TREATING TOBACCO USE

Treating Tobacco Use and Dependence

Michael C. Fiore, MD, MPH


Copyright © 2004 the University of Wisconsin Medical School.

This CME activity "Treating Tobacco Use and Dependence" was originally offered as an online Web-based program certified for CME.

Faculty affiliations and disclosures are at the end of this activity.


Release Date: November 17, 2004; Valid for credit through November 17, 2005

Target Audience

This program is intended for physicians, pharmacists, nurses, technicians, and allied healthcare professionals.

Goal

The goal of this program is to identify efficacious interventions for tobacco use that can be offered during clinical/medical visits.

Learning Objectives for This Educational Activity

Upon completion of this activity, participants will be able to:
  1. Understand the rationale for treating tobacco dependence.
  2. Understand tobacco dependence as a chronic disease.
  3. Understand clinical interventions for tobacco users willing to quit.
  4. Understand clinical interventions to prevent relapse.
  5. Understand clinical interventions for tobacco users not willing to make a quit attempt.

Credits Available

Physicians - up to 1.0 AMA PRA category 1 credit(s)

All other healthcare professionals completing continuing education credit for this activity will be issued a certificate of participation.

Participants should claim only the number of hours actually spent in completing the educational activity.

Accreditation Statements

For Physicians

This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME). The University of Wisconsin Medical School is accredited by the ACCME to provide continuing medical education for physicians.

The University of Wisconsin Medical School designates this educational activity for a maximum of 1.0 category 1 credit toward the AMA Physician's Recognition Award. Each physician should claim only those hours of credit that he/she actually spent in the activity.


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Participation in this self-study activity should be completed in approximately 1.0 hour. To successfully complete this activity and receive credit, participants must follow these steps during the period from November 17, 2004 through November 17, 2005.

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This activity is supported by an independent educational grant from UW-CTRI and Medscape.

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The materials presented here do not necessarily reflect the views of Medscape, The University of Wisconsin Medical School, the companies providing educational grants or the authors and writers. These materials may discuss uses and dosages for therapeutic products that have not been approved by the United States Food and Drug Administration. All readers and continuing education participants should verify all information and consult a qualified healthcare professional before treating patients or utilizing any therapeutic product discussed in this educational activity.



Contents of This CME Activity

  1. Treating Tobacco Use and Dependence: Module 1
    Why Should I Treat Tobacco Dependence?
    How Can the Public Health Service Guideline Treating Tobacco Use and Dependence Assist Me in Intervening With Tobacco Users?

  2. Treating Tobacco Use and Dependence: Module 2
    How Do I Treat Tobacco Smokers Who Are Willing to Quit?
    Pharmacotherapy

  3. Treating Tobacco Use and Dependence: Module 3
    How Can I Help Prevent Relapse?

  4. Treating Tobacco Use and Dependence: Module 4
    How Do I Treat Tobacco Users Who Are Not Willing To Make A Quit Attempt?

  5. Treating Tobacco Use and Dependence: Special Populations
    Special Populations





Treating Tobacco Use and Dependence

Treating Tobacco Use and Dependence: Module 1

Michael C. Fiore, MD, MPH

Why Should I Treat Tobacco Dependence?

In America today, tobacco stands out as the agent most responsible for avoidable illness and death. Millions of Americans consume this toxin on a daily basis. Its use brings premature death to almost half a million Americans each year, and contributes to profound disability and pain in many ways. Approximately one-third of all tobacco users in this country will die prematurely because of their dependence on tobacco. In fact, tobacco use is the chief avoidable cause of illness and death in our society, causing cancer, heart disease, stroke, complications of pregnancy, and chronic obstructive pulmonary disease.

Figure
Figure 1.

With 70 percent of smokers seeing a physician each year, clinicians are uniquely poised to intervene with patients who use tobacco. Moreover, 70 percent of smokers report wanting to quit. Finally, smokers cite a physician's advice to quit as an important motivator for attempting to quit. These data suggest that most smokers are interested in quitting, clinicians are frequently in contact with smokers, and clinicians have high credibility with smokers.

This CME program offers information on assisting smokers to quit smoking based upon the PHS Clinical Practice Guideline Treating Tobacco Use and Dependence.

