By: Thomas L. Petty, M.D.
The huge impact of morbidity and
premature mortality caused by tobacco smoking, primary cigarette
smoking, continues. Many teenagers begin smoking despite efforts to
discourage them, and about 47 million Americans continue to smoke --
percentages are increasing among women -- despite efforts to help the
70% of smokers who want to quit. These smokers are addicted to tobacco
and claim that they do not know how to quit.
Although > 70% of smokers
consult their physicians at least once per year for some reason, many
have never been asked about smoking or advised to quit by their
physician. To initiate smoking cessation and to offer practical and
effective advice about smoking cessation, physicians must first inquire
about a patient's smoking habits. Of patients who quit, 90% do so on
their own. But, in any given year, only about 1.7 million smokers (3.6%)
successfully quit. Studies have shown that a physician's advice to stop
smoking, which requires only about 3 to 5 minutes, may achieve a quit
rate of 3% to 5%. However, when the physician's advice is supported with
follow-up visits and drugs, quit rates of 20% or 25% may be expected
Tobacco addiction includes a habit or a
social component and physical addiction that combine to present a
formidable challenge to smoking cessation. Studies have shown that
tobacco addiction is more severe than alcohol addiction and at least as
binding as narcotic addiction.
The severity of tobacco addiction is
important to assess when developing smoking cessation strategies.
Although complex addiction scoring estimates are available, addiction
severity correlates with the time of day the first cigarette is smoked,
the most important cigarette of the day, and the number of cigarettes
smoked daily. Patients who smoke within minutes of arising, or even
before getting out of bed, and whose first cigarette of the day is the
most important are often severely addicted. Those who also consume >
1 pack/day of cigarettes have the highest addiction scores.
Advantages of quitting: Most smokers who
quit do so for health reasons (see Table1) or economic reasons. Most
smokers do not realize that, on average, 7 minutes of life are lost with
each cigarette smoked. Thus, depending on the age that a person starts
to smoke, or stops, about 7 to 13 years of life are lost due to
smoking-related diseases. The most common fatal smoking-related diseases
among North Americans and Europeans are arteriosclerosis (which results
in myocardial infarction, stroke, and peripheral vascular disease);
lung, pancreatic, bladder, uterine, laryngeal, esophageal, and,
probably, breast and colon cancers; and COPD (emphysema, chronic
bronchitis). These facts must be simply explained to the addicted
Table 1: HEALTH BENEFITS OF SMOKING
Effect of Smoking Cessation
|Myocardial infarction (MI)
Lung function deterioration
|Reduces risk to that of a non-smoker in
about 1 to 2 years.
Reduces risk to that of a non-smoker in 1 to 3 years.
Slows the rate of decline to that associated with age alone.
Reduces the risk to baseline only after 10 to 20 years.
Mitigates the risk of progressive and symptomatic disease.
In terms of economic benefits, smokers
who quit may save > $2/day by not purchasing cigarettes (as
much as $15,000 to $20,000 over a lifetime). Also, costs are further
reduced by fewer instances of burned clothing, furniture, carpets, and
Additional incentives for quitting
include social rewards such as better smelling clothing or breath and
improved appearance (avoidance of premature wrinkling of the face). Some
smokers quit when they learn about the adverse effects of secondhand
smoke on the health of their children (e.g., increased ear and
respiratory tract infections, aggravation of asthma).
Airflow assessment: The newly
developed National Lung Health Education Program, sponsored by
government and professional medical organizations, was designed to
identify early stages of airflow obstruction (i.e., COPD and related
disorders) in smokers. Spirometry of airflow and air volume (i.e.,
forced expiratory volume in 1 second, forced vital capacity) can
indicate whether smokers already have impaired airflow, and this
information may be a potent motivator for smoking cessation. Tracking
airflow over time in a patient who continues smoking or stops smoking is
a powerful indicator of prognosis. A strong public health message is
being prepared to urge all smokers to "Test your Lungs, Know Your
Numbers." The aim is to help smokers at greatest risk (i.e., those
beginning to lose airflow).
Smokers trying to quit go through
stages: pre-contemplation, contemplation, action, and maintenance. The
pre-contemplation stage is not recognized by the patient. Smokers
beginning to plan how to quit can benefit from a physician's assistance.
