Smoking is the single most preventable cause of premature illness and death, and we as health care providers must do our utmost to educate and support smokers.
Pharmacologic aids are recommended to everyone unless contraindiciated, and counselling should certainly also be provided. In fact, the combination of medication and counselling is synergistic, and is the current standard of care (US Public Health Service, 2008).
artwork by Nick Pereira; used with permission
While treatments are effective, unfortunately many patients will relapse. The various options provide alternatives for those who do not succeed on a given treatment.
Best practice includes intensive counselling and follow-up, with at least eight sessions. This has been difficult to translate into usual care, given the majority of health care delivery models. This includes lack of time for primary care providers, lack of funding for pharmacotherapy treatments, and difficulty coordinating care after hospital discharge.
Further work is therefore required to increase the implementation of strategies we know are very effective for people's health.
The benefits of quitting smoking are numerous. It prevents disease and reduces the impact for those who have already developed a disease or complication, especially cardiovascular disease or COPD.
Skull with a Burning Cigarette, Vincent Van Gough, 1886
Smoking cessation can cause weight gain and depression, at least in some. One study found former smokers were 4.4kg heavier for men and 5.0 kg heavier for women, compared with current smokers (Flegal et al, 1995).
Another study followed 100 smokers who had a history of major depression. Those who successfull quit had a higher rate of recurrent depression, OR 7.17 (95% CI 1.5-34.5) (Glassman et al, 2001).
Health care professionals should routinely ask all patients about their smoking status, including adolescents, adults, pregnant
Calculating pack years:
(#cigarettes smoked daily/20)
x (#years smoked)
women, and seniors.
In order to best understand behaviours, it is helpful to ask "Have you used any form of tobacco in the past six months? In the past 7 days?"
A formal screening system can have a large impact on cessation rates (US Public Health Service, 2008). All hospitalized patients should be screened for smoking status, as cessation programs started in the hospital have good success (see below).
Screening should also include an assessment of a patient's readiness to quit smoking. The stages of change include:
Where a person is at should help shape the approach taken. Every smoker should be offered support in quitting, but without judgement. Most smokers knows smoking is harmful, and can easily feel threatened if pushed too much.
Gain a deeper understanding of the smoking habit, asking about:
A cigarette contains approximately 2mg of nicotine, and various products can be used to provide nicotine to the body, to lessen withdrawal and provide psychological reward. This can be described as "breaking the social habit of smoking, while slowing weaning physiological dependence."
Nicotine Replacement Therapy (NRT) includes nicotine gum, patches, lozenges, nasal spray, vaporizers, and mouth spray. All have increase quit rates by 1.5-2 fold at 6 months in motivated patients. There is little evidence that one differs from another; however, the most effective regimen appears to be the patch plus another product (Stead et al, 2008).
It is critical to appropriately titrate the dose and duration in order to effectively address cravings.
These products are safe, though the gum can cause nausea, hiccups, and a sore jaw; the patch can cause headache, nausea, dizziness, and poor sleep; while inhalers can cause throat and nasal irritation, runny nose, sneezing, and coughing. A meta-analysis has shown no increase in cardiovascular events in people using NRT (Greenland, Satterfield, and Lanes, 1998).
Though costs are considerable, NRTs are a useful addition to anti-smoking endeavours. Smokers should be advised not to stop their NRT if they temporarily relapse.
There are two main medications that are used for smoking cessation.
While there are treatment algorithms that have been established, there is some rationale for utilizing medications as necessary, for as long as is necessary.
Buproprion (Zyban) was the first smoking cessation medication. It blocks norepinephrine and dopamine reuptake. A meta-analysis of trials comparing bupoprion with placebo or no treatment showed a doubling of quit success at six months or longer (Hughes, Stead, and Lancaster, 2007).
Zyban is typically started 1-2 weeks before quitting. An initial dose of 150mg is used for three days, after which a maintenance dose of 150mg BID is used. Treatment usually lasts 7-12 weeks.
