Background
Tobacco Cessation Guidelines
Pharmacotherapy for Smoking Cessation
        Pharmacologic interventions to assist in tobacco cessation
Smoking Reduction

Background

Many health risks related to tobacco smoking can be reduced by smoking cessation. Smokers who quit smoking before the age of 50 years have up to half the risk of dying within 15 years compared with people who continue to smoke, and the risk of dying is reduced substantially even among persons who stop smoking after age 70 years.[1] The risk of lung cancer is 30% to 50% lower than that of continuing smokers after 10 years of abstinence, and the risk of oral and esophageal cancer is halved within 5 years of cessation.[1] Former smokers also lower their risk of cervical and bladder cancer.[1,2]

In a randomized trial of heavy smokers, the long-term follow-up results demonstrated that compared with the nonintervention group (n = 1,964), those randomly assigned to a smoking cessation intervention (n = 3,923) experienced a 15% reduction in all-cause mortality rates (8.83 vs. 10.38 per 1,000 person-years, P = .03).[3] The smoking cessation intervention consisted of a strong physician message plus 12 group sessions and nicotine gum administered during a 10-week period. Decreases in the risk of lung and other cancers as well as coronary heart disease, cardiovascular disease, and respiratory disease contributed to the benefit in the group randomly assigned to the smoking cessation intervention.

A number of approaches at the policy, legislative, and regulatory levels have been attempted to effect widespread reduction in or prevention of commencement of tobacco use. Various efforts at the community, state, and national level have been credited with reducing the prevalence of smoking over time. These efforts include: reducing minors’ access to tobacco products, disseminating effective school-based prevention curricula together with media strategies, raising the cost of tobacco products, using tobacco excise taxes to fund community-level interventions including mass media, providing proven quitting strategies through health care organizations, and adopting smoke-free laws and policies.[4,5] School-based interventions alone have not demonstrated long-term impact for smoking prevention. A large, rigorous, randomized trial in which children were exposed from grades 3 through 12 to a theory-based program that incorporated various social-influence approaches found no difference in smoking outcomes either at grade 12 or at 2 years after high school between school districts receiving the intervention and those in the control arm.[6]

The Community Intervention Trial for Smoking Cessation (COMMIT) was an NCI-funded large-scale study to assess a combination of community-based interventions designed to help smokers cease using tobacco. COMMIT involved 11 matched pairs of communities in North America, which were randomly assigned to an arm offering an active community-wide intervention or a control arm (no active intervention).[7] The 4-year intervention included messaging through existing media channels, major community organizations, and social institutions capable of influencing smoking behavior in large groups of people. The interventions were implemented in each community through a local community board that provided oversight and management of COMMIT activities.

In the cohort analysis of COMMIT, there was no difference in the mean quit rate of heavy-smokers in the intervention communities (18.0%) compared with the control communities (18.7%). The light-to-moderate smoker quit rates were statistically significantly different: averages of 30.6% and 27.5% for the intervention and control communities, respectively (P = .004). Although no significant differences in quit rates between the sexes were observed, less-educated light-to-moderate smokers were more responsive to the intervention than were college-educated smokers with a light-to-moderate habit.[8,9]

Clinical interventions targeted at individuals have shown more promising results; however, a meta-analysis of randomized controlled trials shows that 6- to 12-month cessation rates are significantly improved with use of nicotine replacement therapy products compared with placebo or no intervention (summary odds ratio [OR], 1.77; 95% confidence interval [CI], 1.66–1.88).[10] The benefits of nicotine replacement therapy product use have been consistently observed regardless of whether the product used was the patch, gum, nasal spray, inhaler, or lozenge.[10] Smoking cessation counseling alone is also effective; even a brief intervention by a health care professional significantly increases the smoking cessation rate.[11]

Promoting smoking cessation among cancer survivors is essential because the deleterious health effects of cigarette smoking may impact prognosis in both the short term and long term. In a randomized controlled trial of a peer-delivered smoking cessation intervention among childhood cancer survivors, a significantly higher 12-month quit rate was observed in the intervention group (15% vs. 9%, P < .01).[12]

