Continuing Education Activity
Tobacco use, primarily cigarette smoking, is the leading cause of preventable disease and death in the United States. Assisting patients with smoking cessation is one of the most important tasks of clinicians, and the benefits of discontinuing smoking behavior are well established. This activity reviews the options available to assist patients in smoking cessation and addresses the role of the interprofessional team in assisting patients in discontinuing the use of tobacco.
- Describe the effects of smoking on public health in the United States.
- Review the risks to the fetus in a pregnant patient that smokes tobacco.
- Summarize the options available for helping patients discontinue tobacco abuse.
- Outline the options available to assist patients in smoking cessation and address the role of the interprofessional team in assisting patients quit smoking.
Tobacco use, primarily cigarette smoking, is the leading cause of preventable disease and death in the United States. It is well established that smoking increases the risk of different forms of cancer, including lung, liver, and colorectal. Eighty-five percent of lung cancers occur in smokers. Also, smoking increases the risk of respiratory diseases (such as chronic obstructive pulmonary disease) and cardiovascular disease. During pregnancy, smoking increases the rate of complications, including miscarriage, stillbirth, preterm birth, fetal growth restriction, and congenital anomalies. Neonatal and pediatric complications of exposure to cigarette smoking include sudden infant death syndrome and abnormal lung function in children, such as asthma. Despite the magnitude of disease burden related to smoking, 42.1 million adults in the United States smoke cigarettes, according to the National Health Interview Survey data from 2013. This makes quitting smoking one of the most important yet challenging steps a person can take to improve his or her health, and most smokers make several attempts to quit before achieving abstinence from smoking.
Assisting patients with smoking cessation is one of the most important primary care tasks, and the benefits of assessing patients’ smoking behavior are well established. The US Preventive Services Task Force (USPSTF) recommends using the 5 As:
Office systems should ensure that smoking status is documented at every visit.
Use clear, personalized messages. Even brief advice from a physician can improve quit rates compared with patients who receive no advice.
- Assess willingness to quit
Patients assessed as not yet willing to quit should receive the motivational intervention.
Ask patients who are willing to set a quit date.
- Arrange follow-up and support
There is substantial evidence that behavioral interventions alone or in combination with pharmacotherapy improve the achievement of smoking cessation. Both behavioral interventions and pharmacotherapy are effective and recommended, and combinations of interventions are most effective. The best and most effective interventions are those that are feasible for the individual.
Issues of Concern
Behavioral interventions found to be effective in aiding adults in smoking cessation include in-person counseling, telephone counseling, and self-help materials. These interventions may increase rates of smoking cessation from a baseline of 5% to 11% in control groups to 7% to 13% in intervention groups. Both minor and intensive in-person interventions increase the proportion of persons who successfully quit smoking and remain abstinent. However, more or longer sessions improve cessation rates. According to the Public Health Service guidelines, individuals should undergo at least 4 in-person counseling sessions. Interventions delivered by various types of providers, including physicians, nurses, psychologists, social workers, and cessation counselors, can be effective. Effective telephone counseling interventions should provide at least 3 telephone calls and can be provided by trained professional counselors or health care providers. Self-help material shown to be effective is the one that is tailored to the individual patient and is primarily print-based.
Pharmacotherapy interventions approved by the FDA for the treatment of tobacco dependence in adults include bupropion SR, varenicline, and NRT (nicotine replacement therapy).
Nicotine Replacement Therapy (NRT)
Nicotine in itself is not carcinogenic. It acts on the reward pathway as in all addicting substances. The goal of nicotine replacement is to relieve cravings and reduce nicotine withdrawal symptoms. Rates of smoking cessation may increase from 10% in control groups to 17% in persons using any form of NRT, and using 2 types of NRT has been found to be more effective than using a single type. There is evidence that combining a nicotine patch (slow nicotine-releasing) with a rapid-delivery form of NRT (for example, chewing gums, lozenges, nasal spray, and inhalers) is more effective than using a single type.
Smoking cessation may increase from 11% in control groups to 19% in those using bupropion SR. Buproprion was first developed as an antidepressant; however, it has been shown to be effective as a smoking cessation aid. Some studies show that NRT in combination with bupropion SR may be more effective than bupropion alone, but not necessarily NRT alone.
