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19. Etter JF, Huguelet P, Perneger TV, Cornuz J. Nicotine gum treatment before smok- 24. Stapleton JA, Russell MA, Feyerabend C, et al. Dose effects and predictors of ing cessation: a randomized trial. Arch Intern Med. 2009;169(11):1028- outcome in a randomized trial of transdermal nicotine patches in general practice.
20. Bullen C, Howe C, Lin RB, et al. Pre-cessation nicotine replacement therapy: prag- 25. Hajek P, Tønnesen P, Arteaga C, Russ C, Tonstad S. Varenicline in prevention of matic randomized trial. Addiction. 2010;105(8):1474-1483.
relapse to smoking: effect of quit pattern on response to extended treatment.
21. Britton J, Edwards R. Tobacco smoking, harm reduction, and nicotine product Addiction. 2009;104(9):1597-1602.
regulation. Lancet. 2008;371(9610):441-445.
26. 2008 PHS Guideline Update Panel, Liaisons, and Staff. Treating tobacco use and 22. Department of Health. A Smokefree Future: A Comprehensive Tobacco Control dependence: 2008 update U.S. Public Health Service Clinical Practice Guideline Strategy for England. London, England: Dept of Health; 2010.
executive summary. Respir Care. 2008;53(9):1217-1222.
23. Mooney M, White T, Hatsukami D. The blind spot in the nicotine replacement 27. Hajek P, West R, Foulds J, Nilsson F, Burrows S, Meadow A. Randomized com- therapy literature: assessment of the double-blind in clinical trials. Addict Behav.
parative trial of nicotine polacrilex, a transdermal patch, nasal spray, and an inhaler.
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Smoking Cessation Interventions:
A Primer for Physicians
Q uittingsmokingisreallyhard.Everyhealthcare
provider knows how difficult it can be to get Table. A Suggested Approach in Brief
our patients to quit smoking. Although smok- ing prevalence rates have decreased over time in the United • Follow the 5 A’s• Set a quit date States,1 approximately 1 in 5 Americans still smoke,2 and • Refer to a dedicated smoking cessation program or a telephone quitline it is estimated that half of all smokers will die prema-turely from a smoking-caused illness. Most smokers want Initial Drug Treatment
On the quit date, begin treatment with nicotine therapy using long-acting to quit, many try on their own, but the success rate is nicotine patches, approximating the current daily nicotine intake (eg, a low without help, 4% to 7%.3,4 There are few, if any, more patch delivering 21 mg/d for a patient smoking 20 cigarettes per day) for impactful interventions than helping our patients to quit 8 weeks, and consider adding short-acting nicotine therapy (ie, gum, lozenges, or inhalers) for acute cravings, not to exceed an additional 12mg/d of nicotine. Taper the patch doses over a period of 4 weeks.
Alternative Drug Treatment (1)
WHAT WORKS?
Begin sustained-release bupropion hydrochloride 1 to 2 weeks before thequit date using 150 mg every morning for 3 days and then 150 mg twicedaily for 7 to 12 weeks.
There has been steady progress in identifying effective in- Alternative Drug Treatment (2)
terventions for smoking cessation. Smoking cessation in- Begin varenicline tartrate 1 week before the quit date at 0.5 mg/d for 3 terventions that include both counseling and pharmaco- days, then 0.5 mg twice daily for 4 days, and then 1 mg twice daily for 3 therapy appear to be the most effective, and the more intensive the intervention, the greater the probability of suc-cess.3,4 Although brief counseling by physicians and otherhealth care providers has been associated with a small in- ride, and, most recently, varenicline tartrate (Table). Al-
crease in quitting,5 counseling provided by certified smok- though nicotine gum was first marketed in the United ing cessation specialists is likely to produce better re- States in 1984, there are now available several forms of sults.6 Counseling can be delivered in a face-to-face setting NRT besides the nicotine gum, including nicotine loz- or via a telephone quitline. There is now a national toll- enges, patches, nasal sprays, and oral inhalers. These forms free quitline (1-800-QUITNOW) for smokers who want of NRT deliver nicotine in different fashions. The patch help in quitting but prefer not to be counseled in person provides a long-acting dose of nicotine, whereas the gum, or live very far from medical facilities. While trained smok- lozenges, and inhalers deliver a shorter-acting “hit,” more ing cessation specialists may be the best providers of such similar to the physiological effect that occurs with smok- therapy, all health care providers should follow the 5 A’s ing a cigarette and, as such, are better suited to treating of smoking cessation (ie, ask about tobacco use, advise to acute withdrawal symptoms and nicotine cravings.4 Al- quit, assess willingness to quit, assist in a quit attempt, and though there was concern in the past that the use of NRT arrange follow-up).3 Additional sources of self-help smok- might worsen symptoms in patients with vascular dis- ing cessation aids are available as print and Web-based ma- ease, studies7,8 have demonstrated the safety of such use, terials and are helpful, albeit not as well studied.
