Don't Quit on a Quitter: Helping Your Patient Stop Smoking
With November 2012 bringing the American Cancer Society’s 37th Great American Smokeout, nearly one-fifth of Americans continue to smoke cigarettes. The unmet tobacco-related goals of Healthy People 2010 have had to be reintroduced in hope of greater success for 2020. The primary care clinician must be aware of all the resources available to help smoking patients quit—and mindful of the clinician’s own role in that important effort.
Nicotine transdermal patches have been used in the US since 1991. The patches are used in a stepwise fashion; each patch delivers nicotine at a consistent quantity per hour, and over time, patches with increasingly lower doses of nicotine are substituted. There is some evidence that the patch is more efficacious for maintenance after smoking cessation than for the initial effort to quit.18
Nicotine gum and lozenges, orally absorbed forms of NRT, are used as needed, depending on patients’ withdrawal symptoms. Japuntich et al18 found that these products alone are not beneficial. However, combining bupropion with gum or lozenge therapy was found more effective for patients attempting to stop smoking than either agent alone.18 Lozenges have also been described as increasingly beneficial when combined with a longer-acting NRT, such as a transdermal patch, when cravings increase and rapid delivery of nicotine is required.16
The electronic cigarette (e-cigarette) is a battery-operated device that aerosolizes liquid nicotine, which is then orally absorbed. In a 2011 study, Siegel et al19 found that more than two-thirds of smokers reduced the number of cigarettes smoked after using an e-cigarette. Six months after subjects first purchased e-cigarettes, 31% remained tobacco-abstinent.
Since e-cigarettes are flameless, their use has been suggested in areas where smoking was previously prohibited. This short-acting NRT may benefit a patient when craving is provoked by forced denial of nicotine.
Current research is under way to examine two newer potential NRT tools: a nicotine mouth spray and a nicotine vaccine.20,21 In a randomized, double-blind, placebo-controlled study, Tønnesen et al20 found that use of a nicotine mouth spray was associated with significantly higher rates of tobacco abstinence at six, 24, and 52 weeks, compared with patients receiving placebo; however, rates of adverse effects were high in both groups (88% and 71%, respectively).
NRT is inexpensive and easily accessible to patients. Since its forms are all available OTC, consultation with health care providers is unnecessary. For patients who have tried to quit smoking unaided and who need short-term or immediate assistance to prevent a smoking relapse, NRT can be a helpful resource.
Bupropion
For smokers who want to quit without using a nicotine-based intervention, the antidepressant bupropion can be a promising smoking cessation aid. It is not clear what mechanism of action helps smokers who take bupropion to stop, although its chemical structure resembles that of diethylpropion, a drug used as an appetite suppressant.22 Bupropion does hinder norepinephrine and dopamine reuptake in the nervous system—opposing an effect of nicotine withdrawal.
Bupropion’s effects as an antidepressant and as a smoking cessation aid do not appear to be related.22 For this reason, even a patient who has not responded to bupropion for treatment of depression may benefit from using it as a smoking cessation aid.
Bupropion may be used alone or with other agents to stop nicotine use. Many study groups report that a combination of medications is more effective than monotherapy, and this is true for combinations that include bupropion.23-26 When used with nicotine lozenges, bupropion has been found effective in preventing a return to tobacco after previous lapses in smoking abstinence. Aside from a nicotine patch, no other monotherapy or combination was effective at achieving this goal.18 Thus, bupropion may be best utilized as a component in combination therapy.
Varenicline
Approved for use in the US in 2006, varenicline is the newest pharmaceutical therapy for smoking cessation. As a partial nicotinic receptor agonist,7 varenicline prevents nicotine from activating the mesolimbic dopamine system, which is associated with pleasure and reward (among other functions). By stimulating the nervous system’s dopamine (though to a lesser extent than nicotine), this agent reduces cravings for tobacco and symptoms of nicotine withdrawal—which are among the greatest barriers to smoking cessation.10 Because of its mechanism of action, varenicline is not often used in combination with NRT.
Varenicline has been shown to be as effective as the combination therapy of bupropion with nicotine lozenges.7,27 UK investigators Hajek et al27 found that using varenicline for four weeks before attempting to stop smoking had minimal effect on smoking urges and withdrawal symptoms, compared with using varenicline for just one week before attempting to quit. However, those who used varenicline for four weeks before stopping smoking were more likely to be smoke-free at 12 weeks than those who had used it for just one week before quitting.27
Other Pharmaceutical Options
Clonidine, long recognized as an effective antihypertensive medication, was determined by Gourlay et al9 in a 2004 review to have potential for use in supporting smoking cessation. Because significant adverse events (including drowsiness, sedation, and postural hypotension) have been associated with clonidine use7,28 and the FDA has not yet approved it for the indication of smoking cessation, its use may be most appropriate as a second-line treatment option, in combination with bupropion or nortriptyline, or for specialists’ use.28 Clonidine should not be discontinued suddenly.