Selecting a quit date, changing the smoking habit pattern (through
behavior modification), and quitting "cold turkey are important
sequential steps. Physicians must teach and encourage maintenance of a
smoking-free stage and relapse prevention.
Role of the physician: The first step
for the physician in smoking cessation is to simply but seriously advise
smoking cessation and to offer smoking cessation books. Chart reminders
documenting patients' smoking status increased counseling of smokers to
70% and doubled the proportion of all patients counseled. Documentation
of smoking cessation counseling is a part of the Health Plan Employer
Data and Information Set (HEDIS) guidelines used by managed care
organizations. The Agency for Health Care Policy and Research publishes
a booklet for patients, "You Can Quit Smoking," and information for
physicians, which are available free of charge by calling
1-800-358-9295. Many hospital libraries have computer networks that
patients can use to obtain information; also, millions of persons have
personal computers and can search the Internet, which has many valuable
educational sites for smokers interested in quitting (using the key
words tobacco cessation, smoking cessation, and quitting smoking). If
patients can stop on the advice of a physician and through behavior
modification with the assistance of these practical instructional
materials, the expense and adverse effects of drugs may be avoided.
Success also has been reported anecdotally with acupuncture and hypnosis
in selected patients.
Exhaled carbon monoxide testing,
available through some hospital respiratory therapy departments, may
convince the smoker of the poisonous effects of inhaling cigarette or
cigar smoke. This test should be performed on admission because the
decay curve for carbon monoxide is rapid. Many respiratory therapy
departments offer smoking cessation advice and instruction.
Selection of a quit date: Selection of a
quit date is key and should be coordinated with the use of drugs for
tobacco withdrawal (see below). The quit date may be random or on a
social occasion (e.g., a holiday or anniversary); a stressful time
(e.g., tax deadlines) is usually not preferable for a quit date.
Strategies differ depending on the class of drug used. For example,
nicotine replacement, if used, should be started on the quit date,
whereas bupropion, if prescribed, should be started between 1 and 2
weeks before the quit date. The same may be true with other drugs that
reduce the tobacco withdrawal syndrome (e.g., buspirone).
Behavior modification needs to be offered to all patients,
whether or not drugs are prescribed for tobacco withdrawal (see below).
Behavior modification deals with changing the habit patterns that are
cues to smoking in the patient's normal activities of daily living.
These cues may be phone conversations, coffee breaks, meals, sexual
activity, boredom, traffic problems, or other frustrations. Patients who
recognize smoking cues may modify the cues or substitute oral activity
(e.g., sucking on candy, chewing on a toothpick, using ordinary chewing
Quitting cold turkey: Absolute
stopping, known as quitting cold turkey, is generally preferable to
Drug treatment: Many
over-the-counter and prescription nicotine replacement products are
available (see Table 2). Nicotine polacrilex, available as chewing
gum (2 and 4 mg), is widely used and allows patients to titrate the
rate of nicotine absorption. Use of the gum allows for maximum dosing
flexibility and mimics some of the oral activities of cigarette smoking.
Nicotine is absorbed through the oral mucosa, but only in the setting of
an alkaline pH. Thus, for 30 minutes before using the gum, the patient
should not consume anything by mouth (e.g., soda, coffee, tea, acidic
juices, food). The gum is chewed and parked between the teeth and oral
mucosa depending on the sensation of relief of withdrawal symptoms. The
most severely addicted patients should chew 4-mg gum. Use of the gum
usually continues for 1 to 3 months, depending on the success in smoking
Table 2: DRUGS USED FOR SMOKING
Drug and Method of Administration
||2 - 4 mg
||Every 1 - 2 hours*|
||21, 14, and 7 mg
15, 10, and 5 mg
22 and 11 mg
|Over 24 hours
Over 16 hours
Over 24 hours
|Nasal nicotine spray
||8 - 40 mg/day in hourly
or prn dosing|
||Continuous puffing for 20
6 - 16 times/day
||150 mg for 3 days, then
||15, 10, and 5 mg
||7.5 mg bid, starting
60 mg/day, maximum dose
|*Fifteen to 30 pieces may
be chewed over 24 hours.|
The most common adverse effects are
gastric irritation and hiccups if the gum is chewed too vigorously.
