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Tobacco Use and Smoking Cessation
Felix B. Chang, MD, DABMA, FAAMA
image BASICS
DESCRIPTION
  • Use of tobacco of any form
  • Smokeless tobacco refers to tobacco products that are sniffed, sucked, or chewed.
  • Nicotine sources: cigars, pipes, waterpipes, hookahs, and cigarettes
EPIDEMIOLOGY
Incidence
  • 2.4 million new smokers annually in the United States (2.6% initiation rate)
  • 58.8% of new smokers are <18 years of age (5.8% initiation rate for teens).
Prevalence
  • 443,000 deaths annually in the United States
  • Cigarette smoking among adults in the United States: 21.3% of adults in 2012 to 2013
  • Highest among those aged 18 to 25 (40.8%)
  • Adults aged >25 years (28.5%)
  • Race: highest among whites (22.1%) and African Americans (21.3%) and is lower among Hispanics (14.6%) and Asians (12%)
  • Gender: male > female (21.5% vs. 17.3%)
  • Inversely proportional to education level
  • 31% in men >15 years old from 187 countries in 2012
ETIOLOGY AND PATHOPHYSIOLOGY
  • Addiction due to nicotine's rapid stimulation of the brain's dopamine system (teenage brain especially susceptible)
  • Atherosclerotic risk due to adrenergic stimulation, endothelial damage, carbon monoxide, and adverse effects on lipids
  • Direct airway damage from cigarette tar
  • Carcinogens in all tobacco products
RISK FACTORS
  • Presence of a smoker in the household
  • Easy access to cigarettes
  • Perceived parental approval of smoking
  • Comorbid stress and psychiatric disorders
  • Low self-esteem/self-worth
  • Poor academic performance
  • Boys: high levels of aggression and rebelliousness
  • Girls: preoccupation with weight and body image
GENERAL PREVENTION
  • Most first-time tobacco use occurs before high school graduation, so educational interventions should target students in grade and middle schools and must address health consequences and psychosocial aspects of smoking.
  • The AAFP's Tar Wars program has targeted 4th and 5th graders successfully.
  • Other helpful measures include the following:
    • Smoking bans in public areas and workplaces
    • Restriction of minors' access to tobacco
    • Restrictions on tobacco advertisements
    • Raising prices through taxation
    • Media literacy education
    • Tobacco-free sports initiatives
COMMONLY ASSOCIATED CONDITIONS
  • Coronary artery disease
  • Cerebrovascular disease
  • Peripheral vascular disease
  • Abdominal aortic aneurysm (AAA)
  • COPD
  • Cancer of the lip, oral cavity, pharynx, larynx, lung, esophagus, stomach, pancreas, kidney, bladder, cervix, and blood
  • Pneumonia
  • Osteoporosis
  • Periodontitis
  • Alcohol use
  • Depression and anxiety
  • Reduced fertility
Pregnancy Considerations
Women who smoke or are exposed to 2nd-hand smoke during pregnancy have increased risks of miscarriage, placenta previa, placental abruption, premature rupture of membranes, preterm delivery, low-birth-weight infants, and stillbirth.
Pediatric Considerations
  • 2nd-hand smoke increases the risk of the following in infants and children:
    • Sudden infant death syndrome
    • Acute upper and lower respiratory tract infections
    • More frequent and more severe exacerbations of asthma
    • Otitis media and need for tympanostomies
  • Nicotine passes through breast milk, and its effects on the growth and development of nursing infants are unknown.
image DIAGNOSIS
PHYSICAL EXAM
  • General: tobacco smoke odor
  • Skin: premature face wrinkling
  • Mouth: nicotine-stained teeth; inspect for suspicious mucosal lesions
  • Lungs: crackles, wheezing, increased or decreased volume
  • Vessels: carotid or abdominal bruits, abdominal aortic enlargement, peripheral pulses, stigmata of peripheral vascular disease
DIAGNOSTIC TESTS & INTERPRETATION
  • CXR for patients with pulmonary symptoms or signs of cancer but not for screening
  • The USPSTF recommends one-time screening US for AAA in men ≥65 years of age who ever smoked (number needed to screen to prevent 1 AAA = 500).
Diagnostic Procedures/Other
PFTs for smokers with chronic pulmonary symptoms, such as wheezing and dyspnea
image TREATMENT
Both behavioral counseling and pharmacotherapy benefit patients who are trying to quit smoking especially when use in combination.
