Quitting Smoking

“Quitting smoking is easy. I’ve done it a thousand times”—Mark Twain

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At this time of year, many of your patients are likely to make a resolution to stop smoking. But like all good intentions that go awry, patients may need your support and encouragement to help them through the physiologic and psychological barriers they face in quitting. Many of them are also likely to ask you about the latest trend in smoking cessation aids—electronic cigarettes.

Nicotine dependence is the most common form of chemical dependence in the United States,[1] and research suggests that nicotine may be as addictive as heroin, cocaine, or alcohol.[2] Because of the addictive component, quitting smoking is difficult and often requires multiple attempts; relapses are common because of stress, weight gain, and withdrawal symptoms.

But yet, Americans are smoking fewer cigarettes per year. During the past 40 years, the quit rate has outstripped the initiation rate, so there are now more former smokers than current smokers,[3] with 69% of current smokers having expressed a desire to quit.[4]

What makes people want to stop smoking?

Older people are motivated by the health consequences: half of all smokers who keep smoking will end up dying from a smoking-related illness. In the United States alone, smoking is responsible for nearly 1 in 5 deaths, and about 8.6 million people currently suffer from smoking-related lung and heart diseases.[5,6] Younger people cite the cost of cigarettes, the lingering smell, and the fact that most states have enacted smoking legislation that prohibits smoking in all public places.[5]

Because 70% of patients who smoke receive care from primary care clinicians,[7] you’re in a unique position to evaluate your patients’ readiness to quit smoking. You can offer strong support, help set a quitting date, prescribe pharmacologic therapies for nicotine dependence, and suggest behavioral strategies to prevent relapse. At each visit, you can advise smokers to quit in a clear, strong, and personalized manner, linking the advice to the patient’s health status whenever possible. The Agency for Healthcare Research and Quality (AHRQ) 2008 Clinical Practice Guidelines[7] on treating tobacco use and dependence urges clinicians to treat tobacco use as a chronic disease and recommends that you use the 5 A’s (Ask, Advise, Assess, Assist, and Arrange) model when treating patients who smoke.

Both Medicare and private payers cover smoking cessation counseling for outpatient and hospitalized patients who use tobacco, regardless of whether the patient has signs or symptoms of tobacco-related disease. For a list of HCPCS, CPT, and ICD-9 codes related to tobacco cessation counseling see Codes Related to Tobacco Cessation Counseling.

For patients who are ready to quit, pharmacotherapy has historically been a key component of the care plan. There are seven FDA-approved medications specifically for treating tobacco use: bupropion SR (Zyban, Wellbutrin, and generics), varenicline (Chantix), and a number of nicotine replacement therapy (NRT) products in the form of gum, inhalers, lozenges, nasal spray, and patches. All of these medications have specific contraindications, warnings, precautions, other concerns, and adverse effects that should influence your selection, along with pragmatic factors such as insurance coverage, out-of-pocket patient costs, likelihood of adherence, dentures when considering the gum, or dermatitis when considering the patch. Because Chantix and bupropion carry a warning about the possibility of depressed mood, agitation, behavior changes, and suicide, you should consider your patient’s psychiatric history before prescribing either medication.

There continues to be concern about the safety of Chantix. A 2011 meta-analysis from 14 trials suggests that Chantix was associated with a significantly increased risk of serious adverse cardiovascular events compared with placebo.[8] The U.S. Food and Drug Administration (FDA) has addressed this issue by requiring Chantix to carry a label warning of its association with a small, increased risk of adverse cardiovascular events.[9] The drug was effective in helping patients with cardiovascular disease quit smoking, however, the FDA has recommended that you weigh the potential benefits of Chantix against its potential risks when deciding to use the drug in patients with cardiovascular disease.

Since we published this article, a new study has been released, suggesting that NRT has no real effect on smoking relapse.[10] This “real-world” study evaluated 787 Massachusetts residents who had recently quit smoking and followed them at three time points over four years. Initially and at each follow-up, the smokers were asked whether they had used NRT, for how long, and whether they had received behavioral therapy (smoking cessation program or behavioral counseling). After four years of follow-up, two-thirds of the smokers had  relapsed. There was no difference in the relapse rate among those who had used NRT for at least six weeks—with or without professional counseling—or whether they were light or heavy smokers. Those most likely to relapse were heavy smokers (those who had their first cigarette within a half-hour of waking up) who used replacement products without counseling.

