Tobacco Use

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In Process

Author / Curator: Jacob Mirsky MD MA

Faculty Advisor:

GUIDELINES:
The format of each page are recommended guidelines. They should be fluid as each topic will have a unique flow.

(1) Be concise.

(2) Be evidence-based. (Everything should have a reputable citation and resource)

(3) Be clinically relevant. (Avoid unnecessary discussion of pathophysiology and epidemiology if it does not help clinical decision-making).



Learning Objectives 

  • Appreciate the impact that smoking has on individual health and society at large
  • Develop a clinical framework for the primary care clinic for assessing patients who use tobacco and encouraging smoking cessation
  • Understand the basic treatment options for tobacco use

Top Teaching Points

  • Every patient should be counseled at every visit to avoid or stop tobacco use.
  • Quitting smoking increases life expectancy [1]
  • Smokers who quit smoking reduce their risk of developing and dying from tobacco-related disease [2][3]
  • Varenicline appears to be the most effective pharmacotherapy for smoking cessation, and both buproprion and nicotine patch are more effective than placebo. Combination therapy may be more effective, especially with nicotine products. [4]

Background

  • Epidemiology: Cigarette smoking is the leading preventable cause of mortality (15.1% smoking rates in US adults[5], ~500,000 deaths annually) - 70% want to quit, 5% who make an unaided quit attempt remain abstinent 1 year later
  • Risk factors: male, age 25-44, American Indian and Alaska Natives, disability, low socioeconomic status, LGBTQ, psychiatric disease, peer or parental influence [6][7]
  • Physiology / Pathophysiology: Nicotine in tobacco binds to nicotine cholinergic receptors in the brain and lead to the release of dopamine, glutamine, and GABA. Longterm exposure leads to desensitization of nicotinic cholinergic receptors, leading to ongoing dopamine release and addiction to nitocine. Physical nicotine addiction is supported by behavioral cues. [8]
  • Progression and Complications of Disease: cardiovascular disease, stroke, chronic obstructive pulmonary disease (COPD), cancer at multiple sites, pregnancy complications

Diagnosis

History [9]

  • Assess for side effects of and comorbidities associated with smoking such as COPD, coronary artery disease, malignancy, dysphagia, or dental problems

Signs and Symptoms

  • Assess for evidence of COPD, cardiovascular disease, or malignancy

Physical Exam Findings

  • General exam for evidence of malignancy
  • Oral exam for dental staining, gingival recession, leukoplakia, oral cancer
  • Pulmonary exam for evidence of COPD
  • Cardiovascular exam for evidence of cardiovascular disease

Recommended Work-up

  • Diagnosis is based on any acknowledged current tobacco use by patient
  • No testing generally needed, but spirometry can be useful if concern for lung disease

Management

Overview: every patient should be counseled at every visit to avoid or stop tobacco use. The most important aspects of managing patients who use tobacco is to normalize their experience and support them through the cessation process. It is critical to make a therapeutic alliance with the patient and to guide them through the process. Once the decision has been made to quit, it is critical to set a quit date and to follow up on barriers and successes afterward.

Non-pharmacological treatment

  1. Ask about tobacco use (including smokeless tobacco; intensity; frequency; duration of use)
  2. Advise to quit through clear personalized messages
  3. Assess willingness to quit
  4. Assist to quit and provide quitline number (1800-QUITNOW)
  5. Arrange follow-up and support
  • Counseling encompasses multiple modalities such as behavioral therapy, relaxation, practical counseling (skills training), and aversion therapy[15]
  • Acupuncture, mind-body interventions, and comprehensive tobacco control programs are also possibly effective[16]

Pharmacological treatments

  • Nicotine replacement should be offered to all smokers who do not have contraindications (recent MI, severe angina, severe arrhythmia, or pregnancy) if smoking cessation not possible: nicotine patch, nicotine gum, nicotine inhaler, nicotine lozenge, and nicotine nasal spray [17][18][19]
  • Varenicline (Chantix) - best efficacy (side effects of nausea and psychiatric black box but may reduce depression and does not appear to increase cardiovascular adverse events), especially compared to bupropion and likely nicotine replacement therapy monotherapy; avoid if history of suicidality or significant psychiatric disease[20][21][22]
  • Bupropion (Zyban) - inferior to Chantix, but ideal if weight is a problem; overall similar in efficacy to nicotine replacement therapy; avoid if history of seizures or bulimia[23][24][25]

Other Teaching Pearls

  • Advise patients to set a "quit date," preferably as soon as possible[26]
  • Using proactive outreach programs that offer smoking cessation interventions to smokers rather than making it optional has been shown to increase smoking cessation rates [27][28][29]

Trial Summaries

  • Cahill et al. 2016 [30] - varenicline may increase smoking abstinence more than bupropion or nicotine replacement therapy
  • Haas et al. 2015 [31] - combination of counseling, nicotine replacement therapy, and access to community-based resources is associated with greater tobacco abstinence rates for up to 1 year compared with usual care in low socioeconomic status settings