Tobacco Use As A True Drug Dependence

Figure
Figure 2.

All drug addictions warrant clinical intervention, including tobacco dependence. Tobacco dependence exhibits classic characteristics of drug dependence. For example, nicotine is psychoactive, tolerance producing, and causes physical dependence characterized by withdrawal symptoms. Many smokers typically cycle through multiple periods of relapse and remission and persist in tobacco use for many years.

Pharmacokinetics of Cigarette Smoke

Within seconds of inhaling cigarette smoke, a bolus of nicotine travels from the carotid arteries to the brain where the molecules bind to nicotine receptors. Nicotine stimulates the norepinephrine and serotonin systems, enhancing concentration and memory and decreasing anxiety. This results in dopamine secretion that causes pleasurable sensations and relief of symptoms of nicotine deprivation. Nicotine also interacts with acetylcholine receptors, creating a variety of physiologic reactions. Some reactions are beneficial, such as suppressing appetite and pain, while others are not, such as elevated BP and nicotine addiction. Nicotine replacement therapy mimics but does not match these intense effects caused by the nicotine in cigarette smoke. (Fiore, M., & Westman, E. Using pharmacotherapy for cessation. Patient Care. 2001; 35(24):18-27.)

Tobacco Dependence Shows Many Features of A Chronic Disease

Tobacco dependence shows many features of a chronic disease. Although a minority of tobacco users achieves permanent abstinence in an initial quit attempt, the majority persist in tobacco use for many years and typically cycle through multiple periods of relapse and remission.

By recognizing that tobacco dependence is a chronic condition, clinicians will better understand the relapsing nature of the ailment and the requirement for ongoing, rather than just acute care. This framework helps clinicians view relapse as a subsequent component of this chronic disease, rather than a lack of motivation or commitment on the patients' part or lack of ability on the clinicians' part. A failure to appreciate the chronic nature of tobacco dependence may undercut clinicians' motivation to treat tobacco use consistently.


Treating Tobacco Use and Dependence: Module 1

Michael C. Fiore, MD, MPH

How Can the Public Health Service Guideline Treating Tobacco Use and Dependence Assist Me in Intervening With Tobacco Users?

Figure
Figure 3.

In June, 2000 the Public Health Service released its Clinical Practice Guideline Treating Tobacco Use and Dependence (Fiore, et. al., 2000). This Guideline is directed toward physicians, allied health professionals, health care insurers, purchasers and administrators and set a new standard of care for smoking cessation treatment. This Guideline was created by a multidisciplinary panel comprised of 18 experts in the field of tobacco treatment. The recommendations and strategies contained within the Guideline are based upon a review of nearly 6000 articles and more than 50 meta-analyses. It was supported by a consortium of seven public and non-profit organizations.

To order the Treating Tobacco Use and Dependence Guide (http://www.ahcpr.gov/path/tobacco.htm), please contact the Agency for Healthcare Research and Quality (http://www.ahcpr.gov/) at 1-800-358-9295.

Figure
Figure 4.

The Guideline emphasizes the importance of treating all patients who use tobacco at every clinic in the country. Many different treatments can promote long-term abstinence. The first step in providing these efficacious treatments for tobacco use and dependence is determining tobacco use status of every patient. According to the PHS Guideline, asking whether or not a patient uses tobacco products not only increases the rates of clinician intervention, but it also increases abstinence rates compared to controls who were not asked about their tobacco use status. The PHS Guideline provides an algorithm for identifying and assessing tobacco use status.

Figure
Figure 5.

Treating Tobacco Use and Dependence: Module 2

Michael C. Fiore, MD, MPH

How Do I Treat Tobacco Smokers Who Are Willing to Quit?

Figure
Figure 6.
Figure
Figure 7.

Thousands of tobacco users visit a primary care clinician each year. It is, therefore, important that clinicians be prepared to intervene with tobacco users who are willing to quit. The five major steps (the "5 A's") to intervention in the primary care setting are to ASK the patient if he or she uses tobacco, to ADVISE him or her to quit, to ASSESS willingness to make a quit attempt, to ASSIST him or her in making a quit attempt, and to ARRANGE for follow-up contacts to prevent relapse.

