Self Care - Smoking Cessation

Smoking increases risk of:

coronary heart disease 2-4x, stroke 2-4x, lung cancer in men (25x) and women (25.7x), causes cancer almost anywhere in the body

Smoking in pregnancy

preterm delivery, stillbirth, low birth weight, SIDS, ectopic pregnancy, orofacial clefts in infants

Correlated factors of smokers

25-44 years of age, non-Hispanic American Indians/Alaskan Natives, lower education levels, below Federal poverty level, differs by state, mental illness

Second Hand Smoke

41,000 deaths annually

1965 Federal Cigarette Labeling and Advertising Act

surgeon general’s warning on cigarette packaging

1995 President Clinton

announced FDA to regulate, especially sales and advertising to minors (no more cartoons)

2020 US Packaging change

warnings predominantly on packaging; occupy top 50% of package area, front and rear of packing, at least 20% of advertisements; implementation 11/2023

2023 Fighting flavoring

language drafted to end sales of flavored cigars and ciggarettes including menthol

October 2019 news

tobacco companies accused of subtle marketing to undermine plain packaging laws; beveled box edges; “pro-seal” packaging; gives luxury feels to non-branding packaging

Nicotine dependence

induces and sustains chemical dependence (psychoactive effects, used in highly controlled or compulsive manner, reinforces behavior patterns); pharmacologic process similar to heroin or cocain

Nicotine pathophysiology

stimulates mesolimbic dopaminergic system in midbrain; “dopamine reward pathway”; induces pleasant or rewarding effects; promotes continued use

Cigarette smoke

Class A Carcinogen; no safe level of exposure; contains nitrogen, carbon monoxide, ammonia, hydrogen cyanide, benzene, nicotine; gaseous and particulate

Nicotine

distilled when burned; carried in tar droplets to small airways; absorbed into arterial circulation and distributed throughout body; readily penetrates CNS (reaches brain in seconds)

Nicotine effects

decreases appetite; decreases anxiety and tension; increases mood; increases heart rate; increases blood pressure

Chronic users of tobacco

develop tolerance to nicotine; abrupt cessation triggers withdrawal

Withdrawal symptoms

irritability, frustration, anger, anxiety, depression, loss of concentration, impatience, insomnia, restlessness, cravings, impaired performance, constipation, dizziness, cough

Withdrawal timeline

manifest in 1-2 days; peak in 1 week; dissipate in 2-4 weeks; appetite and weight gain may persist for more than 6 months

Drug interactions

reduced therapeutic efficacy is most common; increased toxicity; CYPP450 enzyme inducer; caffeine exposure increased 56% (decreased caffeine during quit attempts)

Significant Drug Interactions

combination hormonal contraceptives

Combination hormonal contraceptive + smoking effects

increased clotting risk, increased risk of CV events; greater risk for those older than 35 years old; greater risk for those who smoke more than 15 cigarettes per day

Smoking Cessation Benefits

cigarette smokers die about 10 years earlier than non-smokers

Tobacco Dependence

chronic disease characterized by multiple failed attempts to quit before long-term cessation is achieved; complex, addictive behavior

Treatment Goals

complete, long-term abstinence from all nicotine containing products; help patients quit tobacco use; prevent relapse; utilize appropriate pharmacotherapy and counseling

No treatment approach

“cold turkey”; 95% of attempts fail

Tobacco cessation counseling

increased odds of quitting; longer and more frequent beneficial

Exclusions for self treatment

serious heart disease, including recent MI, irregular heartbeat, severe angina; uncontrolled hypertension; pregnancy; breastfeeding; <18 years old; active PUD

Comprehensive Counseling

Ask, Advise, Assess, Assist, Arrange

Ask

screening for tobacco use is crucial; routine component of care; consider also asking about secondhand smoke

Advise

clear, strong, and personalized; sensitive and convey concern

Assess

not all patients are ready to quit when approached

Classifications for Assess

not ready to quit in the next month; ready to quit in the next month; recent quitter in past 6 months; former user > 6 months ago

Stages of behavior change

pre-contemplation, contemplation, preparation, action, maintenance

Pre-contemplation

unaware of the problem

Contemplation

aware of the problem and of the desired behavior change

Preparation

intends to take action

Action

practices the desired behavior

Maintenance

works to sustain the behavior change

Assist

be empathetic; acknowledge quitting is a challenge; goal is to maximize success (individualize treatment plan); encourage counseling and medication

