Smoking Cessation

The leading preventable cause of death and disease in the United States is the use of tobacco.¹

Annually, 480,000 Americans die as a result of cigarette smoking. Each year, smoking-related illness costs the United States more than $300 billion.¹An estimated 15% of adults, or 36 million people, in the United States are current cigarette smokers.

Nicotine from a cigarette reaches the brain of a smoker in less than 10 seconds. A sensation of pleasure results from an immediate release of dopamine and norepinephrine, and when the euphoria is gone the brain craves more.²Without a continuous release of these chemicals, the brain initiates symptoms of withdrawal. These withdrawal symptoms can include headache, nausea, diaphoresis, anxiety, tremors, irritability, and tachycardia.²The addiction to nicotine can be equal to the addiction of heroin. Continued exposure to nicotine increases tolerance, resulting in the smoker’s increasing usage to achieve the same effect. This results in an automatic, inevitable addiction.²

The negative impact of smoking is far reaching. Cigarette smoke is composed of more than 7000 chemicals, many of which are toxic and some of which cause cancer. Physical consequences of smoking include the smell of smoke lingering on the clothes, hair, and breath. Gingivitis, yellowing of teeth, and eventually tooth decay can result.^2,3Respiratory symptoms can include coughing, wheezing, and productive sputum.³In the long term, smoking can lead to lung scarring, chronic obstructive pulmonary disease (COPD), and asthma.²Cardiovascular complications of smoking can include myocardial infarction, stroke, and peripheral vascular disease.²Also in the long term, smoking tobacco has been associated with cancers of the lung, mouth, esophagus, larynx, colon, bladder, uterus, cervix, and kidneys.²Smoking cessation, at any time, decreases the risk of these serious conditions.

Nicotine replacement therapies (NRTs) are the first-line medications to assist with smoking cessation.³Using NRT, in any form, increases the likelihood of smoking cessation by 50% to 70%.⁴Although NRTs administer nicotine to the body, they do not contain the carcinogenic and toxic substances found in tobacco smoke.⁵The available forms of NRT include nicotine gum, nicotine inhaler, nicotine lozenge, nicotine nasal spray, and the nicotine patch. These medications do not have significant adverse effects.

NRTs should be used for at least 12 weeks, and can be used for up to 9 months. Nicotine patches are available in 21, 14, and 7 mg doses. The patch releases a small, continuous amount of nicotine, and the user decreases the dose over time.³Providing quicker absorption than the patch, the nicotine lozenge and nicotine gum allow nicotine to be absorbed through the oral mucosa. Gum and lozenges are available in both a 2 and 4 mg dose. Deciding on which dose to use is based on when the patient’s first cigarette is smoked: if within the first 30 minutes of waking, then the 4 mg strength should be used; if the first cigarette is smoked more than 30 minutes after waking, then the 2 mg dose should be used. Available only by prescription, the nicotine inhaler and nicotine nasal spray are less frequently used options. Of the NRT options, the patch is the slowest acting. Patients should be cautioned that using NRT while continuing to smoke can lead to angina or an myocardial infarction.³In none of the NRT options is nicotine absorbed as quickly as the nicotine in cigarettes.⁴

To increase the likelihood of a successful cessation attempt, NRTs can be combined. The use of a nicotine patch and oral NRTs, especially with a heavy smoking history, can increase the chances of success.⁴Adherence to the use of NRTs has been found to be low. It is important for health care providers to encourage adherence by providing clear verbal and written instructions on the use of these therapies.³

Non-nicotinic medication options to consider are varenicline (Chantix) and bupropion sustained-release (Zyban).³Both of these medications have been found to reduce cravings and withdrawal symptoms. Bupropion may also help with the mood changes associated with withdrawal symptoms.⁴A concern with these medications is the increased risk for depression and suicidal ideation.³Initial and ongoing assessment of mental illness and its symptoms is essential.³Varenicline should not be taken with NRTs because it is a nicotine receptor partial agonist, which means it blocks the brain's pleasure response from nicotine.³It should be started one week prior to quitting smoking for optimal results. The usual dose is 1 mg, twice per day.⁴One adverse effect of varenicline is nausea, so patients should be instructed to take the medication after a meal and with a full glass of water. Additional adverse effects can include constipation, headaches, sleep disturbance, and bizarre dreams.³The FDA has issued a black box warning related to psychiatric events while taking varenicline. Patients are advised, via the package insert, that if they experience any such events they should stop the medication and contact a health care provider.³

Bupropion, an antidepressant, is usually prescribed for up to 12 weeks but can be used for a longer timeframe depending on individual need. Initiation of bupropion should begin 2 weeks prior to stopping smoking. Dosing is typically 150 mg once per day for a week, then increasing to 150 mg twice per day. It works by stabilizing levels of dopamine and norepinephrine. A history of seizures, anorexia, or bulimia is a contraindication for the use of this drug. Adverse effects of bupropion include insomnia, bizarre dreams, and dry mouth.³The FDA has also added a black box warning to bupropion, and patients should be monitored for depression, suicidal ideation, and suicide attempts. This package insert also alerts patients to immediately contact a health care provider if these symp- toms are noticed.³A treatment plan for smoking cessation could include the use of NRTs, like the nicotine patch, in combination with the non-nicotine medication bupropion.³

