National Lung Health Education Program

SMOKING CESSATION

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 (see below).

TOBACCO ADDICTION

    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 smoker.
 

Table 1: HEALTH BENEFITS OF SMOKING CESSATION
Risk
Effect of Smoking Cessation
Myocardial infarction (MI)

Stroke

Lung function deterioration

Lung cancer

Other cancers

COPD

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.

Unknown

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 automobile upholstery.

    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).

INITIAL MANAGEMENT

    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: 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 gum).

    Quitting cold turkey: Absolute stopping, known as quitting cold turkey, is generally preferable to tapering off.

    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 cessation.
 

Table 2: DRUGS USED FOR SMOKING CESSATION
Drug and Method of Administration
Unit Dose
Dose Interval
Nicotine polacrilex (oral) 2 - 4 mg Every 1 - 2 hours*
Transdermal nicotine patch 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 0.5 mg/inhalation/nostril 8 - 40 mg/day in hourly or prn dosing
Nicotine inhaler 10 mg/inhaler Continuous puffing for 20 minutes 
6 - 16 times/day
Bupropion sustained-release tablets 150 mg 150 mg for 3 days, then 300 mg/day
Buspirone tablets 15, 10, and 5 mg 7.5 mg bid, starting dose; 
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 cigarette.

    Non-nicotine pharmacologic 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 SMOKING CESSATION

    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 addicted patients.

    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 2486-2490.

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