacco, restrictive smoking policies, and anti-tobacco advertising in reducing smoking prevalence in the community. Just as public policies that ensure clean water and adequate sanitation facilities have made dysentery and cholera rare diseases in this country, emerging public policies designed to restrict and control the use of tobacco may someday make smoking-related diseases rare, rather than the leading cause of preventable death. Tobacco use is as much a public health risk as the infectious diseases of the past century, and the primary care clinician should be a vocal member of the anti-tobacco activism within his or her community.
Specific References*
For annotated General References and resources related to this chapter, visit http://www.hopkinsbayview.org/PAMreferences.
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