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References

  1. Cantera CM, Puigdomènech E, Ballvé JL, et al. Effectiveness of multicomponent interventions in primary healthcare settings to promote continuous smoking cessation in adults: a systematic review. BMJ Open. 2015;5:e008807.
  2. Raw M, McNeill A, West R. Smoking cessation: evidence based recommendations for the healthcare system. BMJ. 1999;318:182-185.
  3. Centers for Disease Control. [Press release] More than 100,000 Americans quit smoking due to national media campaign. Dept. of Health and Human Services. 2013. https://www.cdc.gov/media/releases/2013/p0909-tips-campaign-results.html Accessed January 4, 2017.
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Jennifer Leavitt
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Medscape Pulmonary Medicine

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How to Help Patients Quit Smoking and Stay Tobacco-Free This Year

Jennifer Leavitt  |  January 12, 2017

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Slide 1

Physicians Have the Power to Help Patients Quit Smoking

With volumes of information about the dangers of tobacco use being broadcast so publicly and persistently for decades now, it can be all too easy to conclude that any patient who is still smoking has simply decided to roll the dice when it comes to health and longevity. As it turns out, though, some doctors may be missing valuable opportunities to help patients quit.

A number of studies indicate that just a little more patient education and encouragement could be incredibly useful and effective. With the majority of smokers likely to visit their healthcare providers every year, the good news is that physicians have significantly more influence than they may realize when it comes to smoking prevention and cessation in those they treat.[1,2]

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Slide 2

Quitting Smoking Tops the New Year's Resolution List

Let's face it: Most patients are well aware that tobacco use is one of the greatest causes of preventable premature aging and death in the United States.

Smoking compromises every organ in the human body. According to the Centers for Disease Control and Prevention, it causes 480,000 deaths each year in the United States alone, making it more lethal than HIV, alcohol and illegal drug use, motor vehicle and firearms accidents, combined.

It stands to reason that quitting smoking consistently tops new year's resolution lists nationwide. In January especially, providers may encounter patients who are more receptive than ever to making a change and to suggestions on strategies and treatments that can help them succeed. Physicians can make resolutions of their own by committing to help more patients quit for good this year, using some of the many methods that have helped hundreds of thousands of smokers toss their cigarettes in recent years.[3]

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Slide 3

Enhancing Physician-Patient Relationships Pays Off

Not surprisingly, studies show that stronger physician-patient relationships result in greater success with smoking cessation. When physicians make concerted efforts to build trust through increased communication and patient engagement, patients respond more favorably to provider advice and directives on living a healthier lifestyle.[4]

The most obvious first step is knowing whether patients smoke, forgoing any preconceived notions of who may or may not light up. After gathering all patient data, doctors can ask questions about patient well-being beyond their physical health and about their comfort level with patient care, building a bridge to casual but effective intervention.

"The concept of self-efficacy was put forward by Bandura at Stanford as part of his Social Learning Theory, and has proven to be a very important component of behavior change," Michael P. Eriksen, ScD, told Medscape. "Smokers who are confident in their ability to be successful are much more likely to succeed than smokers who doubt or are pessimistic about their ability to quit. Efforts are often directed at increasing self-efficacy by reminding smokers that," for example, "there are as many ex-smokers as current smokers, or that quitting isn't easy but over 50 million Americans alive today have successfully quit," said Dr Eriksen, former director of the Office on Smoking and Health at the Centers for Disease Control and Prevention.

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Slide 4

Getting to Yes

Before broaching available therapeutics, the most significant first step (sometimes the only step necessary) is getting the patient to actually want to give up tobacco products. "A successful quitter really has to want to quit for themselves," Dr Eriksen stresses.

According to the US Public Health Service, the simple act of urging patients to quit will result in 5%-10% of them actually doing so. The agency suggests making clear, strong, helpful, and personalized statements to convince patients to quit. An example might be "It is vital that you stop using tobacco products in any form. Quitting now is the single most important thing you can do for your current and future health. Reducing secondhand smoke in your home will most likely help your children have fewer asthma attacks as well."

When dialogue with patients reveals their fears, values, or belief systems, it may also be appropriate and useful to tap into those. If a patient is particularly worried about his children, discuss how smoking might affect them. If another patient seems concerned about her physical attributes, talk about how smoking damages the skin, eyes, and teeth.

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Slide 5

The Plan of Action

It can be highly effective to solicit a call to action right after the warning. Studies show that a mere 3 minutes of consultation can prompt patients to quit.[5]

After giving the initial round of strong advice, physicians can ask smokers whether they are willing to quit, and if the response is yes, get patients to commit to a date. Suggest that they share their quit date with friends, family, and coworkers and that they post it on social media.

