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Ambulatory Care - Smoking Cessation - Fast Facts | NEJM Resident 360

Tobacco use is responsible for about one in five deaths in the United States and is the leading cause of preventable death. Helping your patient quit smoking is one of the most important interventions you can do in the primary care setting to reduce morbidity and mortality. Tobacco dependence is a chronic illness and requires ongoing treatment to have lasting benefits. The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians screen patients for tobacco use, advise quitting, and offer pharmacologic and behavioral interventions to achieve smoking cessation. The evidence indicates that the combination of counseling and medication is more effective than either strategy alone.

Counseling

The USPSTF recommends that clinicians ask all adults about tobacco use and provide:

• behavioral interventions and pharmacotherapy to all nonpregnant adults who use tobacco 

• behavioral interventions to pregnant adults who use tobacco

The “5 A’s” model is a good initial framework that can be used to ask adults about tobacco use. Just 3 minutes of counseling can improve someone’s likelihood of quitting, and a dose-dependent relationship exists between duration of counseling and quit rates.

5 A’s Model for Managing Tobacco Use and Dependence
Ask about tobacco use.
Advise to quit.
Assess willingness to make quit attempt.
Assist in quit attempt.
Arrange follow-up.

(Adapted from Treating Tobacco Use and Dependence: 2008 Update, U.S. Department of Health and Human Services 2008 [updated 2014].)

Other patient resources include smokefree.gov and helplines such as 1-800-QUIT-NOW (1-800-784-8669). Local communities may also have group counseling and intensive treatment programs, and you should familiarize yourself with these services.

Behavioral Interventions

Behavioral interventions include physician advice, nurse advice, individual counselling, and group counselling. For pregnant women, consider cognitive behavioral, motivational, and supportive therapies (e.g., health education, feedback, financial incentives, and social support).  

Pharmacotherapy Interventions

All seven FDA-approved medications are recommended and effective. For first-line therapy, consider the two most effective drugs: varenicline and combination nicotine patch with as-needed nicotine replacement (6-month abstinence, 33% and 37%, repectively vs. 14% with placebo).

FDA-Approved Medications for Smoking Cessation

Medication	Use	Notes
Varenicline (Chantix)	Start 1 week before quit date; use for 3–6 months. Titrate dose as per FDA recommendations.

• A nicotinic acetylcholine-receptor partial agonist

• Side effects: nausea, insomnia, vivid or abnormal dreams

• Reduce dose for patients with kidney disease (creatinine clearance <30 mL/min)

• Previous FDA black box warning of neuropsychiatric reactions removed in December 2016

| | Sustained-release bupropion (Zyban) | Start 1–2 weeks before quit date; use for 2–6 months. |

• Contraindicated with history of seizure disorders, eating disorders, or use of monoamine oxidase inhibitors (MAOIs)

• Side effects: insomnia, dry mouth

• Can cause hypertension

| | Nicotine Replacement Therapy | | Nicotine patch | Dose of patch used depends on daily cigarette use. In patients who smoke ≥10 cigarettes/day a higher dose should be commenced. |

• Available over-the-counter

• Use new patch every morning

• Can remove at night if sleep is disrupted

| | Nicotine gum | Chew 1 piece every 1–2 hours initially (max 24/day), then taper. The dose of the gum used will also depend on patient’s daily cigarette use. |

• Available over-the-counter

• Correct technique: chew slowly until you taste the flavor, then “park” between cheek and gums to allow nicotine absorption through mucosa; “chew and park” until taste is gone (~30 min)

• Avoid eating or drinking 15 min before using

| | Nicotine lozenges | Consume 1 piece every 1–2 hours initially (max 20/day), then taper. |

• Available over-the-counter

• Allow to dissolve instead of chewing or swallowing

• Avoid eating or drinking 15 min before using

| | Nicotine inhaler
(Nicotrol) | Use cartridge when craving is present. |

• Prescription only

• Avoid eating or drinking 15 mins before using

| | Nicotine nasal spray
(Nicotrol NS) | Use spray when craving is present. |

• Prescription only

• Highest risk of dependence potential due to higher peak nicotine levels

| | Combination Therapy | | Patch and sustained-release bupropion
Patch and short-acting nicotine replacement (gum, lozenges, inhalers) |

(Adapted from Treating Smokers in the Health Care Setting. NEJM 2011.)

Electronic Cigarettes

The health effects of electronic cigarettes and their usefulness for smoking cessation are uncertain, and the long-term risks are not well understood.

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