S T R A T E G I E S
By Thomas L. Petty, MD
Changing smoking habit patterns and the use of smoking
cessation pharmacological agents are effective strategies in helping
patients kick the nicotine habit.
Because of the compelling addiction to
tobacco and the success of the tobacco industry in recruiting new
smokers to the ranks of the habituated, approximately 47 million
Americans continue to smoke. Women are rapidly catching up with men.
Most adult smokers say that they would like to quit, but because of lack
of knowledge, inertia, or perhaps inadequate involvement by healthcare
professionals, they neither try nor succeed in quitting. The purpose of
this article is to present a pragmatic approach to smoking cessation.
Smoking is a compelling addiction, as
powerful as narcotic or alcohol abuse. Smoking also contains a major
social component. Together, addiction as well as smoking with friends
and in many social circumstances, pose potent challenges for smoking
Most people quit on their own for
socioeconomic or health reasons. The immediate social rewards are better
odor of clothing and breath, and saving money. Avoiding premature
wrinkles of the face is another payoff, which should be promoted in the
young. Protecting the health of children, including aggravation of
asthma, and childhood respiratory infections, is a motivating force for
A physician or other healthcare
worker=s advice to a patient
to stop smoking, which requires only a few minutes, will often achieve a
3% to 5% quit rate. Patients must decide to completely quit and progress
through the sequential stages of decision- making: precontemplation,
contemplation, action, and maintenance. The precontemplation stage, of
course, is not recognized by the individual. By the time patients plan
to stop, they are in the contemplation stage, and can then be directly
assisted by a healthcare professional. The choice of a quit date, along
with changing the smoking/social habit pattern, is an important
approach. Quitting Acold
turkey@ is the most successful
way of stopping. Maintenance of a smoke-free state through relapse
prevention needs to be taught and encouraged.
PREPARING TO QUIT
Behavior modification needs to be
offered to all patients whether or not pharmacologic agents are
prescribed as a part of the stop-smoking strategy. Behavioral
modification deals with the changing of habit patterns that results in
cues to start smoking. Often, these cues are not even recognized by the
individual. These may be as simple as a telephone call, a coffee break,
a pleasant meal, or following sexual activity. Sometimes boredom, delays
in traffic, or other frustrations are signals to light up once again.
The most addicted smokers light up immediately when waking up and find
the first cigarette of the day the most necessary and pleasing. Smoking
more than one pack a day also identifies the heavily addicted smokers.
The quit date should be coordinated
with the use of smoking cessation pharmacological agents. The quit date
may be some special occasion such as a holiday, or anniversary.
Stressful times, such as tax deadlines, just before final examinations,
or a job interview, are not preferable. Pharmacologic strategies differ
and depend on the class of drug used to deal with the nicotine
withdrawal symptoms. For example, if nicotine replacement is used, it
should be started on the quit date. In contrast, if bupropion is
prescribed, this drug should be started approximately 2 weeks before the
Nicotine withdrawal results in many
unpleasant symptoms. These include a craving for tobacco, irritability,
anxiety, poor concentration, restlessness, headache, drowsiness, and
A number of drugs are useful in
nicotine withdrawal. Nicotine replacement products, an antidepressant,
and anxiolytics offer different pharmacologic strategies in the
management and prevention of the symptoms of nicotine withdrawl.
Nicotine gum is preferred by many and comes in two sizes (see Table I).
Thus, the gum allows the patient to titrate their own rate of nicotine
absorption through the buccal mucosa by the route of chewing and the
frequency of gum use. It is important for the mouth to have a neutral pH
for absorption of nicotine. Thus, nicotine gum should not be used
immediately after eating food, drinking soda, etc. On average, one piece
of gum is chewed per hour while the patient is awake. Side effects
include throat irritation, flatulence, and a sore jaw from excess
mastication. The most addicted smokers should receive the 4-mg gum.