GENERAL MEASURES
  • Behavioral counseling includes the 5 As of promoting smoking cessation:
    • Ask about tobacco use at every office visit.
    • Advise all smokers to quit.
    • Assess the patient's willingness to quit.
    • Assist the patient in his or her attempt to quit.
    • Arrange follow-up.
  • Patients ready to quit smoking should set a quit date within the next 2 weeks. No difference in success rates between patients who taper prior to their quit date and those who stop abruptly.
  • Success increased with a quitting partner, such as a spouse, friend, or coworker, to provide mutual encouragement.
  • Patients desiring to quit should dispose of all smoking paraphernalia (such as lighters) on their quit dates to make relapse more difficult.
  • Patients must anticipate and avoid social/environmental triggers for smoking and should have a plan for dealing with the urge to smoke.
MEDICATION
First Line
  • Varenicline (Chantix): 0.5 mg/day PO for 3 days, then 0.5 mg BID for 4 days, then 1 mg BID for 11 weeks (1)[A]:
    • Start 1 to 4 weeks prior to smoking cessation and continue for 12 to 24 weeks.
    • Superior to placebo and to bupropion; number needed to treat = 7
    • May be combined with nicotine replacement therapy
    • S/E: nausea, insomnia, headache, depression, suicidal ideation; safety not established in adolescents or patients with psychiatric or cardiovascular disease; pregnancy Category C
  • Bupropion SR (Zyban): 150 mg PO for 3 days, then 150 mg BID:
    • Start 1 week prior to smoking cessation, and continue for 7 to 12 weeks.
    • Twice as effective as placebo
    • Drug of choice for patients with depression or schizophrenia
    • May be combined with varenicline and NRT in men who smoke >1 PPD
  • S/E: tachycardia, headache, nausea, insomnia, dry mouth; contraindicated in patients who have seizure disorders or anorexia/bulimia; pregnancy Category C(1),(2)[A]
  • Nicotine replacement therapy (NRT) (e.g., patch, gum, lozenge, inhaler, nasal spray) (1),(2)[A]:
    • Improves quit rates by 50-70% versus placebo
    • Over-the-counter
    • P.1047

    • Patch (NicoDerm CQ 21, 14, and 7 mg):
      • 1 patch q24h
      • Start with 21 mg if smoking ≥10 cigarettes/day; otherwise, start with 14 mg.
      • 6 weeks on initial dose, then taper
      • 2 weeks each on subsequent doses
      • No proven benefit beyond 8 weeks
    • E-cigarettes
      • Contain less nicotine than cigarette Considered less “dangerous” than tobacco but not as well studied as other NRT (3)[B]
      • Conflicting data on whether teen use increases or decreases risk to cigarette progression
    • Gum (Nicorette, 2 and 4 mg):
      • Use 4 mg if smoking >25 cigarettes/day
      • Chew 1 piece q1-2h for 6 weeks, then 1 piece q2-4h for 3 weeks, then 1 piece q4-8h for 3 weeks.
    • May use in combination with bupropion; monitor for hypertension
    • S/E: headache, pharyngitis, cough, rhinitis, dyspepsia; all mainly with inhaler and spray forms
    • Pregnancy Category D
Second Line
  • Nortriptyline: 25 to 75 mg/day PO or in divided doses:
    • Start 10 to 14 days prior to smoking cessation and continue for at least 12 weeks.
    • Efficacy similar to bupropion, but side effects more common; pregnancy Category D
    • The antidepressants bupropion and nortriptyline aid long-term smoking cessation (4)[A].
  • Clonidine: 0.1 mg PO BID or 0.1 mg/day transdermal patch weekly (1):
    • Side effects: hypotension, bradycardia, depression, fatigue; pregnancy Category C
ADDITIONAL THERAPIES
The following interventions have been shown to be effective in helping patients quit smoking:
  • Advice from nurses, especially in hospital
  • Individual counseling/group therapy
  • Telephone counseling/web-based cessation programs
  • Exercise (not conclusive, ineffective) (5)[A]
  • Acupuncture: short-term effects (6)[A]
  • Naltrexone. No evidence (7)[A]
  • Opiates antagonist. No evidence (1)[A]
COMPLEMENTARY & ALTERNATIVE MEDICINE
Acupuncture, aversive therapy, and hypnosis have not been proven to enhance long-term smoking cessation.
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
  • Follow up 3 to 7 days after scheduled quit date and at least monthly for 3 months thereafter.