Ongoing controversies / New updates

Teaching Resources

Other links:

References

  1. Pirie et al.: The 21st century hazards of smoking and benefits of stopping: a prospective study of one million women in the UK. Lancet 2013;381:133-41.
  2. Anthonisen et al.: The effects of a smoking cessation intervention on 14.5-year mortality: a randomized clinical trial. Ann. Intern. Med. 2005;142:233-9.
  3. Jha et al.: 21st-century hazards of smoking and benefits of cessation in the United States. N. Engl. J. Med. 2013;368:341-50.
  4. Cahill et al.: Nicotine receptor partial agonists for smoking cessation. Cochrane Database Syst Rev 2016;:CD006103.
  5. Jamal et al.: Current Cigarette Smoking Among Adults - United States, 2005-2015. MMWR Morb. Mortal. Wkly. Rep. 2016;65:1205-1211.
  6. Jamal et al.: Current Cigarette Smoking Among Adults - United States, 2005-2015. MMWR Morb. Mortal. Wkly. Rep. 2016;65:1205-1211.
  7. Benowitz &: Nicotine addiction. N. Engl. J. Med. 2010;362:2295-303.
  8. Benowitz &: Nicotine addiction. N. Engl. J. Med. 2010;362:2295-303.
  9. Benowitz &: Nicotine addiction. N. Engl. J. Med. 2010;362:2295-303.
  10. Siu & U.S. Preventive Services Task Force: Behavioral and Pharmacotherapy Interventions for Tobacco Smoking Cessation in Adults, Including Pregnant Women: U.S. Preventive Services Task Force Recommendation Statement. Ann. Intern. Med. 2015;163:622-34.
  11. Lancaster & Stead: Physician advice for smoking cessation. Cochrane Database Syst Rev 2004;:CD000165.
  12. 2008 PHS Guideline Update Panel, Liaisons, and Staff: Treating tobacco use and dependence: 2008 update U.S. Public Health Service Clinical Practice Guideline executive summary. Respir Care 2008;53:1217-22.
  13. Boyle et al.: Electronic medical records to increase the clinical treatment of tobacco dependence: a systematic review. Am J Prev Med 2010;39:S77-82.
  14. Park et al.: Primary Care Provider-Delivered Smoking Cessation Interventions and Smoking Cessation Among Participants in the National Lung Screening Trial. JAMA Intern Med 2015;175:1509-16.
  15. Kotz et al.: Prospective cohort study of the effectiveness of smoking cessation treatments used in the "real world". Mayo Clin. Proc. 2014;89:1360-7.
  16. Tahiri et al.: Alternative smoking cessation aids: a meta-analysis of randomized controlled trials. Am. J. Med. 2012;125:576-84.
  17. Stead et al.: Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2012;11:CD000146.
  18. Cahill et al.: Pharmacological interventions for smoking cessation: an overview and network meta-analysis. Cochrane Database Syst Rev 2013;:CD009329.
  19. Lindson-Hawley et al.: Interventions to reduce harm from continued tobacco use. Cochrane Database Syst Rev 2016;10:CD005231.
  20. Cahill et al.: Pharmacological interventions for smoking cessation: an overview and network meta-analysis. Cochrane Database Syst Rev 2013;:CD009329.
  21. Kotz et al.: Cardiovascular and neuropsychiatric risks of varenicline and bupropion in smokers with chronic obstructive pulmonary disease. Thorax 2017;72:905-911.
  22. Ebbert et al.: Effect of varenicline on smoking cessation through smoking reduction: a randomized clinical trial. JAMA 2015;313:687-94.
  23. Cahill et al.: Pharmacological interventions for smoking cessation: an overview and network meta-analysis. Cochrane Database Syst Rev 2013;:CD009329.
  24. Kripke &: Antidepressants and smoking cessation. Am Fam Physician 2005;71:67-8.
  25. Banham & Gilbody: Smoking cessation in severe mental illness: what works?. Addiction 2010;105:1176-89.
  26. Aveyard et al.: Should smokers be advised to cut down as well as quit?. BMJ 2014;348:g2787.
  27. Haas et al.: Proactive tobacco cessation outreach to smokers of low socioeconomic status: a randomized clinical trial. JAMA Intern Med 2015;175:218-26.
  28. Fu et al.: Proactive tobacco treatment and population-level cessation: a pragmatic randomized clinical trial. JAMA Intern Med 2014;174:671-7.
  29. Danan et al.: Does Motivation Matter? Analysis of a Randomized Trial of Proactive Outreach to VA Smokers. J Gen Intern Med 2016;31:878-87.
  30. Cahill et al.: Nicotine receptor partial agonists for smoking cessation. Cochrane Database Syst Rev 2016;:CD006103.
  31. Haas et al.: Proactive tobacco cessation outreach to smokers of low socioeconomic status: a randomized clinical trial. JAMA Intern Med 2015;175:218-26.
  32. Walker et al.: Cytisine versus nicotine for smoking cessation. N. Engl. J. Med. 2014;371:2353-62.