Tobacco Cessation

See also

Epidemiology

Up to 20% of U.S. Adults use Tobacco products (Cigarettes, cigars, pipes)
Up to 70% of Tobacco smokers want to quit but only 5% are successful
More than half of adult smokers started before age 18 years

Preparation
Office based Smoking Cessation program

Select an office Smoking Cessation coordinator
Create a smoke free office
Identify all smoking patients: "Do You Smoke"
Review self-help materials with each smoker
Make follow-up visits and call-backs
Consider working with consulting pharmacists to dispense and counsel on Tobacco Cessation products
Tobacco Cessation counseling is billable (CPT 99406 for >3 min and CPT 99407 for >10 min)

Protocol
Interview in clinic

"Do You smoke?"
1. Label Chart "SMOKER" (or sticker)
2. Make Smoking a Vital Sign
How Much do you smoke?
1. Greater Nicotine dependence if >1 pack per day
How soon after waking do you have first Cigarette?
1. Greater Nicotine dependence if under 30 minutes
Have you tried to quit before?
1. Successful cessation requires 3-6 attempts (average)
Other assessment tools
1. CAGE Questions can be applied to Tobacco Abuse
2. Fagerstrom Test for Nicotine Dependence

Precautions
Myths regarding quitting smoking - Anxiety will increase

Smokers (n=101) followed for 4 weeks
No increase in anxiety
Anxiety actually decreased after first week
Reference
1. West (1997) Am J Psych 154:1589-92 [PubMed]

Management
General

See Behavior Modification (Trans-theoretical Model, Five As Technique)
Use similar methods and medications for E-Cigarette Cessation as for Tobacco Cessation
Five As Technique Approach
1. ASK about Tobacco use
2. ADVISE patient quit Tobacco, directly and clearly
3. ASSESS WILLINGNESS to quit Tobacco, prior attempts and current use
4. ASSIST the patient in cessation with support, resources, medications, and expected initial adverse symptoms on quitting
5. ARRANGE QUIT DATE and follow-up, and planned responses to difficult situations with risk of returning to Tobacco
Provide Self-Help materials
1. See resources below
2. "Clearing the Air" (National Cancer Institute)
3. Free NCI Materials: 1-800-4-CANCER
4. Free telephone quit line: 800-QUIT-NOW
5. SmokeFreeTxt: Text 'QUIT' to 47848
Behavioral interventions are effective (with or without pharmacotherapy)
1. Individual or group counseling
2. Guaranteed financial incentives
3. Text message-based counseling
4. Hartmann-Boyce (2021) Cochrane Database Syst Rev (1):CD013229 [PubMed]
Relapse is common in first 6-12 months after cessation
1. Reassess interest in quitting after relapse
Tobacco Cessation office-based billing
1. Medicare covers up to 8 sessions per year
2. Counseling for >3 minutes: CPT 99406
3. Counseling for >10 minutes: CPT 99407
Specific Populations
1. Pregnancy
  1. See Preconception Counseling
2. Adolescents
  1. See Adolescent Substance Misuse
3. Comborbid Mental Health Disorders
  1. Consider Verenicline (high efficacy in this population)