If a patient refuses to quit, reiterate some of the negative consequences of smoking, ask the patient why it's worth the cost and health ramifications, and promise to follow up.

Make every effort to schedule a follow-up with both receptive and unreceptive patients.

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Slide 6

Multicomponent Interventions

Although some fortunate patients do quit smoking with a single treatment modality or even none at all, for many patients, using multicomponent interventions can substantially increase the chances of success. Combining medication with support groups and one-on-one counseling, for instance, typically increases the quit rate by 10%-25% over counseling alone.[6,7]

First- and second-line medications have proven effective as monotherapies initially, but relapse rates are high, with at least 50% of smokers returning to tobacco within 3 months of quitting and approximately 66% doing so within the year. This may be because so many smokers experience significant and highly unpleasant symptoms of withdrawal even on the highest doses of prescribed medication.[8] Offering patients a combination of pharmacotherapies and other resources may afford them the best chance of success.

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Slide 7

Cold Turkey May Be Best

Although traditional wisdom dictates that tapering nicotine will cause the least discomfort, some research suggests that quitting abruptly, or "cold turkey," is more effective. In one study, 49% of participants who had quit smoking abruptly were still abstinent at 4 weeks, while only 39% of those in the gradual-cessation group were still smoke-free. Six months in, 22% of those in the abrupt-cessation group and only 15.5% of participants who underwent gradual cessation were still nonsmokers. Across both groups, participants who reported a preference for gradual cessation over quitting abruptly were far more likely to be smoking again at 4 weeks (38.3% vs 52.2%; P = .007).[9]

Two of the greatest benefits of abrupt cessation are that it is both fast and free. However, most patients will still need a plan. Quitting on a day that is more likely to be stress-free may be wise. Advise patients to avoid trigger situations, stay active, and keep their mouths busy, perhaps with chewing gum or lots of flavored water.

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Slide 8

Medication as an Aid to Smoking Cessation

For patients who can't quit abruptly, prescription medications have proven effective. Medications include varenicline (Chantix®), bupropion (Zyban®), and nicotine replacement therapy (NRT).

One study compared effectiveness of varenicline, bupropion, or NRT gum with that of an NRT patch in terms of ongoing abstinence in smokers who had recently quit.[10]

Varenicline was given to 5052 participants, bupropion to 823, NRT gum to 1944, and the NRT patch to 4149. Point prevalence was measured at 7 days, 1 month, and 6 months from last self-reported cigarette consumption. Varenicline users were most likely to be smoke-free at 1-month and 6-month points. Abstinence rates were similar among those prescribed bupropion, NRT gum, and the NRT patch.

Both varenicline and bupropion are typically started 1 week before the selected quit date so that the drug can build up in the body.

Nicotine replacement should not be started before quitting, unless the patient can carefully replace cigarettes at a maximum ratio of 1:1 mg of nicotine.

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Slide 9

Nicotine Replacement Therapy

For those patients who are reluctant to quit smoking or who can't seem to abandon nicotine abruptly, physicians can consider NRT.

For patients, the most useful aspect of NRT is learning to forego the physical act of smoking while avoiding any major withdrawal symptoms.

Products currently on the market include a transdermal patch, nasal spray, gum, lozenges, sublingual tablets, and an inhaler. Many consumers report an unpleasant taste in the gum or lozenges; warning patients of this in advance may influence their choices and prevent obstacles to success.

The transdermal patch provides longer-term relief, while the other products are designed for on-demand reduction of cravings provoked either by withdrawal symptoms or situational stimuli.[11]

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Slide 10

Vaping: A Controversial and Less Regulated Form of Nicotine Replacement

Originally touted as a great alternative to smoking tobacco, e-cigarettes have faced considerable scrutiny, with a rapid response from regulators, and more to come.

Is the suggestion to vape instead of smoke ever appropriate? Given the controversy, fledgling regulation, and lack of long-term data on vaping, physicians who recommend it may face criticism (or worse) in the future. What most lawmakers are especially worried about, however, is those who never smoked but are starting a new habit with vaping. The current consensus is that vaping is probably less harmful than smoking, so a patient who refuses to give up tobacco might simply be asked whether he has tried vaping instead. Certainly, doctors can share their concerns about a lack of evidence.

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Slide 11

Bupropion

Bupropion (Wellbutrin® and Zyban®) was the first smoking-cessation prescription on the market after decades of NRT as the sole option.

Although bupropion's precise mechanism of action remains elusive, researchers believe that noradrenergic and/or dopaminergic mechanisms are at play. Bupropion mildly inhibits neuronal reuptake of both dopamine and norepinephrine, but not serotonin or monoamine oxidase.

