Smoking Cessation

Tobacco use is responsible for about one in five deaths in the United States and is the leading cause of preventable death. Helping your patient quit smoking is one of the most important interventions you can do in the primary care setting to reduce morbidity and mortality. Tobacco dependence is a chronic illness and requires ongoing treatment to have lasting benefits. The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians screen patients for tobacco use, advise quitting, and offer pharmacologic and behavioral interventions to achieve smoking cessation. The evidence indicates that the combination of counseling and medication is more effective than either strategy alone.

Counseling

The USPSTF recommends that clinicians ask all adults about tobacco use and provide:

behavioral interventions and pharmacotherapy to all nonpregnant adults who use tobacco
behavioral interventions to pregnant adults who use tobacco

The “5 A’s” model is a good initial framework that can be used to ask adults about tobacco use. Just 3 minutes of counseling can improve someone’s likelihood of quitting, and a dose-dependent relationship exists between duration of counseling and quit rates.

5 A’s Model for Managing Tobacco Use and Dependence

Ask about tobacco use.	Identify and document tobacco-use status for every patient at every visit.
Advise to quit.	Provide clear, direct, and personalized reasons for smokers to quit.
Assess willingness to make quit attempt.	Is the patient willing to make a quit attempt at this time?
Assist in quit attempt.	For patients willing to make a quit attempt, offer medication and provide counseling or refer to a therapist. Set a quit date. Encourage the patient to ask friends and family for help and to remove all tobacco from their environment. For patients unwilling to quit, motivate them by explaining why quitting is relevant to them, emphasizing the risks of smoking and benefits of quitting, and identifying barriers. Repeat these motivational interventions at every visit.
Arrange follow-up.	For patients willing to quit, arrange for follow-up contacts, ideally within a week of the set quit date. For patients unwilling to set a quit date, address tobacco dependence at a future visit.

Other patient resources include smokefree.gov and helplines such as 1-800-QUIT-NOW (1-800-784-8669). Local communities may also have group counseling and intensive treatment programs, and you should familiarize yourself with these services.

Behavioral Interventions

Behavioral interventions include physician advice, nurse advice, individual counselling, and group counselling. For pregnant women, consider cognitive behavioral, motivational, and supportive therapies (e.g., health education, feedback, financial incentives, and social support).

Pharmacotherapy Interventions

All seven FDA-approved medications are recommended and effective. For first-line therapy, consider the two most effective drugs: varenicline and combination nicotine patch with as-needed nicotine replacement (6-month abstinence, 33% and 37%, respectively vs. 14% with placebo).

FDA-Approved Medications for Smoking Cessation

Medication	Use	Notes
Varenicline (Chantix)	Start 1 week before quit date; use for 3-6 months. Titrate dose as per FDA recommendations.	A nicotinic acetylcholine-receptor partial agonist Side effects: nausea, insomnia, vivid or abnormal dreams Reduce dose for patients with kidney disease (creatinine clearance <30 mL/min) Previous FDA black box warning of neuropsychiatric reactions removed in December 2016
Sustained-release bupropion (Zyban)	Start 1-2 weeks before quit date; use for 2-6 months.	Contraindicated with history of seizure disorders, eating disorders, or use of monoamine oxidase inhibitors (MAOIs) Side effects: insomnia, dry mouth Can cause hypertension

Nicotine Replacement Therapy
Nicotine patch	Dose of patch used depends on daily cigarette use. In patients who smoke ≥10 cigarettes/day a higher dose should be commenced.	Available over-the-counter Use new patch every morning Can remove at night if sleep is disrupted
Nicotine gum	Chew 1 piece every 1-2 hours initially (max 24/day), then taper. The dose of the gum used will also depend on patient’s daily cigarette use.	Available over-the-counter Correct technique: chew slowly until you taste the flavor, then “park” between cheek and gums to allow nicotine absorption through mucosa; “chew and park” until taste is gone (~30 min) Avoid eating or drinking 15 min before using
Nicotine lozenges	Consume 1 piece every 1-2 hours initially (max 20/day), then taper.	Available over-the-counter Allow to dissolve instead of chewing or swallowing Avoid eating or drinking 15 min before using
Nicotine inhaler (Nicotrol)	Use cartridge when craving is present.	Prescription only Avoid eating or drinking 15 mins before using
Nicotine nasal spray (Nicotrol NS)	Use spray when craving is present.	Prescription only Highest risk of dependence potential due to higher peak nicotine levels

Combination Therapy
Patch and sustained-release bupropion Patch and short-acting nicotine replacement (gum, lozenges, inhalers)

Electronic Cigarettes

The health effects of electronic cigarettes and their usefulness for smoking cessation are uncertain, and the long-term risks are not well understood.

Research

Landmark clinical trials and other important studies

Research

E-Cigarettes and Smoking Cessation in Real-World and Clinical Settings: A Systematic Review and Meta-Analysis

Kalkhoran S and Glantz SA. Lancet Respir Med 2016.

This is a systematic review of e-cigarettes in clinical settings.

Gradual Versus Abrupt Smoking Cessation: A Randomized, Controlled Noninferiority Trial

Lindson-Hawley N et al. Ann Intern Med 2016.

This noninferiority RCT conducted in primary care clinics in England showed that participants randomized to an abrupt smoking-cessation strategy had higher rates of abstinence than those in the gradual-cessation group at 4 weeks and at 6 months.

Randomized Trial of Four Financial-Incentive Programs for Smoking Cessation

Halpern SD et al. N Engl J Med 2015.

In this RCT, 2538 smokers were randomized to usual care or one of four different reward systems consisting of a combination of individual vs. group-based and reward vs. deposit-based incentives. Rates of sustained abstinence at 6 months were higher in both the reward (15.7%) and deposit (10.2%) programs when compared to usual care (6.0%).

Read the NEJM Journal Watch Summary