ASK

It is imperative that clinicians ask EVERY patient about tobacco use status at EVERY visit. This occurs most consistently when there are systems in place, such as a vital signs stamp or electronic prompt on electronic medical records that systematically result in universal tobacco use status documentation.

Figure
Figure 8.

ADVISE

Figure
Figure 9.
Once tobacco use status has been identified and documented, clinicians should advise all tobacco users to quit.

Even brief advice to quit by a clinician results in greater quit rates. Smokers cite a clinician's advice to quit as an important motivator for attempting to stop smoking. Therefore, clinicians should urge all tobacco users to quit. This advice should be clear and strong. For example, "As your physician, I must tell you that the most important thing you can do to improve your health is to stop smoking."

The advice should be personalized to the individual 's own situation (e.g. medical condition, family status, costs of tobacco).

ASSESS

After providing a clear, strong, and personalized message to quit smoking, the clinician must determine whether or not the patient is willing to quit at this time.

One direct way to assess readiness to quit is to follow the ADVISE message with the simple question, "Are you willing to try to quit at this time?"

Overcoming Barriers to Quitting

Figure
Figure 10.

Many smokers are ambivalent about trying to quit because of past unsuccessful attempts, fear they will be unable to quit, dread of withdrawal symptoms, pleasure associated with smoking, etc. Urge these smokers to try at this time, reassuring them that assistance is available.

Figure
Figure 11.

If the patient is willing to make a quit attempt at this time, the clinician can either assist the patient using a brief or intensive intervention. If the patient is not willing to make a quit attempt this time or needs further encouragement to quit, the PHS Guideline outlines motivational interventions which can assist clinicians in encouraging patients unwilling to quit, or to those needing further encouragement to quit. For these tobacco users the Guideline suggests using a strategy based upon the "5 R's" relevance, risks, rewards, roadblocks, and repetition (See Module 4).

ASSIST

Assisting the patient in his or her quit attempt can be done using either a brief or an intensive intervention. Level of intensity of the intervention has a strong dose-response effect.

  • Brief intervention -- Even a minimal intervention, lasting less than 3 minutes, can significantly increase overall tobacco abstinence rates.

  • Intensive intervention -- The longer the session of person-to-person contact, and the more overall person-to-person contact, and the greater the number of visits, the more successful the treatment outcome.

In a 3- to 10-minute intervention, a clinician can provide a counseling session which can significantly impact a smoker's quit success.

Effective assistance can be provided by multiple providers, in multiple formats, including counseling and practice telephone support.

One way to systematically integrate tobacco cessation is by the use of the cessation tear sheet. This tear sheet can allow clinicians to personalize intervention and can be given to patients as a take away.

See Tear Sheet for Use With Patients

Helping Your Patient Develop A Quit Plan

Set a quit date -- In preparation for quitting the patient should set a quit date, ideally within 2 weeks. The patient should tell their family, friends, and coworkers about the quit attempt and request understanding and support.

Review past quit attempt experiences -- Urge the patient to consider reusing strategies that were helpful and to avoid situations that led to relapse.

Anticipate challenges -- It is important for the patient to anticipate challenges to the planned quit attempt, particularly during the critical first few weeks (e.g., withdrawal symptoms such as negative mood, urges to smoke, and difficulty concentrating).

Remove tobacco products -- Prior to quitting, patients should remove tobacco products from their environment and avoid smoking in places where he or she spends a lot of time (e.g., work, home, car). In addition, if a spouse or significant other is continuing to smoke, specific strategies to limit that risk should be established.

Tobacco and alcohol -- About half of smokers who try to quit and relapse have their first drag of smoke with some alcohol in their bloodstream. Avoiding or limiting alcohol in the first few weeks after a quit attempt should be considered.

Counseling

Figure
Figure 12.

It is recommended that counseling include the following components:

  • Provision of practical counseling (problem-solving/skills training) such as helping the patient identify events, internal states, or activities that increase the risk of smoking or relapse, identifying and practicing coping or problem-solving skills, and providing basic information about smoking and successful quitting.
Figure
Figure 13.
  • Provision of intra-treatment social support by encouraging the patient, communicating caring and concern, and encouraging the patient to talk about the quitting process.