Typically, patients are prescribed 150 mg per day for 3 days and then 150 mg twice daily thereafter. Cessation is expected to take 7-12 weeks, but patients can continue with maintenance therapy based on individual risks and benefits.

Two benefits of bupropion are that it independently treats depression and can be used in long-term combination with NRT.[12]

Dosing, interactions, and contraindications

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Slide 12

Varenicline

Varenicline (Chantix®) is the newest of the smoking-cessation prescriptions. Its efficacy appears to be the product of varenicline's activity at α4β2 subtype of the nicotinic receptor, where agonist activity is provoked by binding while nicotine is prevented from bonding.

Binding at α4β2 neuronal nicotinic acetylcholine receptors, with high affinity and selectivity, varenicline blocks nicotine from activating α4β2 receptors and thus the dopamine stimulation that plays a central role in the human reinforcement and reward system.

Varenicline can be started 35 days before quitting, although negative side effects tend to increase if this agent is used in conjunction with any form of nicotine beyond that time frame.[12]

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Slide 13

Alternative Therapies to Aid in Smoking Cessation

Although significant evidence does not exist to support the use of alternative therapies such as hypnosis or acupuncture for smoking cessation, some smaller studies show promise, and there are positive anecdotal reports. More important, though, is that quitting smoking requires substantial psychological adjustment. If patients are enthusiastic about a certain modality, this can make them more receptive to success, so experts recommend not discouraging them.

One study on acupuncture showed relative success in helping smokers remain abstinent for up to 5 years. Researchers hypothesize that acupuncture treatment for smoking cessation diminishes tobacco cravings.[13]

Another study showed that in patients who suffered from depression, hypnosis resulted in statistically significant point-prevalence quit rates that were higher at 6 and 12 months as compared with rates resulting from standard treatments.[14]

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Slide 14

Switching Out Habits

Formed and residing in the basal ganglia and the brain stem, habits become automated and can be incredibly hard to break. Once a habit has been ingrained, people often report that they can "do it in their sleep." Using the bathroom, brushing teeth, tying shoes, and smoking all require virtually no thought or effort.

Some psychologists theorize that it will be easier to break one habit, such as smoking, if it can be pushed aside and replaced by another habit,[15] such as drinking flavored water, chewing gum, singing, or even physical exercise.

Ask patients what they gain from smoking. For some, smoking satisfies an oral fixation. Others need to keep their hands busy, and some people rely on the stimulation of nicotine to help them focus better. Ironically, the deep draw-in of smoke, known as a "drag," can mimic the type of deep breathing that is touted as relaxing. Knowing what patients enjoy about smoking can help them choose an alternative habit that satisfies the same needs.

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Slide 15

A Positive Home Environment

Smoking-cessation programs stress the benefits and importance of a positive home environment, including one devoid of ashtrays and tobacco products. Getting family members involved and asking for their support is important; physicians should bring it up and encourage patients to ask any smoking relatives to smoke out of sight and outside the home.

Environments that once hosted addictive behavior, including work, home, and social settings, have a significant influence on whether patients remain abstinent.[16] Patients should be counseled to plan ahead and make provisions accordingly, removing temptations and garnering support from whoever is willing to give it.

"Things that make smoking less convenient, more expensive, or less popular have been shown to help motivate smokers to quit," Dr Eriksen shared with Medscape, "and some feel that these social factors are as important as individual efforts."

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Slide 16

Genetics Play a Role in How Patients Quit

A patient's genes can influence how and whether attempts at smoking cessation succeed. Variations in nicotine- and medication-metabolizing enzymes play a role, as do differences in receptor targets for these substances.

Smokers who are genetically predisposed to metabolize nicotine more slowly (by CYP2A6 genotype or CYP2A6 phenotype), for example, tend to be more successful at quitting tobacco via counseling, nicotine replacement, and cold turkey versus those who metabolize at a faster rate. They don't do as well as fast metabolizers do on bupropion. Faster nicotine metabolizers quit more easily on varenicline.[17]

For those physicians who are feeling particularly ambitious, ordering a genetic test might provide some valuable input.

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Slide 17

What a Difference a Doctor Makes

One patient told Medscape, anecdotally, that she walked into an emergency room 17 years ago complaining of shortness of breath. When the attending physician asked her if she smoked and she responded in the affirmative, the patient detected a noticeable change in the physician's demeanor—something she read as, "Well, what do you expect? Of course you're in the ER." After 15 years of smoking, she quit on the spot and never smoked again. When a simple glance can accomplish that, imagine what a few sage words from a trusted physician might achieve.

If 100,000 healthcare providers successfully prompt just 10% of their smoking patients to give up tobacco over the next 12 months, 3 million people will quit smoking this year alone.[18] Imagine that.

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