In interviews, several researchers not affiliated with the trial have proposed that the high relapse rate could be due to the fact that the smokers we re using NRT on their own, without medical support. It may be that the one-third of the patients who remained smoke-free saw their healthcare providers more often and were encouraged to use a full course of NRT, which is usually about 12 weeks.[10]

The New Kid on the Block

Perhaps the most controversial topic related to smoking cessation is the increased popularity of electronic cigarettes (e-cigarettes), marketed as an alternative to smoking cigarettes. First patented in China, e-cigarettes became available to the U.S. market about four years ago. Since then, the customer base has grown quickly. Researchers with the U.S. Centers for Disease Control and Prevention surveyed more than 10,000 people in both 2009 and 2010 and found that awareness of e-cigarettes doubled in that time; the portion of respondents who said they had tried them had more than quadrupled to 2.7% in 2010.[11]

E-cigarettes are battery-powered, cigarette-shaped vaporizers that use flavored liquids to deliver a dose of nicotine with each draw. Propylene glycol—the chemical used to generate artificial “smoke” for theatrical productions—is added to the liquid to stimulate the appearance of smoke from a “real” cigarette. The device aerosolizes nicotine so that when the user inhales (“vapes”), nicotine is readily transported into the respiratory tract and then enters the bloodstream, resulting in a near instantaneous nicotine “rush.”[12]

The contents of the liquid solutions vary, but typically include water and flavorings in a propylene glycol or glycerin base. Hundreds of different flavors are available, ranging from regular tobacco and menthol to popular foods and beverages. The solutions that contain nicotine are available in differing nicotine concentrations to suit user preference. They range from no nicotine to extra high (24-36 mg), which corresponds most closely to the amount of nicotine in a cigarette.

Are e-cigarettes less harmful than real ones? Advocates say they help smokers quit, but health officials aren’t so sure.

Unfortunately, little is known about the long-term safety of e-cigarettes. One study has reported that after five minutes, smokers of e-cigarettes (or “vapers”) showed immediate adverse pulmonary metrics compared with placebo.[13] In 2009, the FDA’s Division of Pharmaceutical Analysis analyzed the ingredients in a small sample of cartridges from two leading brands of electronic cigarettes.[14] One sample contained diethylene glycol, a chemical used in antifreeze that is toxic to humans, and several other samples contained carcinogens, including nitrosamines.

There is a paucity of information as to whether e-cigarettes can help folks stop smoking.

Anecdotal evidence from former smokers suggests that vapers are able to stop smoking, even if pharmacotherapy had been unsuccessful. A small study published in 2010 found that among 40 smokers who used e-cigarettes for six months, 50% cut their cigarette use by at least half; nine stopped smoking entirely.[15] Another study has shown a decreased desire to smoke with the use of e-cigarettes after overnight abstinence, when compared with a placebo or regular cigarettes.[16] In a survey of 222 smokers, 31% reported having quit smoking six months after first purchasing an e-cigarette. However, the response rate to the survey was very low.[17] On the other hand, data from the University of Virginia suggest that relative to a ‘regular’ cigarette, 10 puffs from e-cigarettes with a 16-mg cartridge delivered little or no nicotine and was not successful at suppressing cravings.[18]

Public health officials have been slow to embrace e-cigarettes as a smoking cessation tool. They worry that the devices’ fruit flavors, novelty, and ease of access may entice children to take up the practice. They are concerned that there are no methods for proper disposal of e-cigarette products and accessories, including cartridges, which could have a negative impact on water and soil. In addition, batteries, atomizers, cartridges, cartridge wrappers, packs, and instruction manuals lack important information regarding e-cigarette content, use, and essential warnings.

For now, the devices are unregulated by the federal government and there are no safety standards for manufacturing and marketing. That opens the door for individual states to enact their own legislation; Arizona, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, and Washington are all considering, or have enacted, legislation restricting the sale and use of e-cigarettes, particularly to minors.

What can you tell patients?