  • Help the patient obtain extra-treatment social support by training the patient in support-solicitation skills, prompting support seeking, and arranging outside support.

Figure
Figure 14.
Figure
Figure 15.
In a 3- to 10-minute intervention, clinicians can provide counseling that can significantly increase the success of a patient's quit attempt.

Treating Tobacco Use and Dependence: Module 2

Michael C. Fiore, MD, MPH

Pharmacotherapy

The PHS Guideline has identified 5 first-line pharmacotherapies for smoking cessation and recommends that smokers attempting to quit be urged and/or prescribed a medication. These five first-line therapies are: bupropion SR, nicotine gum, nicotine inhaler, nicotine nasal spray, nicotine patch. See the Clinical Use tables for each therapy below.

Figure
Figure 16.
Figure
Figure 17. (Click to enlarge)
Figure
Figure 18. (Click to enlarge)
Figure
Figure 19. (Click to enlarge)
Figure
Figure 20. (Click to enlarge)

Since the guideline was issued in 2000, one additional medication, the nicotine lozenge, has been approved:

Figure
Figure 21.

See the Suggestions for the Clinical Use of Pharmacotherapies for Smoking Cessation table below.

Figure
Figure 22. (Click to enlarge)
Figure
Figure 23.
These medications have all been approved by the FDA for smoking cessation and have been shown to significantly improve abstinence rates.

Because of the lack of sufficient data to rank-order these 5 medications, choice of a specific first-line pharmacotherapy must be guided by factors such as clinician familiarity with the medications, contraindications for selected patients, patient preference, previous patient experience with a specific pharmacotherapy (positive or negative), and patient characteristics (e.g., history of depression, concerns about weight gain ).

Figure
Figure 24.

There are two second-line pharmacotherapies, clonidine and nortriptyline. See the Clinical Use tables for each therapy below.

Figure
Figure 25. (Click to enlarge)
Figure
Figure 26.

These have been shown to improve abstinence rates but have not been approved by the FDA for a smoking cessation indication and have more extensive side-effect profiles.

The PHS Guideline does suggest that some pharmacotherapies can be combined or that pharmacotherapies can be used long-term under certain circumstances.

Figure
Figure 27.

There are special considerations before using pharmacotherapy with selected populations. These populations include:

  • those with medical contraindications,
  • those smoking fewer than 10 cigarettes/day,
  • pregnant/breastfeeding women,
  • adolescent smokers.

Pregnant Women

Since smoking in pregnancy imparts risks to both the woman and the fetus, many women are motivated to quit during pregnancy, and health care professionals can take advantage of this motivation by reinforcing the knowledge that cessation will reduce health risks to the fetus and that there are postpartum benefits for both the mother and child. Quitting smoking prior to conception or early in the pregnancy is most beneficial, but health benefits result from abstinence at any time. Therefore, a pregnant smoker should receive encouragement and assistance in quitting throughout her pregnancy. The PHS Guideline recommends that whenever possible pregnant smokers should be offered extended or augmented psychosocial interventions that exceed minimal advice to quit.

Children and Adolescents

The PHS Guideline recommends that clinicians screen pediatric and adolescent patients and their parents for tobacco use and provide a strong message about totally abstaining from tobacco use. A recent study has shown that adolescents' smoking status was identified in 72% of office visits, but smoking cessation counseling was provided at only 17% of clinic visits of adolescent smokers. Therefore, clinicians both need to assess adolescent tobacco use and offer cessation counseling and behavioral interventions shown to be effective with adults. It is also recommended that the content of these interventions be modified to be developmentally appropriate. Children and adolescents may benefit from community- and school-based intervention activities. The messages delivered by these programs should be reinforced by the clinician. The Guideline further recommends that clinicians in a pediatric setting offer stop-smoking advice to parents to limit children's exposure to second-hand smoke.

Below, see the Clinical guidelines for prescribing pharmacotherapy for smoking cessation.

Figure
Figure 28. (Click to enlarge)

ARRANGE

Arranging follow-up contact is the final step in treating tobacco use and dependence.

The clinician should schedule a follow-up contact soon after the quit date, preferably within the first week. This early follow-up is recommended because the majority of smokers trying to quit who subsequently relapse return to smoking within the first 2 weeks.