Varenicline (Champix) is a partial agonist of nicotinic acetylcholine receptors, believed to be responsible for dependency. Varenicline is thought to reduce withdrawal symptoms through agonist effects, to reduce craving through antagonist effects, and to block pleasurable effects of smoking. A meta-analysis revealed a OR of 3.22 (95% CI 2.43-4.27) at 52 weeks vs placebo. In trials comparing varenicline to buproprion varenicline was more successful, with an OR of 1.66 (95% CI 1.28-2.16) (Cahill, Stead, and Lancaster, 2007). However, extensive exclusion criteria and substantial industry funding require caution.
Varenicline is typically started 1 week before quit date. The inital dose is 0.5 mg for 3 days, followed by 0.5mg BID for 4 days, and then 1mg BID for the remainder of the 12 week treatment.
Second-line agents include nortryptiline and clonidine. SSRIs are not helpful.
Both bupoprion and varenicline have been given a boxed warning by the US FDA for serious mental health events, including behavior, depressed mood, hostility, and suicidal thoughts (source: FDA). Patients should be warned of these, and signs should be monitored.
The most common side effects of buproprion are dry mouth and insomnia. Others include dizziness, difficulty concentrating, nausea, anxiety, constipation, shakiness, and rash. The risk of seizure is 1:1000, and is higher in those with seizure disorders or eating disorders. Side effects are related to dose; reducing the dose can therefore increase the tolerability.
The most common side effect of varenicline is nausea, and can be aided by taking with food. Insomnia and nightmares can also occur. Dose reductions can help this.
Varenicline is excreted by the kidneys and should be used with caution in patients with renal dysfunction.
There is good evidence that NRT can be useful with bupropion (Fiore et al, 2008). NRT and varenicline in combination are now being shown to work with increasing evidence, along with buproprion and varenicline together.
Use the five the 5 A's to help patients quit:
Brief advice has been shown to increase quit rates, and health care providers should talk with patients at every opportunity about their smoking, even for 5 seconds. With an unassisted quit rate of 2 to 3%, brief advice can increase quitting by a further 1-3% (Stead, Bergson, and Lancaster, 2008).
Some helpful intial statements include: Can we talk about your smoking? and What do you think about quitting smoking?
The STAR approach:
Giving patients their "lung age" - the age of the average nonsmoker with the same FEV1 as the patient - increases rates of sustained cessation for those who were not interested in quitting. Quit rates were 6.4% of the control group and 13.6% in the intervention group (P = .005) (Parkes et al, 2008). It can also be helpful to advise patients to "Check your pulse before and after a cigarette - It doesn't calm you down!"
Self-help materials, such as patient handouts, have a very small effect, but certainly don't hurt.
If patients are unwilling to quit, share the five R's with them:
Motivational interviewing has been used to help change many health behaviours, including smoking. It focuses on guiding the patient to change, exploring ambivalence and increasing attention to reasons and abilities for change. A central tenet is that patients' "change-talk" brings about much of the change.
An example of this is as follows: "On a scale of 1-10 where would you put yourself right now to try to quit smoking?" If under 7 then focus should be placed on increasing conviction & confidence. If 7 or over, offer options to help them quit.
A 2010 meta-analysis found, looking at 31 papers, that MI had an odds ratio of 1.45 (95% CI 1.14-1.83) compared to usual treatment. There was no difference noted on treatment duration (mean 1.5 hours), hours of staff training (mean 52 hours) or type of provider. The effect of MI was more significant among adolescents (OR 2.29) and non-existent among pregnant or post-partum women (OR 1.00). This suggests MI should be used preferentially in certain circumstances (Heckman, Egleston, and Hofmann, 2010).
German anti-smoking ad, 1941
"He does not devour it ...it devours him!"
While brief advice can be helpful, and should be offered, greater benefit comes with more in-depth efforts at supporting cessation.
The more counseling, the better, and high-intensity (>10 minutes) is more effective than low-intensity (3-10 minutes), with an OR of 2.3 (CI 2.0-2.7) vs 1.6 (1.2-2.0). As well, more sessions appear better, with eight sessions OR 2.3 (CI 2.1-3.0) vs two-three sessions (OR 1.4 (CI 1.1-1.7) (US Public Health Service, 2008).
Other intensive approaches include:
Of these, telephone counseling can be easily incorporated into primary care practice, by augmenting brief advice with a referral to the phone line.
The Ottawa Model is a program designed for primary care teams.
