Smoking Cessation

Smoking cessation is vital part of preventative health care. As such, primary care providers should be comfortable with an approach to counselling patients around smoking and cessation, and be aware of the pharmacotherapies available to assist in this goal.

Background
As of 2012, 16% of adults in Canada report that they are current smokers. Annually, of these, more than 70% have expressed desires to attempt quitting. Furthermore, 44% of smokers actually attempt to quit each year. Unfortunately, most who attempt quitting do not do so with the use of cessation aids, and thus two thirds usually relapse within the first few days of smoking.

Annually, only about 5-7% of quit attempts will remain successful.

ASK

 * Ask ALL patients if they smoke
 * Ask screening questions in a way to remove ambiguity in answers
 * eg. "Have you used tobacco in the last 6 months? If so, have you used tobacco in the last week?"
 * Ask patients if they have ever considered quitting

ADVISE

 * Advise your patient re: the risks of smoking, and the benefits of quitting
 * Risks of smoking include:
 * Cancer
 * Increased risk of lung cancer 25 fold
 * Can cause cancer almost anywhere in your body.
 * Cardiovascular Disease
 * Increased risk of CAD and stroke by 2-4 fold.
 * Respiratory Disease
 * Increased risk of developing COPD and emphysema
 * Others
 * Infertility
 * Pregnancy risks (IUGR, preterm delivery, SIDS, behavioral disorders)
 * Lower bone density

ASSESS

 * Assess state of change
 * Pre-contemplation
 * Contemplation
 * Preparation
 * Action
 * Maintenance
 * Relapse
 * Assess readiness
 * "In regards to your life right now, how important is it for you to quit smoking on a scale of 1-10?"
 * "How confident do you feel that you will be able to successfully quit, on a scale of 1-10?"
 * Assess challenges
 * Social triggers
 * Friends/family who smoke, social settings
 * EtOH use, other recreational drug use
 * Stress at home/work
 * Fears surrounding quitting
 * Weight gain
 * Increased anxiety

Behavioural therapy
There is well-documented evidence for the positive response relationship between counselling and quit success. Face to face counselling with the patient should be an integral of the quitting process. At minimum, smokers should have counselling once prior to their quit date, the week following their quit date and at regular intervals after.

Smokers attempting to quit should be encouraged to set a quit date within 2-4 weeks, with plenty of time to inform family, friends and colleagues to ensure full support. This also provides adequate time to remove all tobacco products from their environment. The patient should also be counselled to anticipate roadblocks and challenges, including creating plans for dealing with cravings and triggers.

Pharmacotherapy
First line (see section below) Second line Alternatives
 * Nicotine replacement therapy (NRT)
 * Zyban (Buprioprion SR)
 * Champix (Varenicline)
 * Clonidine
 * Nortriptyline
 * Hypnosis
 * Laser
 * Acupuncture

NRT
NRTs have been shown to provide double the quit rates as compared the placebo. Combinations of the various forms of NRT have been shown to provide even more efficacy in smoking cessation.

Options:
 * Patch
 * Dose
 * Smokingpatch.jpg patch - for smokers who intake <10 cigarettes/day
 * 21mg patch - for smokers who intake 10-29 cigarettes/day
 * 28mg patch - for smokers who intake >30 cigarettes/day
 * Few interactions, few side effects
 * Duration is generally recommended to be 4-6 weeks, though new data shows that there may be benefit to keeping the patch on longer (a new RCT out of Pennsylvania has shown some benefit in maintaining the patch for 24 weeks).
 * Gum
 * Bite once or twice on gum, then park gum between teeth and gums for a minute, bite again, then park. Repeat bite/park process for about half an hour. Time of onset 15-30 minutes.
 * Avoid po intake of acidic beverages (alcohol, caffeine, citrus juices) within 15 minutes of chewing
 * Acidic interactions decrease nicotine replacement
 * Dose:
 * 2mg for light smokers
 * 4mg for heavy smokers
 * Max: 20 pieces per day
 * Duration: up to 6 months
 * Side effects: GI upset, insomnia, jaw pain
 * Lozenge
 * Dissolves in mouth, do not chew
 * Do not take within 15 minutes of drinking acidic beverages
 * Onset around 15-30 minutes
 * Initial doses
 * Thrive
 * 1mg if smoking less than a pack a day
 * 2mg if smoking a pack a day or more
 * Max daily dose 25-30mg
 * Nicorette
 * 2mg if first cigarette is taken more than 30 minutes after waking
 * 4mg if first cigarette is smoked within 30 minutes of waking
 * Max: 15 lozenges per day
 * Duration: 6 months (use beyond this is not recommended)
 * Side effects: GI upset, jaw pain, insomnia
 * Inhaler
 * Take short shallow inhalations - each cartridge lasts about 20 minutes and delivers around 2 mg of absorbed nicotine
 * Avoid inhalation within 15 minutes of drinking acidic beverages
 * Dose
 * 1 cartridge as needed (up to a max of 12 per day) to start, titrate down as nicotine requirements decrease
 * Stop when use is reduced to 1-2 cartridges per day
 * Side effects: local irritation, cough, dyspepsia, insomnia, GI upset, headaches
 * Mouth Spray
 * Spray directly into mouth, avoiding the lips and avoiding swallowing immediately post spray.
 * Avoid po intake of acidic beverages within 15 minutes of taking
 * Dose - each spray delivers 1mg of nicotine
 * 1-2 sprays per 30-60 minutes as needed, to a maximum of 4 sprays per hour/64 sprays per day
 * Side Effects: Altered sense of taste, headaches, hiccups, nausea/vomiting, dyspepsia, oral soft tissue pain, stomatitis, dry mouth, burning lips.

Champix (Varenicline)

 * 0.5mg po daily for the first three days, then 0.5-1mg po bid for 12-24 weeks.
 * Cessation of smoking around 7-14 days after starting
 * Side effects: GI upset, insomnia
 * Caution re: neuropsychiatric side effects (suicidal/homicidal ideation). Monitor mood closely.
 * Quit rate is double to triple placebo, comparable with Zyban

Zyban (Buproprion)

 * 150mg SR po daily for the first three days, then BID for the next 7-12 weeks
 * Cessation of smoking about 7-14 days after starting
 * Side effects: GI upset, dry mouth, insomnia, headache, constipation, tremor
 * Contraindicated in those with seizure disorders, liver failure
 * Drug interactions with MAOi use.
 * Quit rate comparable with Champix, with the additional advantage of an antidepressant effect profile.