E-cigarettes are not an approved smoking cessation product. The proper testing and research has not been conducted to prove the efficacy of e-cigarettes as a smoking cessation aid and manufacturers and suppliers of the devices are not permitted to market them as such. The key points for patients include[11]

  • E-cigarettes are not FDA approved as quit smoking devices.
  • The vapors from e-cigarettes are complex mixtures of chemicals, not pure nicotine. It’s unclear whether inhalation of the complex mixture of chemicals in e-cigarettes is safe.
  • There is no evidence that e-cigarettes help smokers to quit smoking.
  • Manufacturers and suppliers are not allowed to market e-cigarettes as nicotine replacement therapies like the patch and the gum.
  • There is increasing resistance to the use of e-cigarettes in public places and outright bans in a growing number of states.
  • The promotion of e-cigarettes may communicate a message to children and adolescents that vaping is harmless, inadvertently increasing the risk of nicotine addiction and tobacco use in a vulnerable population.[12]

Jill Shuman, MS, ELS
Published January 10, 2012
Updated January 11, 2012

References

  1. American Society of Addiction Medicine. Public Policy Statement on Nicotine Dependence and Tobacco. Chevy Chase, MD: American Society of Addiction Medicine, 2008.
  2. How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General. Rockville, MD: Dept. of Health and Human Services, Public Health Service, Office of Surgeon General; 2010.
  3. Centers for Disease Control and Prevention. Vital signs: current cigarette smoking among adults aged ≥18 years—United States, 2009. MMWR Morb Mortal Wkly Rep. 2010;59(35):1135-1140.
  4. Centers for Disease Control and Prevention. Quitting smoking among adults—United States, 2001-2010. MMWR Morb Mortal Wkly Rep. 2011;60:1513-1519.
  5. American College of Chest Physicians. Age affects motivation for quitting smoking. ScienceDaily Website. http://www.sciencedaily.com/releases/2007/10/071022124735.htm. Published October 22, 2007. Accessed January 1, 2012.
  6. American Cancer Society. Guide to quitting smoking. American Cancer Society Website. http://www.cancer.org/acs/groups/cid/documents/webcontent/002971-pdf.pdf. Revised November 21, 2011. Accessed January 1, 2012.
  7. Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service; 2008.
  8. Singh S, Loke YK, Spangler JG, Furberg CD. Risk of serious adverse cardiovascular events associated with varenicline: a systematic review and meta-analysis. CMAJ. 2011;183(12):1359-1366.
  9. FDA Drug Safety Communication: Chantix (varenicline) may increase the risk of certain cardiovascular adverse events in patients with cardiovascular disease. U.S. Food and Drug Administration Website. http://www.fda.gov/Drugs/DrugSafety/ucm259161.htm. Published June 16, 2011. Accessed January 1, 2012.
  10. Alpert HR, Connolly GN, and Biener L. A prospective cohort study challenging the effectiveness of population-based medical intervention for smoking cessation [published online ahead of print January 10, 2012]. Tob Control. doi: 10.1136/tobaccocontrol-2011-050129.
  11. Regan AK, Promoff G, Dube SR, Arrazola R. Electronic nicotine delivery systems: adult use and awareness of the ‘e-cigarette’ in the USA [published online ahead of print November 28, 2011]. Tob Control. doi:10.1136/tobaccocontrol-2011-050044.
  12. Kuschner WG, Reddy S, Mehrotra N, Paintal HS. Electronic cigarettes and thirdhand tobacco smoke: two emerging health care challenges for the primary care provider. Int J Gen Med. 2011;4:115-120.
  13. Vardavas CI, Anagnostopoulos N, Kougias M, et al. Acute pulmonary effects of using an e-cigarette: impact on respiratory flow resistance, impedance and exhaled nitric oxide [published online ahead of print December 22, 2011]. Chest. doi: 10.1378/chest.11-2443.
  14. U.S. Food and Drug Administration. FDA warns of health risks posed by e-cigarettes. Food and Drug Administration Website.  http://www.fda.gov/downloads/ForConsumers/ConsumerUpdates/UCM173430.pdf. July 2009.
  15. Polosa R, Caponnetto P, Morjaria JB, et al. Effect of an electronic nicotine delivery device (e-cigarette) on smoking reduction and cessation: a prospective 6-month pilot study. BMC Public Health. 2011;11:786.
  16. Bullen C, McRobbie H, Thornley S, et al. Effect of an electronic nicotine delivery device (e cigarette) on desire to smoke and withdrawal, user preferences and nicotine delivery: randomised cross-over trial. Tob Control. 2010;19(2):98-103.
  17. Siegel MB, Tanwar KL, Wood KS. Electronic cigarettes as a smoking-cessation tool: results from an online survey. Am J Prev Med. 2011; 40(4):472-475.
  18. Eissenberg T. Electronic nicotine delivery devices: ineffective nicotine delivery and craving suppression after acute administration. Tob Control. 2010;19(1):87-88.