In 1996, the Agency for Health Care Policy and Research (AHCPR), now the Agency for Healthcare Research and Quality released a landmark set of clinical smoking-cessation guidelines for helping nicotine-dependent patients and healthcare providers.[13] The Tobacco Cessation Guidelines have subsequently been updated and are available online.[14,15]

The broad elements of these guidelines are:

1. Clinicians should document the tobacco-use status of every patient.
2. Clinicians should assess the readiness to quit of patients who use tobacco and assist those who wish to quit in setting a quit date.
3. Patients using tobacco should be provided with at least one of the effective brief cessation interventions that are available.
4. In general, more intense interventions are more effective than less intense interventions in producing long-term tobacco abstinence, reflecting the dose-response relationship between the intervention and its outcome.
5. One or more of the three treatment elements identified as being particularly effective should be included in smoking-cessation treatment:
   1. Social support from clinicians in the form of encouragement, assistance.
   2. Skills training/problem solving (cessation/abstinence techniques).
   3. Pharmacotherapy, such as nicotine-replacement, e.g., patches, gum.
6. To be effective, health care systems must make institutional changes resulting in systematic identification of tobacco users and intervention with these patients at every visit.

For individual interventions, the guidelines [14,15] suggest a model based on outcomes from six major clinical trials of physician-delivered smoking intervention conducted in the late 1980s:[16] the ASK, ADVISE, ASSESS, ASSIST, and ARRANGE model. The physician provides a brief intervention that entails asking about smoking status at every visit, advising abstinence, assisting by setting a quit date, providing self-help materials and recommending use of nicotine replacement therapy, and arranging for a follow-up visit. See below for brief and expanded intervention outlines. The recommendations also strongly support the value of referral to more intensive counseling.

Ask, Advise, Assess, Assist, Arrange: Key Elements

1. Ask
   • Screen for smoking status at every visit or admission.
2. Advise
   • Minimal Advice: “As your physician, I must advise you that smoking is bad for your health, and it would be important for you to stop.”
   • Augmented Advice: “Because of your (__________) condition, it is particularly important for you to stop. If you stop now, (briefly educate patient about basic health benefits from quitting).”
3. Assess
   • Minimal Assessment: Ask every tobacco user if he/she is willing to make a quit attempt at this time.
   • Augmented Assessment: Assess characteristics of smoking history and patterns.
     • Amount smoked.
     • Quit history.
     • Stage of Change:
       • Precontemplator: Is not seriously considering stopping smoking.
       • Contemplator: Is seriously considering stopping within 3 to 6 months.
       • Preparation: Is seriously considering stopping within the next week to month and has already made changes such as cutting back.
       • Action: Has recently stopped smoking (within last 6 months).
       • Relapse: Has quit for at least 48 hours but is smoking again.
       • Maintenance: Has quit for at least 6 months but may still be vulnerable to a relapse up to 1 year.
     • Nicotine Addiction: Fagerstrom Test for nicotine dependency.
     • Behavioral Patterns: "Why Do You Smoke?" Scale.
4. Assist/Counsel
   • Minimal Assistance: Provide self-help materials; assess interest in quitting; and assess interest in and appropriateness of pharmacological aids.
   • Augmented Assistance: Provide brief 5 to 7 minute patient-centered counseling. See below for an outline of the counseling content.
5. Arrange Follow-up Support
   • Minimal Follow-up Support: Arrange for single follow-up contact by visit or by telephone in about 2 weeks; provide referral to a smoking counselor or group.
   • Extended Follow-up Support: Establish “quit smoking” contract with quit date. Arrange three or more follow-up contacts by visit or by telephone.