Additional interventions are available to assist with smoking cessation success. Encouragement and advice from health care providers, along with referrals for counseling, should be considered.⁴Behavioral therapy, either individual or group-based, especially in the early weeks of smoking cessation, has proven to be beneficial. With ongoing behavioral support, smokers are 4 times more likely to quit.³In behavioral therapy, smokers receive advice, information, support, and encouragement. This allows the smoker to address issues like motivation to remain abstinent from smoking, discovering behavior change techniques, and developing coping skills.³Smokers can also identify triggers such as stress and develop coping strategies to overcome stressful situations. Relaxation techniques and stress reduction strategies further promote the likelihood of successful smoking cessation. Behavioral interventions can also include encouraging the smoker to set a quit date, to share their plans to quit with family and friends, and to prepare their homes for smoking cessation by removing items such as cigarette lighters and ash trays.³

Support programs for smoking cessation are also available online and via telephone quit lines.⁶These options offer easily accessible support for smokers trying to quit. Online resources are available day and night and can provide information and interaction to support cessation attempts at times convenient to the patient.⁶

Exercise and physical activity can also reduce nicotine cravings and withdrawal symptoms.³Additionally, exercise can offset the weight gain sometimes associated with smoking cessation. Symptoms of stress, anxiety, and depression experienced during smoking cessation can also be minimalized by daily exercise.³Recommended activities should be based on the patient’s abilities and interests. Walking, cycling, and swimming offer great aerobic benefit and should be considered.³

Electronic cigarettes (ECs), also known as e-cigarettes and electronic nicotine delivery systems, are devices that heat a liquid for inhalation.⁴Sale and use of these devices has continued to increase in recent years. The liquid used in these devices varies widely and may or may not contain nicotine. Some of the liquid also have added flavoring. Concerns related to the safety of ECs are based on a lack of regulation for the liquids used in the devices.⁷A large variety of ECs are available for purchase, and research on the safety of their use is limited. Other concerns related to the use of ECs include the risk of poisoning in children and adults who handle the nicotine-containing cartridges used in the devices.⁷Currently, clinicians are advised to recommend other smoking cessation therapies until more is known about the safety of ECs.⁷

Discussion with smokers about smoking cessation should always include education on the harmful effects of tobacco. Health care providers should also obtaining a detailed smoking history, including prior cessation attempts and discussions on the benefits of available pharmacotherapies.⁴Combination therapy of NRTs, such as the nicotine patch with nicotine gum or lozenges, has been found to be more successful with patients who have a longer and heavier smoking history.⁴Considering the use of non-nicotinic medications with or without NRT and addressing behavioral therapy interventions all increase the chances of success in a smoking cessation attempt. An individualized plan for smoking cessation should be tailored to each patient’s situation and needs and could include combining medication, behavioral therapy, support, and follow-up.⁴Providing patients with available resources and support, especially in the early weeks of a smoking cessation attempt, increases the likelihood of success.

Lisa Bridwell Robinson, DNP, CCRN, CNE, NP-C, is a doctorally prepared family nurse practitionerand certi ed nurseeducator who practices in a retail clinic and as a worksite health coach. Dr. Robinson also serves as a faculty member,for graduate nursing students in both masters and doctoral programs of study.

References

1. Burden of tobacco use in the U.S. CDC website. cdc.gov/tobacco/campaign/tips/resources/data/cigarette-smoking-in-united-states.html Updated February 2, 2017. Accessed February 25, 2017.
2. Porter A. The role of the advanced practice nurse in promoting smoking cessation in the adult population.Medsurg Nurs.2013;22(4):264-268.
3. Channey S, Sheriff S. Evidence-based treatments for smoking cessation.Nurse Pract.2012;37(4):24-31. doi: 10.1097/01.NPR.0000412892.27557.e8.
4. Siddiqui F, Huque R, Dogar O. Updated evidence-based guide to smoking cessation therapies.Br J Community Nurs.2016;21(12):609-611. doi: http://dx.doi.org/10.12968/bjcn.2016.21.12.607.
5. Phillips A. Supporting smoking cessation in older patients: a continuing challenge for community nurses.Br J Community Nurs.2016;21(9):457-461. doi: 10.12968/bjcn.2016.21.9.457.
6. Papandonatos G, Erar B, Stanton CA, Graham AL. Online community use predicts abstinence in combined internet/phone intervention for smoking cessation.J Consult Clin Psychol.2016;84(7):633-644. doi:10.1037/ccp0000099.
7. Siu AL; US Preventive Services Task Force. Behavioral and pharmacotherapy interventions for tobacco smoking cessation in adults, including pregnant women: U.S. preventive services task force recommendation statement.Ann Intern Med.2015;163(8):622-634. doi: 10.7326/M15-2023.