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Smoking Cessation

for Health Care Providers

Smoking Cessation

See also: VHA smoking and tobacco use cessation policy and tools

Note: Some medications mentioned in this chapter may not be available on the VHA National Formulary. Consult VA pharmacists for alternatives.

Key Points

  • Smoking is the leading cause of preventable death and disease in the United States, accounting for approximately 440,000 deaths each year. It is a chronic, relapsing disorder that often requires repeated interventions and multiple attempts to quit.
  • Patient interest in smoking cessation is high (>66% in most surveys).
  • HIV-infected patients are 2-3 times more likely to be smokers than their age-matched HIV-uninfected counterparts.
  • HIV-infected smokers face traditional tobacco-related risks, such as cardiac disease, stroke, COPD, and osteoporosis. These conditions are likely to become more prevalent with the aging of the HIV-infected population on effective ART. Smoking and HIV infection substantially increase the risks of respiratory tract infection, including acute bronchitis, bacterial pneumonia, PCP, and TB.
  • HIV-infected smokers also are at higher risk of several tobacco-related cancers, and may be at increased risk of poorer immunologic and virologic responses to ART.
  • Asking patients about smoking is an important part of primary care management. Current users should be asked about smoking at every visit.
  • Brief (<3 min) tobacco dependence interventions are effective, and every tobacco user should be offered treatment.
  • Counseling and medication are effective when used by themselves for treating tobacco dependence. The combination of counseling and medication, however, is more effective than either alone.
  • Evidence-based treatment options include behavioral counseling and support, nicotine replacement therapy, and bupropion. Varenicline is a second-line option at the VHA for patients who fail other therapies and do not have suicide or violence risks.

Background

  • Smoking is a cause of cancers of the bladder, cervix, esophagus, kidney, larynx, lung, oral cavity, pancreas, and stomach; of leukemia; of peripheral atherosclerosis, cerebrovascular disease, and coronary artery disease; of COPD, decreased lung function, and lung infections; of pregnancy complications; and of peptic ulcer disease.
  • HIV-infected patients are 2-3 times more likely to be smokers than their age-matched HIV-uninfected counterparts.
  • In the United States, 30-65% of patients in HIV primary care clinics are smokers.
  • HIV-infected smokers have higher rates of certain diseases (compared with HIV-uninfected smokers and HIV-infected nonsmokers), such as lung cancer, head and neck cancers, anal and cervical cancers, oral candidiasis, and oral hairy leukoplakia.
  • HIV infection increases the risk of respiratory tract infections, and smoking further increases the risks of acute bronchitis, bacterial pneumonia, PCP, and TB.
  • Smoking may decrease the immunologic and virologic response to ART. In a cohort of HIV-infected women, smokers had lower CD4 cell counts and higher HIV viral loads compared with age-matched HIV-infected female nonsmokers after initiation of ART.
  • Smoking is the leading cause of preventable death and disease in the United States. Tobacco use is a chronic, relapsing disorder that often requires repeated interventions and multiple attempts to quit.
  • Most smokers are interested in quitting. Surveys have found that two thirds of HIV-infected smokers want to quit.
  • Smoking cessation programs for HIV-infected smokers are effective. For example, among patients who were given a 10-week supply of nicotine patches, self-help booklets, and initial physician counseling plus (by randomization) 8 counseling phone calls or no calls, 37% of those in the counseling group were not smoking at a 3-month follow-up, compared with 10% of those who did not receive the counseling phone calls.

Veterans with HIV*

Tobacco Use: 38%

*Veterans in the VA HIV Clinical Case Registry in care in 2007 who had an ICD-9 code corresponding to this condition

Evaluation

The 5 A's for Patients Unwilling to Quit

These strategies are designed to be brief (<3 minutes of direct clinician time). They need not be delivered by the same clinician; for example, a clinic nurse may ask about tobacco use, whereas a prescribing clinician (eg, MD, PA, or NP) may advise, assess, and assist, with referral to another provider for counseling services.