Management
Pharmacotherapy

Indications for pharmacotherapy (Nicotine Dependence)
1. Tobacco use at or exceeding 1 pack per day
2. First Cigarette smoked within 30 minutes of waking
3. History of withdrawal symptoms during prior quit attempt
Nicotine Replacement therapy (NRT)
1. Eight week course is sufficient with little added benefit to longer use
  1. Schnoll (2015) JAMA Intern Med 175(4): 504-11 [PubMed]
2. Base dose on Nicotine dependence
3. See Fagerstrom Test for Nicotine Dependence
4. Nicotine Patch
  1. Start at 21 mg patch for those with more than 10 Cigarettes per day (more than one half pack), and 14 mg patch if less
  2. Taper patch dose to off over 6-8 weeks
5. Nicotine Gum
  1. Consider an occasional low dose gum (2 mg) as an adjunct to Nicotine Patch to treat breakthrough cravings
6. Nicotine Nasal Spray
7. Nicotine Inhaler
Controller Medications (reduce the impulse to use Tobacco)
1. Background
  1. Consider controller medications even in those reluctant to quit
  2. ATS recommends as of 2021 extending controller medications up to one year for higher sustained quit rate (NNT 19)
    1. Controller medications have been previously limited to 12 week course
    2. Leone (2020) Am J Respir Crit Care Med 202(2): e5-31 [PubMed]
2. Bupropion (Zyban, Wellbutrin)
  1. Start XR 150 mg daily for 3 days, then 150 mg twice daily
  2. May also help avert the weight gain associated with Tobacco Cessation
  3. Effective for sustained cessation at 6 months, but adverse effects may limit use, and less effective than Varenicline
    1. Hajizadeh (2023) Cochrane Database Syst Rev 5(5):CD000031 +PMID: 37230961 [PubMed]
3. Varenicline (Chantix)
  1. Start 1 week before quit date, at 0.5 mg daily for 3 days, then 0.5 mg twice daily for 4 days, then 1 mg twice daily for 12 weeks
  2. ATS preferred agent for sustained Smoking Cessation at 6 months (NNT 7)
    1. Cahill (2016) Cochrane Database Syst Rev 2016(5):CD006103 +PMID: 27158893 [PubMed]
  3. More effective when combined with Nicotine Replacement
    1. Koegelenberg (2014) JAMA 312(2): 155-61 [PubMed]
4. Nicotine Patch (see above)
5. Other medications used historically
  1. Nortriptyline
    1. Titrate to serum level 50-150 ng/ml (~75 mg/day)
    2. As effective as Bupropion
    3. Da Costa (2002) Chest 122:403-8 [PubMed]
    4. Hall (2002) Arch Gen Psychiatry 59:930-6 [PubMed]
Efficacy
1. Smokers interested in quitting: 70%
2. Smokers who quit without additional help: 7.9%
3. Smokers who quit with only advice of physician: 10.2%
4. Smokers who quit with Nicotine Replacement: 26%
5. Smokers who quit with combined therapy below: 35%
  1. Behavioral support
  2. Bupropion
  3. Nicotine Replacement
References
1. Jorenby (1999) N Engl J Med 340:685-91 [PubMed]

Precautions
Major Depression

Initial risk of Major Depression exacerbation
Higher risk in first 6 months of Tobacco Cessation
Confirm Major Depression control prior to cessation
Consider Bupropion use for cessation
Glassman (2001) Lancet 357:1929-32 [PubMed]

Precautions
Medications with no proven efficacy in Tobacco Cessation (avoid)

Silver acetate (gives Cigarettes bad taste)
Alprazolam (Xanax) or other Benzodiazepine
Clonidine (Catapres)

Precautions
Devices with increased risk or unknown safety

Avoid Electronic Cigarette (E-Cigarette)
1. Inadequate safety available for these devices and the inhaled vapor compared other Nicotine Replacement forms
2. No good evidence that e-cigs assist patients in quitting Nicotine completely (may simply trade one drug for another)
3. More than half of e-cig users are dual users (use Tobacco also)
  1. Emphasize the need to completely quit Tobacco
Avoid Hookah Pipe (Tobacco smoke drawn through water before inhalation)
1. Water does not filter Tobacco-related toxins
2. Hookah users tend to smoke for longer and have greater exposure
References
1. (2013) Presc Lett 20(5): 27
2. Vardavas (2012) Chest 141(6):1400-6 [PubMed]
3. Trtchounian (2011) Tob Control 20:47-52 [PubMed]

Resources

AHRQ Smoking Cessation Guidelines
1. http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/index.html
CDC Smoking and Tobacco
1. http://www.cdc.gov/tobacco
National Cancer Institute
1. http://www.cancer.gov/cancertopics/tobacco/smoking
Quitnet
1. http://www.quitnet.com
Nicotine Anonymous
1. http://www.nicotine-anonymous.org
SmokeFree.gov (NIH)
1. http://www.smokefree.gov

References