If the patient has used tobacco, discuss the circumstances surrounding the relapse and attempt to elicit a recommitment to quitting. Remind the patient that a relapse should be viewed as a learning experience. It may take the tobacco user multiple attempts to successfully quit smoking. Each time the patient relapses he or she learns more about what will help and what will be harmful for the next quit attempt. Also, relapse is consistent with the chronic nature of tobacco dependence; it is not a sign of personal failure of the tobacco user or the clinician.

"Not since the polio vaccine has this nation had a better opportunity to make a significant impact in public health." David Satcher, MD, PhD, Former U.S. Surgeon General


Treating Tobacco Use and Dependence: Module 3

Michael C. Fiore, MD, MPH

How Can I Help Prevent Relapse?

Figure
Figure 29.

Due to the chronic relapsing nature of tobacco dependence, clinicians should provide brief, effective relapse prevention treatment to all patients who have recently quit tobacco use. With the extraordinarily high rates of relapse to smoking, clinicians must assist their patients in staying quit.

Clinicians should:

  1. reinforce the patient's decision to quit,
  2. review the benefits of quitting,
  3. assist the patient in resolving any residual problems arising from quitting.

Minimal relapse prevention consists of:

  1. congratulating success

  2. encouraging continued abstinence

  3. discussing with the patient the benefits of quitting, the problems encountered during quitting and the anticipated challenges to staying quit (e.g., alcohol, weight gain, stress, and other tobacco users in the household).

Individualize Relapse Prevention

Figure
Figure 30.

A more intensive prescriptive relapse prevention intervention, individualized to address the problems and concerns of the individual patient, can also be utilized by clinicians.

  • Some patients report feeling a lack of support for their cessation attempt. In response to this concern, clinicians can schedule follow-up visits or telephone calls, help the patient identify sources of support within his or her environment, work to increase his or her extra-treatment social support, or refer to the patient to an appropriate organization that offers smoking cessation counseling or support.

  • If the patient reports negative mood or depression, the clinician should provide counseling, and if appropriate, prescribe medication or refer the patient to a specialist. If the patient reports extended or severe withdrawal symptoms such as cravings, the clinician should consider extending the use of approved pharmacotherapy or combining pharmacotherapies to reduce the nicotine withdrawal.

  • Weight gain is a common concern among smokers who are trying to quit. It is important that the clinician be honest and inform the patient that some weight gain is quite common but it is usually self-limiting. Emphasize the importance of a healthy diet and physical activity. The clinician may also choose to maintain the patient on pharmacotherapy known to delay weight gain (e.g., bupropion SR, and nicotine replacement therapies, particularly nicotine gum).

  • If patients report flagging motivation and feelings of deprivation, the clinician should reassure the patient that these feelings are common and recommend rewarding activities. The patient should also be reminded that beginning to smoke (even a puff) will increase urges and make quitting more difficult.

Figure
Figure 31.

Although most relapse occurs early in the quitting process, some relapse occurs months or even years after the quit date. Therefore, clinicians should continue to engage in relapse prevention interventions even with former tobacco users who no longer consider themselves actively engaged in the quitting process.


Treating Tobacco Use and Dependence: Module 4

Michael C. Fiore, MD, MPH

How Do I Treat Tobacco Users Who Are Not Willing To Make A Quit Attempt?

Figure
Figure 32.

Patients unwilling to commit to make a quit attempt during a visit may lack information about the harmful effects of tobacco, may lack the required financial resources, may have fears or concerns about quitting, or may be demoralized because of previous relapses. Such patients may respond to an intervention that provides the clinician an opportunity to educate, reassure, and motivate such as interventions built around the "5 R's", RELEVANCE, RISKS, REWARDS, ROADBLOCKS AND REPETITION.

Figure
Figure 33.

RELEVANCE

Clinicians should encourage the patient to indicate why quitting is personally relevant, being as specific as possible. Motivational information has the greatest impact if it is relevant to a patient's disease status or risk, family or social situation (e.g., having children in the home), health concerns, age, gender, and other important patient characteristics (e.g., prior quitting experience, personal barriers to cessation).