  • Telephone follow-up if office visits not feasible
  • Refraining from tobacco products for first 2 weeks is critical to long-term abstinence.
  • Encourage patients who relapse to try again. Most smokers experience ≥1 failed attempts before quitting permanently. Reinforce behavioral interventions (8)[A].
Patient Monitoring
  • Short-term withdrawal symptoms include dysphoria, depressed mood, irritability, anxiety, insomnia, increased appetite, and poor concentration.
  • Longer term risks of smoking cessation include weight gain (4 to 5 kg on average) and depression.
  • Quitting also is associated with exacerbations of ulcerative colitis and worsening of cognitive function in patients with schizophrenia.
  • Nicotine withdrawal syndrome: dysphoric or depressed mood, insomnia, irritability, frustration, or anger; anxiety, difficulty concentrating, restlessness, and increased appetite or weight gain
  • Lung cancer risk by smoking status: heavy smokers 1.00, light smokers 9.44 (0.35 to 0.56), ex-smokers 0.17 (0.13 to 0.23), never smoker 0.09 (0.06 to 0.13); adjusted hazard ratio (95% CI) (9)
DIET
Healthy eating for limiting weight gain following smoking cessation
PATIENT EDUCATION
1-800-QUIT-NOW: free counseling, resources, and support for quitting
PROGNOSIS
  • Measurable cardiovascular benefits of smoking cessation begin as early as 24 hours after quitting and continue to mount until the risk is reduced to that of nonsmokers by 5 to 15 years.
  • People who quit smoking after a heart attack or cardiac surgery reduce their risk of death by 1/3.
  • Relapse rates initially >60% but decrease to 2-4% per year after completing 2 years of abstinence (8)[A].
REFERENCES
1. Cahill K, Stevens S, Perera R, et al. Pharmacological interventions for smoking cessation: an overview and network meta-analysis. Cochrane Database Syst Rev. 2013;(5):CD009329.
2. Thomsen T, Villebro N, Møller AM. Interventions for preoperative smoking cessation. Cochrane Database Syst Rev. 2014;(3):CD002294.
3. Bhatnagar A, Whitsel LP, Ribisl KM, et al. Electronic cigarettes: a policy statement from the American Heart Association. Circulation. 2014;130(16):1418-1436.
4. Hughes JR, Stead LF, Hartmann-Boyce J, et al. Antidepressants for smoking cessation. Cochrane Database Syst Rev. 2014;(1):CD000031. doi:10.1002/14651858.CD000031.pub4.
5. Ussher MH, Taylor AH, Faulkner GE. Exercise interventions for smoking cessation. Cochrane Database Syst Rev. 2014;(8):CD002295. doi:10.1002/14651858.CD002295.pub5.
6. White AR, Rampes H, Liu JP, et al. Acupuncture and related interventions for smoking cessation. Cochrane Database Syst Rev. 2014;(1):CD000009. doi:10.1002/14651858.CD000009.pub4.
7. David SP, Lancaster T, Stead LF, et al. Opioid antagonist for smoking cessation. Cochrane Database Syst Rev. 2013;(6):CD003086.
8. Agboola S, McNeill A, Coleman T, et al. A systematic review of the effectiveness of smoking relapse prevention interventions for abstinent smokers. Addiction. 2010;105(8):1362-1380.
9. Godtfredsen NS, Prescott E, Osler M. Effect of smoking reduction on lung cancer risk. JAMA. 2005;294(12):1505-1510.
Additional Reading
&NA;
  • Larzelere MM, Williams DE. Promoting smoking cessation. Am Fam Physician. 2012;85(6):591-598.
  • Quitnet: www.quitnet.com
See Also
&NA;
Nicotine Addiction; Substance Use Disorders
Codes
&NA;
ICD10
  • F17.210 Nicotine dependence, cigarettes, uncomplicated
  • F17.213 Nicotine dependence, cigarettes, with withdrawal
  • F17.211 Nicotine dependence, cigarettes, in remission
Clinical Pearls
&NA;
  • Every patient who uses tobacco should be offered smoking cessation.
  • Use the 5 As: ask, advise, assess, assist, and arrange
  • Behavioral counseling and medication are most effective for helping patients to quit smoking when they are used in combination.
  • Depression with suicidal ideations is a contraindication to use varenicline.
  • Even brief advice to quit has been shown to increase quit rates.
  • Following relapse, smokers should be encouraged to make another attempt to stop smoking.