even among hospitalized patients. Although safe, NRT There are 3 classes of first-line drugs available and is generally avoided during pregnancy, in the presence proven to aid smokers in quitting: nicotine replacement of serious arrhythmias, and within 2 weeks of new- therapy (NRT), sustained-release bupropion hydrochlo- onset unstable angina or a myocardial infarction.
ARCH INTERN MED/ VOL 171 (NO. 8), APR 25, 2011 2011 American Medical Association. All rights reserved.
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Sustained-release bupropion, an atypical antidepres- The standard NRT doses available from patches (ie, sant, was approved for use in smoking cessation in the Յ21 mg/d) may be insufficient to prevent withdrawal United States in 1997. Like NRT, sustained-release bu- symptoms in heavy smokers. For select highly depen- propion is proven to increase quit rates.3 Bupropion is be- dent smokers, NRT in doses sufficient to provide greater gun while patients are still smoking, with a TQD set 1 to than 21 mg/d of nicotine may be considered, approxi- 2 weeks after beginning treatment and with a usual treat- mating the patch dose to the number of cigarettes smoked ment duration of 7 to 12 weeks. Because bupropion low- daily.4,14 Another approach that requires additional in- ers the seizure threshold, it is contraindicated in patients vestigation is to extend NRT duration beyond 14 weeks, with a seizure disorder. Patients who are prescribed bu- treating nicotine addiction as a chronic disease.15 propion also require consistent follow-up because of its Additional pharmacotherapies are in the pipeline (eg, potential to produce neuropsychiatric symptoms. Bupro- the nicotine vaccine), and innovative nonpharmaco- pion can be used concurrently with other antidepres- logic approaches continue to be investigated (eg, Web- sants except for monoamine oxidase inhibitors.3,9 Fur- based interventions, hypnosis, and text messaging). How- thermore, a recent meta-analysis10 confirmed the safety and ever, there already exists a sufficient evidence base for efficacy of bupropion in patients with schizophrenia. On counseling and drug interventions that if broadly, whole- average, quit rates of approximately 20% can be expected heartedly, and effectively implemented would likely re- sult in decreased tobacco-related misery.
The newest medication for smoking cessation is vareni- cline, which was approved for use in the United States in 2006. Short-term quit rates as high as 50% and a longer-term quit rate of 29% have been reported with its use.12 Author Affiliations: General Internal Medicine Section,
Like bupropion, which is begun before a smoker’s TQD, San Francisco VA Medical Center, University of Califor- guidelines for the use of varenicline recommend a 1-week period of treatment before the quit date and a usual total Correspondence: Dr Simon, Professor of Clinical Medi-
of 12 weeks of therapy.3 Hajek and colleagues herein ex- cine and Epidemiology & Biostatistics, General Internal amined whether a longer 4-week period of pretreatment Medicine Section (111A1), San Francisco VA Medical would increase quit rates compared with the currently Center, 4150 Clement St, San Francisco, CA 94121.
recommended 1-week period. The authors reported that Financial Disclosure: None reported.