RISKS

Clinicians should ask the patient to identify potential negative consequences of tobacco use.

  • Acute risks include shortness of breath, exacerbation of asthma, harm to pregnancy, impotence, increased serum carbon monoxide.

  • Long-term risks include heart attacks and strokes, lung and other cancers (larynx, oral cavity, pharynx, esophagus, pancreas, bladder, cervix), chronic obstructive pulmonary diseases (chronic bronchitis and emphysema), long-term disability and need for extended care.

  • Environmental risks include increased risk of lung cancer and heart disease in spouses; higher rates of smoking by children of tobacco users; increased risk for low birth weight, SIDS, asthma, middle ear disease, and respiratory infections in children of smokers. Clinicians may suggest and highlight those that seem most relevant to the patient.

Figure
Figure 34.

REWARDS

Clinicians should ask the patient to identify potential benefits of stopping tobacco use.

Clinicians may suggest and highlight those that seem most relevant to the patient (e.g., such as improved health, improved sense of smell, food will taste better, saving money, improved self-esteem, home, car, clothing, breath will smell better, no more worrying about quitting, setting a good example for kids, have healthier babies and children, no more worrying about exposing others to smoke, feel better physically, perform better in physical activities, and reduced wrinkling/aging of skin).

ROADBLOCKS

Clinicians should ask the patient to identify barriers or impediments to quitting and note elements of treatment (problem-solving, pharmacotherapy) that could address barriers.

Typical barriers might include withdrawal symptoms, fear of failure, weight gain, lack of support, depression, and enjoyment of tobacco.

REPETITION

Motivational interventions should be repeated every time an undecided or continuing smoker visits the clinic setting.


Treating Tobacco Use and Dependence: Special Populations

Michael C. Fiore, MD, MPH

Special Populations

Figure
Figure 35.

The PHS guidelines for treating tobacco use and dependence address numerous special populations, including pregnant women, racial and ethnic minorities, hospitalized smokers, smokers with other psychiatric comorbidities and/or chemical dependency, children and adolescents, and older smokers. Generally, the same treatments are found to be effective in all populations.

Pregnant Women

Since smoking in pregnancy imparts risks to both the woman and the fetus, many women are motivated to quit during pregnancy, and health care professionals can take advantage of this motivation by reinforcing the knowledge that cessation will reduce health risks to the fetus and that there are postpartum benefits for both the mother and child. Quitting smoking prior to conception or early in the pregnancy is most beneficial, but health benefits result from abstinence at any time. Therefore, a pregnant smoker should receive encouragement and assistance in quitting throughout her pregnancy. The PHS Guideline recommends that whenever possible pregnant smokers should be offered extended or augmented psychosocial interventions that exceed minimal advice to quit.

Racial and Ethnic Minorities

Tobacco dependence and desire to quit appear to exist in all racial and ethnic groups. Moreover, ethnic and racial minority groups in the United States -- African Americans, American Indians/Native Americans, Alaskan Natives, Asian and Pacific Islanders, Hispanics -- experience high mortality in a number of smoking-related disease categories. Therefore, there is a critical need to deliver effective tobacco dependence interventions to ethnic and racial minorities.

Studies have demonstrated the efficacy of a variety of smoking cessation interventions in minority populations. Nicotine patch, physician advice, counseling, and tailored self-help manuals, materials and telephone counseling have been shown to be effective with African-Americans. Nicotine patch and self-help materials including a mood management component have been shown to be effective with Hispanic smokers. Screening for tobacco use, physician advice, clinic staff reinforcement and follow-up materials have been shown to be effective for Native American populations. As a result, the Panel recommends that members of racial and ethnic minority groups be provided treatments that have been shown to be effective in the Guideline.

Few studies have examined interventions specifically designed for particular ethnic or racial groups, and there is no consistent evidence that targeted cessation programs result in higher quit rates in these groups than do generic interventions of comparable intensity. Therefore, physicians should offer treatments identified as effective to all of their patients. It is essential, however, that cessation counseling or self-help materials be conveyed in a language understood by the smoker. Additionally, culturally-appropriate models or examples may increase the smoker's acceptance of treatment. Clinicians should remain sensitive to individual differences and health beliefs that may affect treatment acceptance and success in all populations.