Patient-Centered Counseling: Key Elements

• Motivation
  • Basic Question:
    • “How do you feel about smoking?”
  • Follow-up Questions:
    • “How do you feel about stopping smoking?”
    • “Have you ever tried to stop before?” “What happened?”
    • “What do you like about smoking?”
    • “What do you not like about smoking?”
• Anticipated Problems
  • Basic Question:
    • “What problems will you have if you stop smoking?”
  • Follow-up Questions:
    • “Anything else?”
    • “On the ‘Why Do You Smoke?’ questionnaire, you scored high on (_______). How do you think you can handle that type of situation?”
• Resources for Coping with Problems
  • Basic Question:
    • “How do you think you can handle that?”
  • Follow-up Questions:
    • “What else could you do?”
    • “How do you expect your (family/spouse/friends) to help you?”

Pharmacological agents have been used successfully to aid in the cessation of smoking in the general population.[17] Since the original AHCPR guidelines [13] were published in 1996, various nicotine replacement products have been approved for over-the-counter sale, and additional evidence of the effectiveness of therapies for smoking cessation has been published.[18-21] Pharmacotherapy of smoking, including nicotine replacement therapies (gum, patch, spray, lozenge, and inhaler) and nonnicotine medications (e.g., bupropion and varenicline) result in statistically significant increases in smoking cessation rates compared with a placebo. Several trials have shown cessation rates in groups using nicotine replacement therapies as an adjunct to behavioral therapies to be higher than in groups using a placebo at 6 and/or 12 months.[18] For example, in one randomized controlled trial of 227 patients, 26% of those randomly assigned to active treatment with nicotine nasal spray (n = 30) were abstinent throughout 1 follow-up year, compared with 10% (n = 11) of those randomly assigned to a placebo (relative abstinence rate 2.6; CI, 1.5–4.5).[22] The impact in a study of nicotine patch and nicotine nasal spray used with minimal behavioral intervention in a nonspecialized setting, however, was smaller in magnitude. Approximately 8% of smokers had sustained cessation at 6 months after a 6-week treatment with the patch, nasal spray, or a combination of the two.[23] In a randomized controlled trial of 615 people administered various doses of bupropion or placebo, after 7 weeks of treatment with bupropion, cessation rates were statistically significantly higher in a dose-dependent fashion (19% for placebo, 28.8% in those treated with 100 mg/day, 38.6% in those treated with 150 mg/day, and 44.2% in those administered 300 mg/day). Despite high rates of recidivism at 1 year, the positive effect of the intervention persisted (19.6%–23.1% for the bupropion groups compared with 12.4% for placebo).[19] In another controlled trial, 244 patients received bupropion only, 244 patients received a nicotine patch, 245 patients received both, and 160 patients received a placebo.[20] Interventions lasted 8 to 9 weeks. At 1 year, the abstinence rate was better for bupropion compared with placebo (30.3% vs. 15.6%) than for patch compared with placebo (16.4% vs. 15.6%). The combination of patch and bupropion resulted in better quit rates than bupropion alone (35.5% vs. 30.3%), but this was not statistically significant. Varenicline is a selective alpha-4-beta-2 nicotinic acetylcholine receptor partial agonist. In two randomized controlled trials for smoking cessation, varenicline titrated to a dose of 1.0 mg twice a day was compared with bupropion SR 150 mg twice a day and with a placebo group.[24,25] Treatment lasted for 12 weeks, with an additional 40 weeks of posttreatment follow-up. In both studies, varenicline was significantly more efficacious than bupropion and placebo for continuous abstinence from smoking at 9 to12 weeks and 9 to 24 weeks of follow-up. For 9 to 52 weeks of follow-up, varenicline was significantly more efficacious than placebo in both studies.[24,25] At 52 weeks of follow-up, the 7-day point prevalence of smoking abstinence was 46% higher in the varenicline group than in the bupropion SR group (OR, 1.46; 95% CI, 1.04–2.06).[24] The other study also showed a 46% higher continuous abstinence in the varenicline group (OR, 1.46; 95% CI, 0.99–2.17).[25] Approximately 30% of the participants who were randomly assigned to receive varenicline reported nausea, more than double that in the buproprion groups and triple that seen in the placebo groups.

