1. SMOKING CESSATION
Anju Mattoo, M.D.

2. Learning Objectives
Appreciate the significance of smoking cessation as a means of reducing a major threat to public health.
Learn about the attitudes and policies that can have a major impact on smoking behavior.
Review the various strategies available for smoking cessation.
Role of drug therapy in achieving successful smoking cessation.

3. Introduction
Cigarette smoking responsible for 5 million premature deaths worldwide (2000).
In the US - the major preventable cause of disease; results in more than 400,000 deaths annually.
Most important causes of smoking related mortality- atherosclerotic disease, lung cancer, and COPD.
Smoking cessation - a major health care goal with clear benefits.

4. Benefits of cessation.
CV disease - rapid decrease in the risk of new myocardial events ; reduced risk of complications of atherosclerotic vascular disease.
COPD - reduces the decline of FEV1 in smokers; improved FEV1 and symptoms after quitting.
Reduced risk of other pulmonary diseases.
Malignancy- reduced risk of cancers ( lung, liver, kidney, pancreas, stomach, uterine cervix, and mesothelioma).

5. Benefits of cessation
Reproductive disorders – cessation reduced the risk of premature menopause related to smoking. (smoking also associated with infertility, spontaneous abortion, and ectopic pregnancy).
Osteoporosis – smoking related to accelerated bone loss and a risk factor for hip fracture ; reversal of risk with cessation after about 10 yr.
PUD – cessation decreases the risk of developing peptic ulcer and also accelerates the healing of existing ulcers.

6. Social attitudes and policies
Public debate – important in a democratic society; active participation by health care providers.
Restriction of minors to tobacco products.
Restriction of smoking in public places.
Restriction on advertisement.
Increase in price through taxation.

7. Role of PCP
THE 5 A’s
Ask, identify and document tobacco use status for every patient at every visit.
Advise smokers to quit
Assess readiness to quit
Assist in smoking cessation effort
Arrange for follow up visit.

8. Strategies for Cessation
Behavioral approaches.
Nicotine replacement therapy.
Other pharmacological therapies.
Combined approach.

9. Behavioral therapy
70 percent of patients who smoke say they would like to quit - only 7.9 percent are able to do so without help.
Physician counseling : the advice of a physician alone can improve the smoking cessation rate to 10.2 percent.
Group counseling : includes lectures, group interactions, self recognition, development of coping skills, and suggestions for relapse prevention. One year quit rates are approx 20%.
Hypnosis and acupuncture – scientific evidence of support weak.

10. Pharmacological therapy.
Drug therapy is designed to ameliorate symptoms due to loss of nicotine, while the smoker deals with the behavioral aspects of smoking cessation.
Symptoms of nicotine withdrawal:
Depressed or dysmorphic mood
Insomnia
Irritability, anger, restlessness
Anxiety
Difficulty in concentration
Increased appetite, weight gain

11. Nicotine replacement
Nicotine replacement is a safe intervention, even in out patients with known CV disease.
Concurrent use of nicotine replacement with smoking is not recommended. However concerns about excess cardiac toxicity associated with nicotine appear to be unfounded.

12. Nicotine patch Easy dosing and available OTC
Nicoderm CQ : One patch per day ( 21 mg for 6 weeks, 14 mg for 2 weeks, 7 mg for 2 weeks).
Nicotrol : single dose patch (16 hrs/day for 6 weeks with no tapering).
Local skin irritation ( upto 50% ) ; insomnia with 24 hr dosing.
Caution : pregnant women, recent MI (4 wk ), serious arrythmias.

13. Nicotine gum Multiple doses required each day. Available OTC.
Satisfies oral behavior
Nicorette gum : 2 mg and 4 mg strength.
<25 cigs/day use: 2 mg tab
>25 cigs /day use:4 mg tab
1 to 2 tab/hr for 6 weeks, taper over 6 weeks
Multiple doses required each day.

14. Nicotine inhalers and spray
Inhaler (Nicotrol Inhaler) :
6-16 cartridges/ day (4mg/ cartridge), initial Tx 6-12 wk and taper over 6-12 wk.
Substitutes for behavioral aspect of smoking.
Frequent continuous puffing x 20 mts each cartridge.
Local irritation, cough, and bronchospasm.
Nasal spray (Nicotrol NS) :
1-2 sprays each nostril Q hr (max 80 sprays/d).
Initial Tx 8 wk, taper over 4-6 wk.

15. Bupropion Provides therapy for depression.
Zyban or Wellbutrin: 150 mg qd for 1st 3 days then 150 mg bid..
Start 1-2 wk prior to quit date and continue 7-12 wk after the quit date (questions remain on the optimal duration of treatment).
Two trials of extended therapy with bupropion to prevent relapse after initial cessation, failed to detect a long-term benefit.
Caution in smokers with seizures, head trauma, alcohol use, and anorexia.

16. Combination Therapy
Bupropion (150 mg qd for 3 days followed by 150 mg bid for 60 days, starting one week before the quit date) and Transdermal nicotine ( 21 mg/day starting on the quit date and continued for 6 weeks, 14 mg/day for 1 week, and 7 mg/day for 1 week).
In one trial the combination of bupropion and nicotine patch produced slightly higher quit rates than the patch alone, but this was not replicated in a second study.

17. Other agents
Clonidine : initially promising, but now regarded as having limited efficacy.
Nortriptyline : has shown benefit in some trials, but not FDA approved.
Anxiolytic drugs : no significant effects on smoking cessation.
Lobeline and Mecamylamine are currently being evaluated.

18. Treatment and follow up
The process of quitting smoking begins with a “Quit date”.
Patients should be prepared for withdrawal symptoms, even on nicotine or bupropion.
Common suggestions to help smokers cope with early days of smoking cessation include chewing gum, increased physical activity, and avoidance of high risk situations.
Follow up visit should be scheduled within 3 to 7 days of quit date.

19. Reimbursement issues
Currently only 36 states provide Medicaid coverage for tobacco treatment and only 10 of these cover counseling.
Most private health plans provide limited benefits for tobacco treatment.

20. Questions

21. How to manage patients who fail the first regimen?
Advise patients not to think of themselves as failures.
Most smokers make many attempts to quit before they achieve success.
Figure out reasons for failure and explore solutions to use in the next attempt.
Consider trying different cessation methods.
Trial of hypnosis and acupuncture may encourage renewed attempts to stop smoking by patients who have failed with other techniques.

22. Is Group therapy helpful?
Groups are better than self-help and other less intensive interventions. However, not enough evidence on their increased efficacy or cost-effectiveness compared to intensive individual counseling.

23. Does wellbutrin work?
The antidepressant Bupropion can aid smoking cessation but selective serotonin reuptake inhibitors (e.g. fluoxetine) do not.

24. Does higher dose help?
The potential for higher doses of bupropion to improve rates of abstinence from smoking was assessed in a prospective trial of over 1500 patients treated with bupropion 150 mg QD, bupropion 300 mg QD, or placebo for eight weeks
Treatment with either dose improved abstinence rates, but the difference between these groups was not significant.
Increased side effects : insomnia, tremor, difficulty concentrating, and gastrointestinal symptoms.

25. Resources
Cochrane library
UPSTF
Uptodate
American family physician.