Hospitalized Smokers

It is vital that hospitalized patients attempt to quit smoking. Smoking may interfere with their recovery since it negatively affects bone and wound healing. Among cardiac patients, second heart attacks are more common in those who continue to smoke. Lung, head, and neck cancer patients who are successfully treated, but who continue to smoke, are at elevated risk for a second cancer.

The PHS Guideline revealed that providing hospitalized smokers with an augmented intervention significantly increases abstinence rates over the patients who receive usual care. Therefore, hospitalized smokers should be given augmented interventions. Patients in long-term care facilities should also receive tobacco dependence interventions identified as efficacious in the PHS Guideline.

Smokers With Psychiatric Co-Morbidity and/or Chemical Dependency

According to the PHS Guideline, smokers with comorbid psychiatric conditions should be provided smoking cessation treatments found to be effective in the general population of smokers. While psychiatric comorbidity places smokers at increased risk for relapse, such smokers can be helped by smoking cessation treatments. Currently there is insufficient evidence to determine whether smokers with psychiatric comorbidity benefit more from specialized or tailored cessation treatments than from standard treatments. Because bupropion SR and nortriptyline are effective at treating depression and are efficacious smoking cessation medications, they should especially be considered for use in depressed patients. Some smokers may experience exacerbation of a comorbid condition upon quitting smoking, however, most evidence suggests that abstinence entails little adverse impact (e.g., little increase in aggression). It is important to note that stopping smoking may affect the pharmacokinetics of certain psychiatric medications. Therefore, physicians may wish to monitor closely the actions or side effects of psychiatric medications in smokers making a quit attempt.

The treatment of tobacco dependence can be provided concurrent to treating patients for other chemical dependencies (alcohol and other drugs). With regard to patients in treatment for chemical dependency, there is little evidence that patients with other chemical dependencies relapse to other drug use when they stop smoking. However, such patients should be followed closely after they stop smoking.

Children and Adolescents

The PHS Guideline recommends that physicians screen pediatric and adolescent patients and their parents for tobacco use and provide a strong message about totally abstaining from tobacco use. A recent study has shown that adolescents' smoking status was identified in 72% of office visits, but smoking cessation counseling was provided at only 17% of clinic visits of adolescent smokers. Therefore, physicians both need to assess adolescent tobacco use and offer cessation counseling and behavioral interventions shown to be effective with adults. It is also recommended that the content of these interventions be modified to be developmentally appropriate. Children and adolescents may benefit from community- and school-based intervention activities. The messages delivered by these programs should be reinforced by the physician. The Guideline further recommends that clinicians in a pediatric setting offer stop-smoking advice to parents to limit children's exposure to second-hand smoke.

Older Smokers

Figure
Figure 36.

It is estimated that 13 million Americans aged 50 and older and 4.5 million adults over 65 smoke cigarettes. Smokers over the age of 65 can both quit smoking and benefit from abstinence. Smoking cessation in older smokers can reduce the risk of myocardial infarction, death from coronary heart disease, and lung cancer. Moreover, abstinence can promote more rapid recovery from illnesses that are exacerbated by smoking and can improve cerebral circulation. Age does not appear to diminish the benefits of quitting smoking.

The smoking cessation interventions that have been shown to be effective in the general population have also been shown to be effective with older smokers, and the PHS Guideline recommends that they be used to treat older adults. Research has demonstrated the efficacy of the 5-A's, counseling interventions, clinician advice, buddy support programs, age-tailored self-help materials, telephone counseling, and the nicotine replacement therapies (NRT) in treating tobacco use and dependence in adults aged 50 years and older.




Authors and Disclosures

It is the policy of the University of Wisconsin Medical School that the faculty and sponsor disclose real or apparent conflict of interest relating to the topics of this educational activity, and also disclose discussions of unlabeled/unapproved uses of drugs or devices during their presentation(s).

Author

Michael C. Fiore, MD, MPH

Founder and Director of the Center for Tobacco Research and Intervention (CTRI), Department of Medicine, University of Wisconsin Medical School, Madison, Wisconsin

Disclosure: Consultant/Lecturer/Research: GlaxoSmithKline, Pfizer, Sanofi.

 

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