It is clear that pharmacotherapy offers a useful adjunct to smoking cessation counseling. The choice of therapy should be individualized based on a number of factors, including past experience, patient and/or physician preference, and potential agent side effects. As more is learned about specific genetic variants that influence a smoker's response to smoking cessation pharmacotherapies—such as polymorphisms in genes encoding enzymes involved in nicotine metabolism—this information could eventually be integrated into smoking cessation treatment planning.[26] Presently, the evidence is not yet sufficient to be integrated into clinical practice.

The following sections summarize available pharmacologic interventions to assist in tobacco cessation. More comprehensive information is available from product package inserts.

These products are designed to aid in the withdrawal symptoms associated with nicotine. Several precautions are warranted before initiating therapy, but it should be noted that these precautions do not constitute absolute contraindications. In particular, special considerations are necessary in some patient groups, e.g., those with medical conditions such as arrhythmias, uncontrolled hypertension, esophagitis, peptic ulcer disease, insulin-treated diabetes, or asthma, pregnant or breast-feeding women, and adolescent smokers.[27]

Also used as an antidepressant, bupropion HCl is a nonnicotine aid to smoking cessation. It is a relatively weak inhibitor of the neuronal uptake of norepinephrine, serotonin, and dopamine, and does not inhibit monoamine oxidase. The exact mechanism by which bupropion HCl enhances the ability of patients to abstain from smoking is unknown; however, it is presumed that this action is mediated by noradrenergic or dopaminergic mechanisms.

Although Zyban (bupropion HCl) is the only antidepressant approved by the U.S. Food and Drug Administration (FDA) for smoking cessation, Prozac (fluoxetine HCl) has been shown to be effective.[28]

Lobeline (Bantron) is classified as a category III agent by the FDA, safe but no proven effectiveness. This product is not recommended for use in any smoking cessation program due to its lack of efficacy.[29]

Clonidine and nortriptyline have been suggested as possibly useful second-line pharmacotherapies, but are not approved for smoking cessation by the FDA. Nortriptyline is an antidepressant that does not contain nicotine. A meta-analysis of five randomized controlled trials found that smokers who received nortriptyline were 2.4 times more likely (95% CI, 1.7–3.6) than smokers who received a placebo to remain abstinent from smoking after 6 months.[30]

Among dependent smokers, complete abstinence from smoking is the ultimate goal. Even in instances when complete abstinence from smoking is not achieved, smoking cessation pharmacotherapies may benefit individual health—and ultimately the public’s health—if the smoker reduces the number of cigarettes smoked. The relationship between cigarette smoking and lung cancer, and other smoking-associated malignancies, is strongly dose-dependent. Thus, an individual smoker who is unable to achieve abstinence or who is not motived to quit smoking may benefit by using pharmacotherapies (or other means) to reduce the number of cigarettes smoked per day. Nicotine replacement therapy (NRT) has thus generated attention as a viable means of “harm reduction.” In studies that randomly assigned smokers who were not trying to quit to NRT or placebo, a greater proportion of those randomly assigned to NRT compared with placebo reduced the number of cigarettes per day.[31,32] However, the impact of NRT on smoking reduction appears not to be sustained in the long run.[33] Less evidence is available for bupropion and psychosocial interventions as a means of harm reduction. A potential problem with such a harm reduction strategy would be if it prevented cessation among smokers who would have otherwise quit smoking. To the contrary, evidence shows that smoking reduction is actually associated with increased likelihood of future cessation.[32,34] Another potential negative aspect of harm reduction would be if smokers reduced the number of cigarettes smoked per day but modified the way the cigarettes were smoked in such a way that exposure to tobacco toxins was not actually reduced, for example, by inhaling more deeply. Compensatory behaviors such as inhaling more deeply or smoking more of a cigarette are attempts by the smoker to try to maintain nicotine levels, so the use of supplemental NRT presumably safeguards against this. Evidence from studies of smoking reduction with NRT that measured smoking biomarkers indicates that compensation occurs, but not to such an extent that it would be expected to outweigh the reduction in exposure from the reduced number of cigarettes per day.[31]

References

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