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Subsections
Tobacco Abuse: Cessation of Smoking

Tobacco Abuse

Tobacco Abuse: Cessation of Smoking

Background

  1. Definition
    • Discontinuation of smoking
  2. General Information
    • Pt should inquire about smoking cessation first to be successful
  3. Epidemiology
    • Incidence/Prevalence
      • Prevalence
        • 42.1 million U.S. adults smoke cigarettes
        • 20% of males and 15% of females
        • 16 million suffer from diseases like COPD, infections and more
        • Since 2005, overall prevalence of tobacco use declining
    • Morbidity/Mortality
      • 480,000 attributable deaths each yr (1 of every 5 U.S. deaths)
      • $100 billion in lost productivity

Pathophysiology

  1. Pathogenesis
    • Nicotine addiction develops as neurobiological adaptation to chronic nicotine exposure
    • Various transmitter systems involved in the rewarding effects of nicotine and in adaptations occurring in response
    • These same pathways are thought to drive withdrawal symptoms and continuation of smoking behavior
  2. Risk Factors
    • Smoking known risk factor for development of many cancers including
      • Lung
      • Laryngeal
      • Oral
      • Throat
      • Bladder
      • Cervix
      • Stomach
      • Smoking also causes COPD and other respiratory diseases
      • Benefits of quitting
      • 1 yr after cessation
      • Risk of myocardial infarction reduced by 50%
      • 5 yrs after cessation
      • Stroke risk falls to that of general population
      • 10 yrs after cessation
      • Lung and other cancer risk decreases by 50%

Diagnostics

  1. History/Symptoms
    • Evidence-Based Physician Counseling
      • ASK at every visit if patient smokes and document response
      • ADVISE all smokers to quit in clear, strong and understandable language
      • ASSESS smoker’s willingness to try quitting within the next 30 days
      • ASSIST smokers willing to make quit attempt by providing brief counseling and drug treatment
      • ARRANGE follow-up, preferably w/in the first week

Treatment/Management

  1. Acute Treatment
    • Physician counseling (3-10 mins) along w/ the following treatments shows strong evidence for successful cessation after 6 mns of intervention
      • Varenicline w/ nicotine replacement therapy
      • Bupropion w/ nicotine replacement therapy
      • Cytisinicline w/ nicotine replacement therapy
        • Up to 9 mg qday
        • Fewer side affects than varenicline
  2. Further Management
    • In a meta-analysis of seven randomized trials, nicotine e-cigarettes resulted in higher quit rates than nicotine replacement therapy (17.5 versus 10.2 percent)
    • Nicotine replacement therapy includes
      • Over-the-counter: patches, gum, lozenges
      • Prescription: patches, inhalers, nasal spray
    • Drug therapy not indicated in patients who
      • Smoke < 10 cigarettes/ day
      • Under 18 years of age
      • Currently pregnant
      • Use smokeless tobacco
  3. Additional therapies that are significantly better than no intervention
    • Acupuncture
    • SSRIs
    • Naltrexone
    • Hypnosis
    • Full financial coverage of treatment
    • Training health professionals in smoking cessation
    • Print-based handouts
    • Work-based programs and workplace competitions
    • Financial incentive-based programs
    • Telephone-based interventions
    • Internet-based interventions
    • Quitlines: 1-800-QUIT-NOW
    • Other Behavioral Therapy
  4. Not currently recommended
    • Nicotine vaccine
  5. Strong evidence for prevention
    • School-aged intervention and prevention programs
    • Pregnancy intervention and prevention programs

Follow-Up

  1. One week after quit-date and at least 4 times after quit date

Prognosis

  1. Pts can experience withdrawal symptoms for 4-6 wks and include
    • Cravings
    • Hunger
    • Weight gain
    • Insomnia
    • Dizziness
    • Chest pain
    • Constipation
    • Irritability
    • Fatigue
    • Cough
    • Decreased concentration
  2. Relapse common
    • Encourage continued cessation attempts

Prevention

  1. USPSTF recommendations (Grade A) (Go to USPSTF)
    • USPSTF recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products
    • USPSTF recommends that clinicians ask all pregnant women about tobacco use and provide augmented, pregnancy-tailored counseling for those who smoke

Clinical Inquiries

  1. What is most effective nicotine replacement therapy?
  2. What interventions can help patients stop using chewing tobacco?
  3. What predicts a successful smoking cessation attempt?
  4. What are the most effective ways you can help patients stop smoking?
  5. How much does smoking cessation cut CHD risk?
  6. Which smoking cessation interventions work best?
  7. Does any antidepressant besides bupropion help smokers quit?

Evidence-Based Practice

  1. What factors predict a successful smoking cessation attempt?
  2. Are physician efforts at encouraging smoking cessation in adults effective?
  3. How effective is hypnosis in promoting smoking cessation?
  4. Do antidepressants aid in long-term smoking cessation?
  5. Are nicotine receptor agonists more effective for smoking cessation than nicotine replacement patches?

PURLs

  1. Counseling is a must with this smoking cessation aid
  2. Help smokers quit: Tell them their "lung age"

References

  1. 2014 Surgeon General's Report: The Health Consequences of Smoking - 50 Years of Progress. Centers for Disease Control and Prevention Website. Available at http://www.cdc.gov/tobacco/data_statistics/sgr/50th-anniversary/. [Accessed April 2024]
  2. Auer R, Schoeni A, Humair JP, et al. Electronic Nicotine-Delivery Systems for Smoking Cessation. N Engl J Med. 2024;390(7):601-610
  3. Hartmann-Boyce J, Cahill K, Hatsukami D, Cornuz J. Nicotine vaccines for smoking cessation. Cochrane Database Syst Rev. 2012;8:CD007072
  4. Hartmann-Boyce J, Stead LF, Cahill K, Lancaster T. Efficacy of interventions to combat tobacco addiction: Cochrane update of 2012 reviews. Addiction. 2013;108(10):1711-1721
  5. Larzelere MM, Williams DE. Promoting smoking cessation. Am Fam Physician. 2012;85(6):591-598
  6. Lindson N, Butler AR, McRobbie H, et al. Electronic cigarettes for smoking cessation. Cochrane Database Syst Rev. 2024;1(1):CD010216
  7. Livingstone-Banks J, Fanshawe TR, Thomas KH, et al. Nicotine receptor partial agonists for smoking cessation. Cochrane Database Syst Rev. 2023;5(5):CD006103
  8. Rigotti NA, Benowitz NL, Prochaska J, et al. Cytisinicline for Smoking Cessation: A Randomized Clinical Trial. JAMA. 2023;330(2):152-160.
  9. Smoking and Tobacco Use. Centers for Disease Control and Prevention Website. Available at http://www.cdc.gov/tobacco/. [Accessed April 2024]
  10. Treating Tobacco Use and Dependence: 2008 Update. Agency for Healthcare Research and Quality. U.S. Department of Health & Human Services Website. Available at: http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/index.html. [Accessed April 2024]

Contributor(s)

  1. Gordon, Daniel, MD
  2. Marshall, Robert, MD MPH MISM
  3. McPhillips, Kristin, MD MPH
  4. Scott, Carol, MD
  5. Ausi, Michael, MD, MPH

Updated/Reviewed: April 2024