ASK ...

  • All patients about tobacco use at every clinic visit:
    • If a patient has never used, you do not need to ask again.
    • If a patient quit years ago, congratulate and check in periodically.
    • Consider making it a part of your office practice to ask about and record tobacco use while patients are having vital signs recorded.

ADVISE ...

  • Smokers with clear, strong, and personalized suggestions:
    • Clear: "I think it is important that you quit smoking. I can help."
    • Strong: "Quitting smoking is one of the most important things you can do to protect your health."
    • Personalized: Associate smoking with something that is important to the patient, such as exposure of children to tobacco smoke, the expense of cigarettes, or pulmonary and cardiovascular comorbidities. "Remember the time you had that terrible pneumonia?" "Do you realize that you can save almost $2,000 a year on cigarette expenses if you quit?"

ASSESS ...

  • Smokers' readiness to quit within 30 days: "Are you willing to give quitting a try in the next 30 days?"
  • If not ready, consider using motivational interviewing to increase patient's readiness to quit (see the 5 R's for Patients Unwilling to Quit, below*).
  • If ready, assist and arrange (following).

ASSIST ...

  • A patient's preparations for quitting:
    • Setting a quit date. Ideally, the quit date should be within 2 weeks.
    • Telling family, friends, and coworkers about quitting, and requesting understanding and support.
    • Anticipating challenges to the upcoming quit attempt, particularly during the critical first few weeks. These include nicotine withdrawal symptoms.
    • Removing tobacco products from the environment. Before quitting, avoiding smoking in places where a lot of time is spent (eg, work, home, car). Making the home smoke free.
  • Offer nicotine replacement or, if appropriate, bupropion, varenicline, or other medication (see below for more details on medication options).
  • Provide practical counseling (problem-solving/skills training; see below).
  • Offer intensive treatment options (smoking cessation intervention programs and groups).
  • Offer readily available counseling and support services: phone support, clinic counselors.

ARRANGE ...

  • Enrollment in a VHA-based smoking cessation clinic, if the patient wishes.
  • Referral to appropriate counseling services.
  • Referral to evidence-based cessation program in the community or to phone quit lines if VHA-based interventions are not convenient for the patient or if the patient is interested (800-QUIT-NOW is a national portal for state programs).
  • Follow-up contact during the first week after quit date (in person or by phone).
  • Follow-up visit 1 month after quit date.
  • Subsequent follow-up visits; congratulate upon success in quitting; anticipate further support with relapses (approximately 35-40% patients relapse 1-5 years after quitting).

Adapted from Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 UpdateLink will take you outside the VA website.. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service; May 2008.

* For more detailed suggestions on how to conduct motivational interviewing with smokers, see Fiore, et al. Chapter 3, Section B.

(Print tool)

Management

Current tobacco users who are not ready to quit:

Continue to encourage smoking cessation.

The 5 R's for Patients Unwilling to Quit

  • Relevance: Explain to patients why cessation is personally relevant (eg, comorbidities, cost).
  • Risks: Ask patients to explain their perceived potential risks of smoking; discuss these risks with them (eg, sexual dysfunction, infertility, fetal harm, CV and pulmonary disease, malignancies, secondhand smoke). Explain that:
    • 20 minutes after quitting, heart rate and blood pressure drop
    • 12 hours after quitting, carbon monoxide levels drop to normal
    • 2 weeks to 3 months after quitting, circulation and lung function improve
    • 1 year after quitting, risk of coronary heart disease is cut in half
    • 5 years after quitting, stroke risk is the same as for nonsmokers
    • 10 years after quitting, lung cancer risk is cut in half
  • Rewards: Ask patients to explain what they might gain from cessation (eg, breath smells better, stained teeth get whiter, bad odor of clothes goes away, food tastes better, sense of smell returns to normal, everyday activities do not result in shortness of breath, skin tone gets better, health improves, worries about secondhand smoke lessen, respiratory symptoms improve, lung function improves).
  • Roadblocks: Ask patients to identify barriers to quitting (eg, fear of failure, weight gain, depression) and offer options to address those barriers.
  • Repetition: Discuss these issues with patients at each visit.