Other adverse effects are throat irritation, flatulence, and the gum
sticking to the teeth. Temporomandibular joints may become painful from
excessive chewing. Edentulous patients and patients with
temporomandibular joint disease are not candidates for nicotine gum.
Addiction to the gum is rare. Thus far, all studies of nicotine
replacement do not report increased blood pressure, altered serum
lipids, or cardiac arrhythmias.
When the gum is used with aggressive
behavior modification, success rates at 1 year (which are biologically
proven by measuring exhaled CO2 or cotinine, a nicotine
metabolite) can be 20% to 25%. Casual use of the gum without behavior
modification is generally ineffective.
Use of a transdermal patch is a
more convenient way of delivering nicotine. Different patch dosing
strategies are available (see Table 2). Either a single stable dose or a
decreased dose may be used at 2-week intervals. No comparison studies
have shown that any patch dosing strategy is superior. The patch may
cause skin irritation.
Commonly, the patch is used daily for 6
weeks, but smoking cessation, if achieved, usually occurs within 2
weeks. The success of the patch also depends, in part, on the degree of
associated behavior modification. In general, the patch will double the
cessation rate with any level of behavior modification. A 20% to 25%
confirmed cessation rate at 1 year is possible.
A prescription nasal spray can
be used alone or in conjunction with the gum or patch. All three agents
can be used simultaneously to provide nicotine, but no studies have
indicated greater success with combined nicotine dosing forms.
Generally, when used alone, gum, patch, or spray produces lower blood
levels than peaks achieved through smoking (a cigarette smoked for about
10 minutes provides 1 mg of nicotine). Use of multiple nicotine
replacement products can produce higher nicotine blood levels and may be
necessary in the most heavily addicted patients.
A nicotine inhaler, which looks
like a cigarette holder, has nicotine impregnated with menthol. Nicotine
inhalers more faithfully duplicate the way smokers obtain nicotine. Each
inhalation produces a small amount of nicotine; 40 to 80 puffs are
needed to produce 1 mg of nicotine, the equivalent of smoking one
agents include bupropion, a neurotransmitter modifier, which has
dopaminergic properties. Bupropion has a tendency to incite seizures and
may elevate blood pressure and is therefore not recommended for patients
with a seizure history or with difficult-to-control hypertension. When
bupropion has been used with nicotine replacement, up to a 50% cessation
rate was proven biochemically at 1 year under study conditions and may
or may not be duplicated in the primary care physician's office. The
most common adverse effects are dry mouth and insomnia.
Buspirone, a nonbenzodiazepine
tranquilizer, may help patients with tobacco withdrawal anxiety. In one
controlled clinical trial, success rates with buspirone and nicotine gum
were equal. Other tranquilizers may also be useful.
PROBLEMS ASSOCIATED WITH
Tobacco withdrawal may result in many
unpleasant symptoms, including craving for tobacco, irritability,
anxiety, poor concentration, restlessness, headache, drowsiness, and
stomach upset. Tobacco withdrawal is most troublesome in severely
Many tobacco addicts relapse
after the first attempt at smoking cessation; five to seven failures
commonly precede success. Failure should not be regarded as an
indication of futility. The more often a patient makes a serious attempt
to quit smoking, the more likely the patient ultimately will succeed.
Different strategies of behavior modification and various treatment
modalities often are necessary.
Weight gain is a concern,
particularly in women, who may use tobacco as a weight control measure
because it suppresses appetite and slightly increases the basal
metabolic rate. The average weight gain in women over the first 6 months
is about 10 pounds (5 kg). This modest weight gain is not a health
hazard compared with the risk of morbidity and premature death from
continued tobacco use. Dietary consultation, nicotine replacement, and
increased exercise coincident with smoking cessation can help prevent
weight gain. Exercise may also reduce the craving for tobacco.
Some smokers use tobacco to combat
depression. Thus, depressed patients who attempt to quit smoking
must be counseled, and the physicians and patient need to be alert to
the possibility of worsening depression. Bupropion is also widely used
as an antidepressant and may be particularly useful in persons who are
depressed or at risk of depression.
Beers MH, Berkow R: (eds) The Merck
Manual of Diagnosis and Therapy. Merck Research Laboratories.
Whitehouse Station, NJ 1999 Chapter 290, pp