Varenicline is a selective alpha4-beta2 nicotinic receptor partial agonist. It works by reducing cravings and withdrawal symptoms while blocking the binding of smoked nicotine. Smoking cessation rates have been shown to increase from 12% in control groups to 28% in those using varenicline. In 2009, the FDA applied a black-box warning to varenicline because of safety reports of an association between the drug and adverse psychiatric events, including depressed mood, agitation, and suicidal behavior. The FDA required Pfizer (the manufacturer of Chantix) to conduct a clinical trial to evaluate the risk of psychiatric events. The risk of these events was found to be lower than previously suspected, and therefore, the FDA removed the black-box warning for serious mental health side effects from the Chantix drug label in December 2016. In 2011, the FDA advised that varenicline may slightly increase the rate of cardiovascular events in persons with cardiovascular disease. Results are still pending from a large trial conducted to address this issue.
Combination Behavioral and Pharmacotherapy
Combining behavioral and pharmacotherapy may increase smoking cessation rates from 8% to 14% when compared with minimal behavioral interventions such as brief advice on quitting. Combination interventions usually include behavioral components delivered by specialized smoking cessation counselors combined with NRT. Combination interventions are made up of several sessions (more than 4) and are more successful with more sessions. Adding behavioral interventions to pharmacotherapy also increased cessation rates from 18% in persons receiving pharmacotherapy alone to 21% in patients using a mix of pharmacotherapy and behavioral support.
Electronic Cigarettes for Smoking Cessation
In a Cochran review, electronic cigarettes with nicotine increased smoking cessation rates compared with placebo, with cessation rates similar to that of nicotine patches. The most common reason given for using electronic cigarettes has been to quit or reduce cigarette smoking. However, little is known about the ingredients or long-term effects of electronic cigarettes, and to date, no electronic cigarette manufacturer has applied for or received FDA approval to market its product for smoking cessation. Initial studies show that electronic cigarettes contain nicotine and also made add other harmful chemicals, including carcinogens and lung irritants. The USPSTF found insufficient evidence of the use of electronic cigarettes as a smoking cessation tool in adults.
Smoking during pregnancy contributes to preterm deliveries, low-birthweight term deliveries, sudden infant death syndrome, and preterm-related deaths. Approximately 23% of women smoked during the three months before conception, and data from 2011 showed that 10% of women smoke during the last 3 months of pregnancy. According to the U.S. Preventive Services Task Force (USPSTF), behavioral interventions substantially improve the achievement of tobacco smoking abstinence in pregnant women, increase infant birth weight, and reduce the risk of preterm birth. There is not enough evidence regarding the benefits of NRT during pregnancy and no evidence on the benefits of bupropion SR, varenicline, or electronic cigarettes for smoking cessation in pregnant women. Although a few studies suggest a potential benefit of NRT on perinatal outcomes in pregnancy, it is a pregnancy category D medication, meaning there is evidence of fetal risk. Both Buproprion SR and varenicline are pregnancy class C medications.
Physicians should make it a priority to help patients stop smoking. Smoking even a few cigarettes a day or only smoking occasionally increases a person's chance of developing lung cancer. There are immediate benefits to smoking cessation, which occur only hours, weeks, and months after a person stops smoking. These primary benefits included lowering of blood pressure, decreased cough and phlegm production, increased lung capacity. In the long term, quitting smoking reduces a patient's risk of developing cancer, heart disease, and chronic lung disease. The earlier a person stops smoking, the more their risk of developing lung cancer is reduced. However, stopping smoking at any age is beneficial, and the benefits of smoking cessation are cumulative over time. When a person stops smoking before the age of 40, they reduce their chances of dying from smoking-related disease by 90%. Even people already diagnosed with cancer benefit from smoking cessation. In some forms of cancer, quitting smoking at the time of diagnosis can reduce the chances of dying from cancer by as much as 40%.
Enhancing Healthcare Team Outcomes
There is no longer any question that nicotine is harmful and affects almost every organ in the body. It is estimated that smoking accounts for 20% of deaths in the United States and the healthcare costs exceed $300 billion. Nicotine has been linked to many cancers and even second-hand exposure to nicotine can increase the risk of lung and heart disease. Despite four decades of urging the public to stop smoking, people continue to smoke in large numbers. There is no magic pill that can help people quit smoking. All the currently available medications to help people quit smoking are no better than a placebo. The big problem is that while many people can cease smoking for a few days, the urge to smoke is overwhelming and relapse rates are high. Clinicians, pharmacists, and nurses should assist in educating patients about the adverse effects of smoking. Today both family- and school-based smoking prevention programs are in operation, but scientific evidence reveals that their benefits are limited. The majority of patients simply quit smoking on their own but why they succeed in quitting smoking and others cannot is not well understood. All healthcare workers should continue to insist that patients not smoke - even if only a few percentage stop smoking; with nicotine addiction, even 1% is considered a success. [Level 5]