Quitting smoking: Still a challenge, but newer tools show promise

WHEN IT’S TIME TO QUIT

A useful prescribing plan is:

• For most people, begin with nicotine patches plus gum
• If nicotine replacement therapy fails, prescribe varenicline
• Prescribe bupropion for patients with depression or if varenicline fails.

According to the US Public Health Service guideline,¹² in a meta-analysis comparing various tobacco cessation medications with placebo and nicotine patch, the combination of nicotine patch (> 14 weeks) plus gum was 3.6 times as effective as placebo and 1.9 times as effective as nicotine patch alone. Varenicline at 2 mg per day was 3.1 times as effective as placebo and 1.6 times as effective as nicotine patch alone. Therefore, the combination of nicotine patch and gum is an inexpensive yet effective way to begin a course of smoking cessation therapy.

Behavioral counseling

Timing is important to successful quitting. Patients generally know when it’s a good time to quit—and when it’s not. Avoid trying to get patients to quit when they are stressed, overly busy, fatigued, or anxious. Try to get the patient to set a time to quit that’s ideal, and then encourage the patient to stick to it. For example, scheduling the quit day on a celebration, anniversary, or birthday gives that date added significance and enhances motivation. Follow the patient frequently for 6 to 12 months with intense monitoring and encouragement, and to assess for any adverse effects of medication.

In July 2009, the FDA issued boxed warnings for bupropion SR and for varenicline because of neuropsychiatric symptoms

The 2008 update to the Public Health Service Clinical Practice Guidelines on treating tobacco use and dependence concludes that counseling and medication are each effective alone in increasing smoking cessation and are even more effective when used together.¹² Even very brief, 3-minute discussions and encouragement have been shown to be helpful. The Public Health Service evidence-based clinical practice guideline on cessation states that brief advice by medical providers to quit smoking is an effective intervention.¹²

Doctors who show great interest in smoking cessation seem to be more effective in persuading patients to quit. They should take note of smoking rather than ignoring it. A modified version of the CAGE questionnaire to assess problem drinking is recommended as a tool to assess patients’ smoking behavior and initiate a discussion about it (Table 1).²² Emphasize the health and financial costs to the patient. Try to form a therapeutic alliance with the patient against smoking: “Let’s see what we can do about this problem.” Be positive and optimistic in offering help with counseling, support, and medications.

Caution smokers against switching to “light” tar and nicotine cigarettes, as controlled experiments have failed to show consistent reductions in the amounts of tar and nicotine these products deliver into the lungs. Smokers also appear to compensate or adapt their smoking habits to increase the yield from these products. There is insufficient evidence to support the supposed health benefits of such low-yield smoking products.²³

Always refer the patient for counseling with the pharmaceutical company help line or with a supported quit line. Some manufacturers of smoking cessation medications offer counseling or web-based support for patients trying to quit. For example, patients who are prescribed varenicline are offered the GETQUIT Plan, a free program that includes online education, tracking of progress, and “check-ins with slip-up support.” These services are often underused yet represent a ready source of helpful support.

If relapses occur, encourage the patient to keep trying again and again, as it may take several attempts to succeed.

Quit lines

To help smokers and other tobacco users quit, all states now have a toll-free cessation quit line, a telephone service accessible through a national toll-free number (1-800-QUIT-NOW). Quit lines also can be a referral source for health care providers who might not have the time or staff to provide all of the steps in the recommended “five-A” cessation counseling model,¹² ie:

• Ask about tobacco use
• Advise to quit
• Assess willingness to make a quit attempt
• Assist in quit attempt
• Arrange follow-up.

Quit lines have been shown to improve outcomes when compared with people trying to stop on their own.¹² Quit line services have evolved from their modest beginnings as providers of information and counseling to a level at which  in many states, evidence-based medications are provided through quit lines.^13,24 Medication use, coupled with quit line counseling intervention, increases the likelihood of tobacco abstinence and is consistent with US Public Health Service guideline recommendations that all tobacco users should be offered at least one medication as part of their quit attempt.¹²

WOMEN SMOKERS HAVE UNIQUE HEALTH RISKS

Women have unique health risks arising from smoking: low-birth-weight babies, sudden infant death syndrome, cervical cancer, and an increasing rate of lung cancer. In general, women have poorer responses to nicotine replacement therapy, are more concerned about gaining weight after quitting, and demonstrate more mood lability after quitting. Women seem more energized by the taste, smell, and overall sensations involved in smoking.

Weight gain will occur when quitting smoking; this is hard to overcome. More exercise may help, and a trial of bupropion with nicotine replacement therapy may mitigate weight gain.

Women who are pregnant present a special challenge when it comes to weighing the benefit of medications against continued smoking. For pregnant women who want to quit smoking, the best treatment is counseling without nicotine replacement or other pharmacotherapy. There are inadequate data for the use of varenicline or bupropion in pregnancy. If medication is needed, start nicotine replacement therapy early in pregnancy, as its risk is the same as or less than the smoking risk to the fetus.

Smokers say it is much easier to quit after 7 days on varenicline

The US Public Health Service guideline provides a useful discussion and bibliography related to this topic.¹² All of the FDA-approved medications for tobacco cessation carry an FDA pregnancy category designation of C or D—ie, not recommended for use by pregnant women. These designations are not absolute contraindications and do allow for use in life-threatening situations or when other treatment modalities have failed. Some clinicians and their patients may decide that the potential for fetal harm, including fetal death, with continued smoking is high enough to warrant use of medications.

A careful and thorough discussion of the risks and benefits is recommended between the patient and her physician regarding this issue.

A CALL TO ARMS

The statistics are incontrovertible but do not tell the whole story. The day-to-day practices of physicians bear witness to the suffering that compulsive smoking creates for the smoker. As in all addictions, those around the addict suffer as well, from secondary smoke but also from fear and anxiety about premature loss of their loved ones. Smoking causes suffering and early death, and it is vitally important that doctors—the front-line troops—take up the fight against it as America’s number-one preventable cause of health problems and death.

To be effective champions in the public health fight against smoking, doctors must develop an understanding of compulsive smoking as a biologically driven process of addiction. The smoker attempting to quit is literally in the fight of his or her life and needs emotional support, cognitive-behavioral tools, and state-of-the-art pharmacology to overcome the slow destruction caused by the “dirty weed.”