2 steps to Assist

helping make decision to quit; setting a quit date

Arrange

multiple counseling interactions preferred; follow-up is crucial; better success

Pre-contemplation counseling

always ask permission first; use open-ended question; motivation interviewing; 5 R’s

Brief Intervention

Be familiar with local resources; Ask, advise, refer

Resources

smokefree.gov; 1-800-Quit Now; quitSTART App; SmokefreeTXT

Motivational Interviewing

techniques to assist with behavior change; always ask permission first; use open ended questions; Motivational interviewing techniques

Develop Discrepancy

patient is smoking (knows it’s harmful; cannot acknowledge that quitting is important); human tendency not to think about it; techniques (readiness ruler or decisional matrix)

Readiness Ruler

helps focus the gap between where the person has been, and where they want to be

Decisional Matrix

essentially a pro/con list for a fair “hearing”

Express Empathy

understand patient’s point of view; people want to feel understood; reflect on patient’s perspective; no judgement zone

Amplify Ambivalence

exploring two sides of thought; help bring quitting to the forefront of patient’s mind

Roll With Resistance

humans resist change; avoid the “righting reflex”

Support Self-Efficacy

many lack confidence to change; maintain positive tones

Pharmacotherapy

Nicotine replacement therapy (NRT) gum; NRT lozenge; NRT patches; NRT inhaler; NRT nasal spray; sustained-release bupropion; varenicline

Nicotine Replacement Therapy

FDA approved for cigaratte cessation

NRT MOA

stimulates the release of dopamine in the CNS

NRT General Counseling

do not use tobacco products while using NRT; AEs may occur (N/V, hypersalivation, perspiring, abdominal pain, dizziness, weakness, palpitations, headache, insomnia, abnormal dreams)

NRT Gum/Lozenge

2mg/4mg; various flavors; lozenge available in mini formulation; buffering agent helps absorption in buccal mucosa

NRT Gum/Lozenge dosing

time to first cigarette (TTFC)

NRT gum/lozenge peak

30 minutes

NRT gum/lozenge duration

2-3 hours

NRT gum/lozenge AE

general NRT AEs; unpleasant taste; mouth irritation; jaw soreness/fatigue; hypersalivation; hiccups; dyspepsia

NRT Gum use

chew and park method; park gum between cheek and gum

NRT Lozenge use

place in mouth and allow to dissolve (standard: 20-30 min; mini: 10 minutes); do not chew or swallow

NRT patch

7mg/14mg/21mg; deliver continuous, low levels of nicotine over 24 hours; waterproof; dosed on # of cigarettes/day

NRT patch AEs

general NRT AEs; local skin reactions at application site; sleep disturbances (may remove patch at night)

NRT Patch Use

apply to clean, dry, hairless area; rotate patch application site; apply firm pressure for 10 seconds; remove after 24 hours; do not cut patches

Combination therapy

NRT patch + NRT gum/lozenge PRN; NRT patch + bupropion SR (RX); NRT patch + nicotine inhaler (RX)

Choosing therapy

patient factors (comorbidities; smoking habits; gum difficult with dental work); patient preference (frequent vs. infrequent dosing; perceptions from past attempts); contraindications

Electronic Cigarettes

available in the US; marketed as substitute for cigarettes; data insufficient to support safety or efficacy

Electronic Cigarette Use

most common teen “tobacco” product in US; ¼ teens use e-ciggs for “dripping”; gateway to other tobacco products

E-cigg risks

decision making and impulse control in teens; attention and learning in teens; nicotine addiction; mood disorders; aerosol related lung damage; fires and explosions; secondhand smoke

2016 FDA Center for Tobacco Products (CTP)

authority over electronic cigarettes extended

US E-cigg regulations

contents of products non-regulated

US Surgeon General and Vaping

declared vaping a youth epidemic in 20182

2019 Vaping Death Epidemic

tied to vitamin E; safe to ingest not to inhale

Cardiovascular Conditions and Tobacco Use

patients with recent MI, serious arrhythmias, serious or worsening angina pectoris use NRT with doctor supervision

Pregnancy and tobacco use

fetal harm; use with doctor supervision

Adolescent Cessation

no FDA approved products < 18 years old; use with doctor supervisionE

Elderly Cessation

same recommendations as adult population

Pediatrics

no risk-free level of secondhand smoke; ear infections; asthma attacks; respiratory symptoms; risk of URTI and SIDS