Ask: 30 seconds
Advise and refer: 2 minutes
Act: 10-20 minutes
It is important to ensure the following:
The Ottawa Heart Institute provides NRT very rapidly after admission, in order to minimize smoking and withdrawal symptoms.
There is substantial evidence that intensive, hospital-initiated programs which carry into the community can help patients who have suffered a heart attack and who want to quit, so much so that it is now considered 'best practice'. A successful intensive program has included 45-60 minutes of bedside education/counselling, followed by 7 nurse-initiated telephone counselling sessions after discharge. Counselling included patient-centred develeopment of behavioural, cognitive, and social support strategies for high-risk situations, while telephone counselling lasted 5-10 minutes and focused on reinforcement of the above strategies (Smith and Burgess, 2009).
In the above study, almost half of inpatients did not want to quit. Alternative strategies, such as motivational interviewing, could be used to increase ambivalence and move patients toward change.
A meta-analysis has shown that the postdischarge follow-up is critical for success, and with more than one month of support after leaving hospital, there was an 81% increase in odds of quitting (Rignotti, Munafo, and Stead, 2008).
Many incentives in health care are aimed at health care providers. As patient behaviour is increasingly responsible for health outcomes, however, it makes good sense to aim incentives at patients directly. This can come in the form of decreased health premiums or direct payments. Offering up to $750 increases participation in smoking cessation programs and quit rates 9-12 months after (14.7% control vs. 5.0% incentives group, P<0.001) (Volpp et al, 2009). The savings to employers of having their employees stop smoking is estimated to be about $3,400 USD per year due to as a result of increased productivity, decreased absenteeism, and a reduced incidence of illness (CDC, 2002).
Sugar, rum, and tobacco, are commodities which
are no where necessaries of life, which are become
objects of almost universal consumption, and which
are therefore extremely proper subjects of taxation. . . .
- Adam Smith, 1776, Book V, Chapter III, pp. 474
Due to the difficulties accompanying addiction, government intervention is useful. If only one intervention is taken, taxation has the greatest impact and is the most cost-effective. Taxation is an important means of reducing consumption while increasing revenues. For every 10% rise in price, tobacco use generally falls 2-10% (Chaloupka et al, 2000). This appears more true for smokers who are young or with low incomes.
Clean air laws protect non-smokers from the dangers of second-hand smoke, as well as encourage reduction or quitting of smoking.
Bans on advertising can reduce consumption. In countries where advertising is permitted, tobacco companies make advertising and promotion their single largest item of expenditure, often exceeding costs of raw tobacco leaf. (WHO, 2002).
Education, through warning labels, advertising, and other approaches are needed to reach the many people who do not fully understand the risks of tobacco use and benefits of quitting. Important efforts include:
Graphic health warnings through pictures on cigarette packs began in Canada and are being used increasingly around the world. These appear to have a stronger influence on smokers in low-resources countries, perhaps in part due to the effectiveness in communicating with patients with low literacy (Fong et al, 2009).
Anthonisen NR, Connet JE, et al. 1994. for the Lung Health Study Research Group. Effects of smoking intervention and the use of an inhaled anticholinergic bronchodilator on the rate of decline of FEV1. The Lung Health Study. JAMA. 272:1497-1505.
Chaloupka FJ, Hu TW, Warner KE, Jacobs R, Yurekli A. The taxation of tobacco products. In: Jha P, Chaloupka FJ, editors. Tobacco control in developing countries. Oxford: Oxford University Press; 2000. p.237-72.
Myung SK, McDonnell DD, Kazinets G, Seo HG, Moskowitz JM. 2009. Effects of Web- and computer-based smoking cessation programs: meta-analysis of randomized controlled trials. Arch Intern Med. 169:929-37.
Surgeon General. 1990. The Health Benefits of Smoking Cessation: A report of the Surgeon General. U.S. department of Health and Human Services (DHSS), Public Health Service (PHS), Center for Disease Control (CDC), Centre for Chronic Disease Prevention and Health Promotion, Office of Smoking and Health, DHSS Publication No. (CDC) 90-8416.
PHS Guideline Update Panel, Liaisons, and Staff. Treating tobacco use and dependence: 2008 update U.S. Public Health Service Clinical Practice Guideline executive summary. Respir Care. 2008;53:1217-22.