The transdermal patch is more
convenient. Different patch dosage strategies are available. These are
listed in Table 1. The patch is often used for 6 weeks. There have been
no comparisons between the effectiveness of the various strengths of
Pharmacological agents useful as adjuncts to smoking
nicotine patch, 3 types
||21 mg, 14 mg, 7 mg 15
mg, 10 mg, 5 mg 22 mg, 11 mg
||Over 24 hours Over 16
hours Over 24 hours|
||8-40 mg/day in hourly
or PRN* dosing|
||10 mg per
||10 puffs over 10
minutes. Delivers approximately 1-mg nicotine|
||150 mg for 3 days, then 300 mg (2
tablets) each day|
||15 mg, 10 mg, 5 mg
||7.5-mg b.i.d., starting dose 60
mg/day, maximum dose|
|* PRN = as occasion
A new nasal spray is available by
prescription. It can be used instead of gum or patch, or used in
conjunction with other nicotine-containing products. A nicotine inhaler,
which looks very much like a cigarette holder, has nicotine impregnated
in menthol. It will give immediate relief from nicotine withdrawal
symptoms in many patients.
Non-nicotine replacement products include
bupropion, which is a neurotransmitter modifier.1 Bupropion
has dopaminergic features. It should not be used in patients with a
seizure history or hypertension that is difficult to control with
medications. Bupropion can also be used with nicotine replacement. Up to
a 50% quit rate has been claimed when buspirone and nicotine replacement
are used together.
Buspirone, a non-benzodiazepine
tranquilizer, is also useful in dealing with nicotine withdrawal. In one
controlled trial, its success was equal to nicotine-containing
Other methods of dealing with the most addicted
smoker include acupuncture and hypnosis. These are successful in
selected patients. Demonstrating the presence of exhaled carbon
monoxide, which is available through many hospitals= respiratory departments, may also
convince smokers that poisonous levels of carbon monoxide are associated
with daily smoking of tobacco.
STRATEGIES IN SMOKING
The first step in smoking
cessation is for the patient to decide to quit. Seeking advice from a
health care practitioner can be very helpful. Using the comprehensive
booklet, AYou Can Quit
Smoking,@ produced by the
Agency for Health Care Policy and Research, is an excellent educational
aid. It is available by calling (800) 358-9295.
Many hospital libraries offer patient
information services through their computer networks. Additionally, many
homes now have personal computers and are able to search the Internet
for clues in stopping smoking. Key words are Atobacco cessation,@ Asmoking cessation,@ and Aquitting smoking.@
Many addicted patients fail on the first or
subsequent attempts to stop smoking. Failure should not be regarded as
an indication of futility. In fact, the more often the patient tries to
quit, the more the chances for success. On average, five to seven
failures occur before the patient succeeds in stopping.
Concerns of smokers about stopping
include the problems of weight gain and depression. Weight gain is a
concern, particularly in women. Many women use nicotine as a weight
control measure. Nicotine replacement helps mitigate weight gain, which,
on average, is 10 pounds over the first 6 months. This weight gain can
be controlled through exercise, however. Exercise itself, may reduce the
craving for tobacco.
Some women also use nicotine to combat
depression. Thus, depressed patients who are candidates for smoking
cessation must be closely counseled by their health care professionals.
If the possibility of worsening depression is a realistic consideration,
bupropion is also used as an antidepressant. This drug may be
particularly useful in women who are on the verge of depression while
The money caved over a lifetime by not
purchasing tobacco products may be $15,000 to $20,000. Reducing the risk
of heart attack, lung cancer, stroke, and chronic obstructive pulmonary
disease (COPD) is also a major payoff.
Today, we need a grassroots
effort in smoking cessation. Such an effort may be the result of the new
National Lung Health Education Program, which aims to identify smokers
at risk of developing symptomatic COPD and associated diseases of lung
cancer, heart attack, and stroke. All of these disease states have a
much greater prevalence when airflow obstruction is present than when it
is normal. Thus, the spirometer becomes a tool in early identification
of the four most common killers in the United States.3
Knowledge of spirometric abnormalities can also help encourage smoking
Thomas L. Petty, MD, is chairman of
the National Lung Health Education Program and professor of medicine,
University of Colorado Health Sciences Center, Denver.
1. Hurt RD, Sachs DP, Glover ED, et al. A comparison
of sustained-release bupropion and placebo for smoking cessation. N
Engl J Med. 1997;337:1195-1202.
2. Hilleman DE, Mohiaddin SM, Delcore MG. Comparison
of fixed-dose transdermal nicotine, tapered-dose transdermal nicotine,
and buspirone in smoking cessation. J Clin Pharmacol.
3. Petty TL. Spirometry for all. RT Magazine.
Journal for Respiratory Care Practitioners/RT C 13:49-51.