second major cause of death in the world and the leading cause of preventable death.
Since 1964, 29 reports by the U.S. surgeon general have concluded that tobacco use is the single most avoidable cause of disease, disability and death.
Today, published clinical guidelines state that every patient who uses tobacco should be offered treatment or provided with a brief intervention to increase the motivation to quit using tobacco.
Effective strategies are available to achieve smoking cessation.
Guide for Screening
The most widely used theory model for smoking cessation is the transtheoretical model of behavior change. By determining the patient's stage of readiness, the provider can more effectively tailor interventions.5 The five stages of change are precontemplation, contemplation, preparation, action and maintenance.
Once a patient has reached the preparation or action stage, more concrete and in-depth interventions can be used.3 The U.S. Public Health Service recommends using the 5 A's to evaluate and guide smoking cessation interventions in patients who are ready to quit:3
Ask: Ask every patient about smoking.
Advise: Advise tobacco users to stop.
Assess: Assess motivational stage. Discuss barriers and provide education.
Assist: Develop a quit plan with the patient.
Arrange: Arrange counseling and follow-up care.
Based on these steps, the first intervention is an evaluation of smoking status. Therefore, assessment should begin early in the clinical encounter. A charting tool is essential to the consistent documentation of smoking evaluation. It can be as simple as the following: Smoking: _Current _Former _Never. Evaluate smoking status at every patient visit.
Although it has not been proven to promote further interventions or increase the rate of smoking cessation on its own, a charting tool may be an effective part of the total intervention plan.6
Multiple therapies are available for smoking cessation (see table). Most are approved by the FDA; off-label use of others is supported by literature.
Tobacco withdrawal symptoms include headache, insomnia, fatigue, increased appetite and depression.7 Nicotine replacement reduces these symptoms and is available in gum, patches, nasal spray, inhalers, lozenges and tablets. Many of these are inexpensive and require no prescription. Nicotine replacement nearly doubles successful outcomes, especially in combination with nonpharmacologic strategies.7
Until recently, bupropion (Wellbutrin, Zyban) had been the only FDA-approved pharmaceutical alternative to nicotine replacement therapy.8 Bupropion use has doubled cessation rates when used alone and may have a greater influence on long-term cessation when combined with nicotine replacement.9 Bupropion is thought to improve cessation rates by addressing the depression component of nicotine addiction.
Nortriptyline and Clonidine
Nortriptyline (Pamelor, Aventyl) is a tricyclic antidepressant that can be an effective smoking cessation intervention. It has similar success rates to bupropion.9 Treatment of smoking cessation with nortriptyline is an off-label use.
Clonidine (Catapres) is another off-label choice for smoking cessation.3 A Cochrane Review recommends that clonidine be prescribed to patients only when other pharmacotherapy has failed, due to the possible serious adverse effects of this medication.10
Click to view larger graphic.
The FDA approved varenicline (Chantix) in 2006, and 2010 ushered in strong consumer marketing campaigns for this drug. Varenicline is the first alpha-4 beta-2 nicotinic acetylcholine receptor (nAChR) medication on the market. It works on brain receptors, specifically nAChR, where the addictive properties of nicotine are believed to be initiated.11,12 Research indicates that varenicline increases the rate of sustained cessation by three times compared with nonpharmacologic interventions.13 This rate of effectiveness is also higher than nicotine replacement therapies and bupropion.14
Special considerations are necessary for select populations, such as those with medical contraindications, those who smoke fewer than 10 cigarettes per day, pregnant or breastfeeding women, and adolescents.3 Encourage pregnant and breastfeeding smokers to attempt to quit smoking without pharmacologic therapy, and offer them intensive counseling. Nicotine replacement should be used during pregnancy only if the increased likelihood of quitting smoking outweighs the risks of nicotine replacement therapy.14 Adolescent patients should be considered candidates for nicotine replacement only with clear evidence of nicotine dependence and a clear desire to quit.14
Patients who are particularly concerned about weight gain would benefit from bupropion and nicotine replacement therapies, specifically nicotine gum.3 A combination of bupropion and nortriptyline appears to be effective for patients with a history of depression. Patients with a history of cardiovascular disease can safely use nicotine replacement therapies, except in the case of cardiac arrhythmias, immediately after myocardial infarction, and in the presence of severe angina pectoris, hypertension or vasospastic coronary heart disease.3
Putting It Into Practice
Nicotine dependence interventions can be adapted to the readiness of each patient. A consistent message from a healthcare provider can dramatically influence a patient's decision and ability to quit.
1. World Health Organization. Report on the global tobacco epidemic, 2009: implementing smoke-free environments. http://who.int/tobacco/mpower/. Accessed March 4, 2011.
2. Centers for Disease Control and Prevention. Targeting tobacco use: the nation's leading cause of preventable death. http://cdc.gov/NCCDPHP/publications/aag/pdf/osh.pdf. Accessed March 4, 2011.
3. Brief clinical interventions. In: Fiore MC, et al. Clinical Practice Guideline: Treating Tobacco Use and Dependence. Rockville, MD: US Dept of Health and Human Services; 2000:chap 3.
4. Ranney L, et al. Systematic review: smoking cessation intervention strategies for adults and adults in special populations. Ann Intern Med. 2006;145(11):845-856.
5. Detailed overview of the transtheoretical model. Cancer Prevention Research Center. http://www.uri.edu/research/cprc/TTM/detailedoverview.htm. Accessed March 4, 2011.
6. Piper ME, et al. Use of the vital sign stamp as a systematic screening tool to promote smoking cessation. Mayo Clin Proc. 2003;78(6):716-722.
7. Nicotine substitutes/nicotine replacement therapy. American Heart Association. http://www.americanheart.org/presenter.jhtml?identifier=4615.Accessed March 4, 2011.
8. Red Book. 112th ed. Montvale, NJ: Thomson Healthcare; 2008.
9. Hughes JR, et al. Antidepressants for smoking cessation. Cochrane Database Syst Rev. 2007;(1):CD000031.
10. Gourlay SG, et al. Clonidine for smoking cessation. Cochrane Database Syst Rev. 2004;(3):CD000058.
11. Coe JW, et al. Varenicline: an α4β2 nicotinic receptor partial agonist for smoking cessation. J Med Chem. 2005;48(10):3474-3477.
12. Jorenby DE, et al. Efficacy of varenicline, an α4β2 nicotinic acetylcholine receptor partial agonist, vs placebo or sustained-released bupropion for smoking cessation: a randomized controlled trial. JAMA. 2006;296(1):56-63.
13. Cahill K, et al. Nicotine receptor partial agonists for smoking cessation. Cochrane Database Syst Rev. 2011;(2):CD006103.
14. Gonzales D, et al. Varenicline, an α4β2 nicotinic acetylcholine receptor partial agonist, vs sustained-release bupropion and placebo for smoking cessation: a randomized controlled trial. JAMA. 2006;296(1):47-55.