Adapted from Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 UpdateLink will take you outside the VA website.. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service; May 2008.

(Print table)

Current tobacco users who are ready to quit:

  • Offer smoking cessation treatment at every visit to every patient who smokes.
  • Even minimal (<3 minute) intervention can yield benefit, including simply advising a patient to quit.
  • For patients with symptoms suggestive of COPD, particularly shortness of breath, consider pulmonary function testing, including spirometry, lung volume, and diffusion studies, and provide medication to support a quit attempt (see COPD).
  • Patients who are informed of abnormal pulmonary function test results may be more likely to quit.
  • If applicable, discuss challenges patients have encountered during previous attempts to quit and tailor current recommendations to what patients can accomplish.
  • Research strongly supports treatment in the form of behavioral counseling (even brief sessions [<3 minutes]) and first-line smoking cessation medications. Specifically, U.S. Public Health Service's 2008 update of the Clinical Practice Guideline on Treating Tobacco Use and Dependence (see References, Fiore et al.) finds strong evidence in favor of:
    • Using medications to assist in smoking cessation
    • Combining medication with behavioral counseling
    • Providing multiple counseling sessions as opposed to single counseling sessions
  • Pharmacologic interventions included in the table below are first-line therapies found to be effective by the USPHS. All were found to be more effective than placebo at assisting in cessation. A list of 7 monotherapies is provided, along with 4 combination therapies. Not all therapies listed in the Guideline are considered first-line by the VHA (see below). Combination therapies may be particularly effective at blunting nicotine withdrawal symptoms, but may cost more and may expose the patient to a wider range of side effects.
  • Two components of counseling have been found to be particularly effective: working with patients to develop problem-solving skills and strategies, and delivering social support as part of counseling.
Examples of Problem-Solving Skills
Adapted from Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 UpdateLink will take you outside the VA website.. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service; May 2008.
Type of SkillExamples
Identifying situations that endanger smoking cessation
  • Negative stressors
  • Being around smokers
  • Alcohol
  • Smoking cues
  • Availability of cigarettes
Identifying coping skills
  • Learning to anticipate and avoid tempting situations
  • Cognitive strategies for improving mood, decreasing stress
  • Changing routines that expose the patient to smoking cues
Identifying feelings that can threaten cessation
  • A single puff increases the risk of relapse
  • Withdrawal symptoms peak 1-2 weeks after quitting but may persist for months
  • Withdrawal symptoms can include negative mood, urges to smoke, difficulty concentrating
Examples of Social Support
Adapted from Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 UpdateLink will take you outside the VA website.. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service; May 2008.
Type of SupportExamples
Encouragement to quit
  • Effective treatments are available
  • Half of people who have ever smoked have been able to quit
  • Communicate belief in patient's ability to quit
Communicate caring and concern
  • Ask how patient feels about quitting
  • Express willingness to help as often as needed
  • Ask about patient's fears and ambivalence about quitting
Encourage patient to talk about the quitting process
  • Why does patient want to quit?
  • What are patient's concerns about quitting?
  • What success and difficulties in quitting has patient had in past?
  • Continue to encourage cessation even if the patient relapses. Relapse does not mean that the patient will not quit successfully on a future attempt.
  • Counsel patients on potential nicotine withdrawal symptoms. Note that 25% of smokers who quit do not have these symptoms. Nicotine withdrawal symptoms include:
    • Depressed mood
    • Insomnia
    • Irritability
    • Anxiety
    • Difficulty concentrating
    • Restlessness
    • Decreased heart rate
    • Increased appetite and weight gain (10% of patients gain >13 kg after smoking cessation)

