Smoking Cessation

  1. In all patients, regularly evaluate and document smoking status, recognizing that people may stop or start at any time.

  2. In smokers:

    1. Discuss the benefits of quitting or reducing smoking.

    2. Regularly assess interest in quitting or reducing smoking.

  3. In smokers motivated to quit, advise the use of a multi-strategy approach to smoking cessation.

General Overview

  • Tobacco use status should be updated, for all patients/clients, by all health care providers on a regular basis

  • Ask, Assess, Advice, Assist, Arrange

    • Motivational interviewing is encouraged to support patients/clients willingness to engage in treatment now and in the future

      • Relevance to patient

      • Risks of smoking

      • Rewards of quitting

      • Roadblocks to quitting

  • Advise patients/clients to quit

    • Assess the willingness of patients/clients to begin treatment to achieve abstinence (quitting).

      • Precontemplation

        • Increase awareness of risks in nonjudgmental manner (avoid resistance)

          • Benefits:

            • Leading cause of preventable death (6.5-9y premature death)

            • Financial gains (1ppy = $3650 per year)

              • Somebody who smokes a pack a day will smoke through almost $1 million after forty years (if they had invested that money)

            • Reduce risks of erectile dysfunction

            • 8h - Carbon monoxide eliminated

            • 24h - Risk of heart attack begins to drop

            • 2w - Improved in lung function, walking easier

            • 1mo - Decreased coughing, nasal congestion, shortness of breath

            • 1y - Risk of coronary heart disease halved

            • 5y - Risk of stroke same level as non-smokers

            • 10y - Risk of mouth, throat and esophageal cancer halved, death rate from lung cancer also halved

            • 15y - Risk of heart attacks similar to that of non-smokers

      • Contemplation

        • Discuss pros/cons of quitting (understand ambivalence)

      • Preparation

        • Offer practical advice and anticipate diffiiculties

      • Action

        • Support, reward, prevent relapse

        • Review action plan

          • Quit day

          • Tell family, friends, coworkers about quitting for support

          • Remove tobacco products from environment

          • Exercise program

          • Alternative oral behaviours (gum, lozenges)

          • Obstacles (withdrawal, weight gain, triggers)

          • Support groups (eg. 1-800-QUIT-NOW)

          • Combining counselling and smoking cessation medication is more effective than either alone

            • Counselling by a variety or combination of delivery formats (self-help, individual, group, helpline, web-based)

            • Multiple counselling sessions

            • Practical counselling on problem solving skills or skill training

          • Regular follow-up to assess response, provide support and modify treatment as necessary

            • Peak withdrawal at 2-3d

            • Highest relapse at 2-3w

          • Refer patients/clients to relevant resources where appropriate

      • Maintenance

        • Address stressors and anticipate temptations

Pharmacotherapy

As per ATS, consider Varenicline plus Nicotine patch > Varenicline alone > NRT or Buproprion

  • Varenicline begin 1w before quit date 0.5mg/d x3d then 0.5mg BID x3d then 1mg BID >12 weeks (evidence up to 12 months) [OR 2.89]

    • AE: Insomnia, headache, abnormal dreams, GI upset

    • Note: No evidence that varenicline increases neuropsychaitric adverse events compared to placebo

  • Nicotine replacement therapy [OR 1.84]

    • Gum (4mg >25mg/d, 2mg), patch (21mg >10 cig/d, 14mg, 7mg), inhaler (10mg), lozenge (4mg, 2mg).

    • AE: Local irritation

    • Note: No evidence of increased risk of cardiovascular events in patients with CVD

  • Bupropion begin 1w before quit date at 150mg/d x 3d then 150mg BID [OR 1.85]

    • AE: Insomnia, headache, dizziness, tachycardia, xerostomia, weight loss

    • Avoid in seizure disorder, eating disorder, alcohol withdrawal

  • Nortriptyline [OR 2.03]

    • AE: Sedation, dry mouth

    • Second-line due to side effects

  • Combination

    • Combination nicotine replacement therapy (i.e., pairing a nicotine patch with nicotine gum, lozenges, inhalers or oral sprays) is more effective than placebo (OR 2.73, 95% CI 2.07–3.65) or nicotine replacement monotherapy (OR 1.34, 95% CI 1.00–1.8)

    • Nicotine replacement therapy in conjunction with bupropion has a modest but significant effect (OR 1.24, 95% CI 1.06–1.45)

    • Varenicline in conjunction with a nicotine replacement patch is more efficacious than varenicline alone (OR 1.62, 95% CI 1.18–2.23)