the longer duration of varenicline treatment in the pe-riod before the TQD more than doubled the probability 1. Centers for Disease Control and Prevention (CDC). State-specific preva- of short-term abstinence, from 21% in the group receiv- lence and trends in adult cigarette smoking—United States, 1998-2007. MMWR ing the currently recommended 1-week pre-TQD treat- Morb Mortal Wkly Rep. 2009;58(9):221-226.
ment to 47% in the intervention group receiving the ad- 2. Centers for Disease Control and Prevention (CDC). Vital signs: current ciga- rette smoking among adults aged Ն18 years—United States, 2009. MMWR ditional 3 weeks. Although these findings are exciting and Morb Mortal Wkly Rep. 2010;59(35):1135-1140.
have the potential to change the clinical use of vareni- 3. Fiore MC, Jae´n CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update: Clinical Practice Guideline. Rockville, MD: Public Health Ser- cline, replication with a longer duration of follow-up vice, US Dept of Health and Human Services; May 2008.
4. Hurt RD, Ebbert JO, Hays JT, McFadden DD. Treating tobacco dependence in a medical setting. CA Cancer J Clin. 2009;59(5):314-326.
5. Stead LF, Bergson G, Lancaster T. Physician advice for smoking cessation.
NEW APPROACHES
Cochrane Database Syst Rev. 2008;(2):CD000165.
6. Hughes JR. Tobacco treatment specialist: a new profession. J Smoking Cessation.
Historically, we used one pharmacotherapeutic agent at a 7. Stead LF, Perera R, Bullen C, Mant D, Lancaster T. Nicotine replacement therapy time for smokers who wanted to quit. We now know that for smoking cessation. Cochrane Database Syst Rev. 2008;(1):CD000146.
combining drug therapy, perhaps analogous to the treat- 8. Rigotti NA, Munafo MR, Stead LF. Interventions for smoking cessation in hospitalised patients. Cochrane Database Syst Rev. 2007;(3):CD001837.
ment of tuberculosis or AIDS, increases the chance of suc- 9. Hurt RD, Isaacs SL, Schroeder SA, Simon JA, eds. Treating tobacco depen- cess compared with monotherapy.3,4 Combinations of drugs dence in a medical setting: best practices. In:VA in the Vanguard: Building on that have been demonstrated to be more effective than Success in Smoking Cessation. Bethesda, MD: Dept of Veterans Affairs; 2005:43-76.
monotherapy include the nicotine patch plus the nicotine 10. Tsoi DT, Porwal M, Webster AC. Efficacy and safety of bupropion for smok- gum, nasal spray, or inhaler.4 At our institution, we have ing cessation and reduction in schizophrenia: systematic review and also used successfully the nicotine patch plus the nicotine meta-analysis. Br J Psychiatry. 2010;196(5):346-353.
11. Roddy E. Bupropion and other non-nicotine pharmacotherapies. BMJ. 2004; lozenge, a form of NRT that we have found to be well ac- cepted. The nicotine oral inhaler plus sustained-release bu- 12. Hays JT, Ebbert JO. Varenicline for tobacco dependence. N Engl J Med. 2008; propion is another efficacious drug combination,4 and a re- 13. Steinberg MB, Greenhaus S, Schmelzer AC, et al. Triple-combination phar- cent study13 reported triple combination therapy with the macotherapy for medically ill smokers: a randomized trial. Ann Intern Med.
nicotine patch, the nicotine inhaler, plus ad libitum bu- 14. Hays JT, Ebbert JO, Sood A. Treating tobacco dependence in light of the 2008 propion to be superior to nicotine patches alone in a popu- US Department of Health and Human Services clinical practice guideline.
lation of medically ill smokers. However, combining vareni- Mayo Clin Proc. 2009;84(8):730-735, quiz 735-736.
cline with NRT is not recommended because of an increased 15. Steinberg MB, Schmelzer AC, Richardson DL, Foulds J. The case for treat- ing tobacco dependence as a chronic disease. Ann Intern Med. 2008;148 ARCH INTERN MED/ VOL 171 (NO. 8), APR 25, 2011 2011 American Medical Association. All rights reserved.
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