Pharmacologic Interventions

Key points:

  • Nicotine replacement therapies (NRTs) such as nicotine patch, gum, and lozenges, do not interact with ARVs and have low toxicity at recommended dosages, even in patients with cardiovascular disease.
  • In moderate to heavy smokers, the "patch plus" combination NRT regimens have achieved better 6-month abstinence rates in several trials of than the use of a single product. The nicotine patch is used to deliver a consistent level of nicotine, and the gum or lozenge is used to minimize symptom flares as needed during the day.
  • Bupropion with the nicotine patch or bupropion with PRN nicotine lozenges also achieved better 6-month abstinence rates in several trials than use of the patch alone.
  • Varenicline has been associated in rare instances with violent thoughts, intent, or actions toward oneself or others and is not considered first-line therapy for smoking cessation by the VHA. It is a second-line medication for patients who have failed an appropriate trial of NRT, bupropion, or combination therapy in the past year. Patients being considered for or who are on varenicline should be screened, warned of, and monitored for suicidality and violence risk. Assessment questions include:

    1. Are you feeling hopeless about the present or future?

    2. Have you ever had a suicide attempt?

    3. Have you had thoughts about taking your life or harming others in the past 12 months? (if Yes, ask question 4)

    4. Do you have a plan to take your life?

    See the Varenicline Criteria for Prescribing.

VHA Formulary Choices for Pharmacotherapy of Smoking Cessation

Table 1: VHA Formulary Choices for Pharmacotherapy of Smoking Cessation

(See full table)

Table 2. Combinations of Pharmacologic Therapies Found to Be Effective
TherapyDosage and DurationComments
Preferred Combinations
Nicotine patch + gum
  • Studies used patch for >14 weeks
  • Use standard dosages and durations of each component drug
  • Patch + gum had 36.5% 6-month abstinence rate in trials vs 23.4% with patch alone (metaanalysis)
  • Patch + bupropion had 28.9%, and lozenge + bupropion had 29.9% 6-month abstinence rates
  • Coadministration with RTV ↑ bupropion levels: use cautiously, especially at high dosages.
Nicotine patch + bupropion SR
Nicotine lozenge + bupropion SR

Print table

Preventing or Addressing Relapse with Patients Who Have Quit

  • Congratulate patients at each visit and discuss the benefits and challenges of quitting.
  • Use open-end questions relevant to the topics below to discover whether the patient wishes to discuss issues related to quitting:
    • The benefits, including potential health benefits, the patient may derive from cessation
    • Any success the patient has had in quitting (eg, duration of abstinence, reduction in withdrawal)
    • The problems encountered or anticipated threats to maintaining abstinence (eg, depression, weight gain, alcohol, other tobacco users in the household, significant stressors)
    • If the patient is still taking medication, assess effectiveness, side effects, and other medication issues
  • Interventions to address barriers to maintaining cessation:
    • Lack of support: Refer patients to a group, schedule follow-up phone calls, help identify potential sources of support (individuals, community or religious organizations).
    • Prolonged withdrawal symptoms: Prolong pharmacologic interventions or consider combination therapy.
    • Depressed mood: Consider using antidepressants and initiating psychotherapy.
    • Weight gain: Reassure patients that weight gain is common and self-limited, encourage patients to increase exercise, counsel on a healthy diet (avoid strict dieting), preferentially use pharmacologic interventions that cause less weight gain (eg, bupropion, nicotine gum).
    • Flagging motivation: Reassure patients that flagging motivation is common, check to see if patients might be using tobacco periodically, and counsel that taking even a single puff will increase urges and make quitting more difficult.
    • Smoking lapses: Suggest continued use of medications, which can reduce the likelihood that a lapse will lead to a full relapse. Encourage another quit attempt or a recommitment to total abstinence. Reassure that quitting may take multiple attempts, and use the lapse as a learning experience. Provide or refer for intensive counseling.

References