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smoking cessation

Benefits: - increased life expectancy - smoking cessation is the single most important thing a smoker can do to improve life expectancy & quality of life [8] - 14 year mortality lower with smoking cessation [4] - smoking cessation at age 65 associated with increase in life expectancy of 1.4-12 year (male), 2.7-3.4 years (female) [3] - lower cardiovascular mortality (independent of age) - even if they gain weight [16] - risk decreases by 50% in the 1st year - risk returns to that of a non smoker in 10-15 years - risk-advancement for cardiovascular death for former smokers is 2.2 years [39] - cardiovascular risk appears to remain elevated well beyond 5 years in heavy smokers after they quit [61] - lung function & circulation improve immediately after smoking cessation [3] - respiratory ciliary function recovery - ciliary function returns within 2 weeks - a transient productive cough may occur - risk of respiratory infections declines - smoking cessation reduces risk of lung cancer [8,17] - risk decreases more slowly than cardiovascular disease - risk returns to that of a non smoker in 15 years - smoking cessation may diminish prostate-specific mortality [43] - risk of post-operative complications diminishes [1,9] - smoking cessation 1 year prior to surgery may eliminate increased postoperative mortality [18] - improvements in anxiety, depression, stress, quality of life, & affect, including patients with physical or psychiatric disorders [25] - 30 years after quitting, risk of cardiovascular disease, cancer & respiratory tract disease returns to normal [70] - it is never too late to late to quit smoking [13] Adverse effects: - 1 year after quitting smoking, people have gained an average of 10 lb (4.5 kg); however, 16% actually lose weight [14] - weight gain may limit pulmonary benefits of smoking cessation, especially abdominal obesity in men [5] - cardiovascular benefits of smoking cessation even with weight gain [16,58] - weight gain poses a trivial risk of harm compared with the benefits of smoking cessation [65] - symptoms of nicotine withdrawal (see nicotine) - smoking cessation may adversely affect glycemic control in patients with diabetes mellitus type 2 [36] - temporary increase in risk of type 2 diabetes risk, but risk offset by long-term reduction in mortality [58] Management: 1) Public Health Services 5-step brief intervention (5 A's) [8] a) Ask about tobacco use b) Advise to quit c) Assess willingness to attempt to quit d) Assist in attempt & discuss a quit date <== (next step after advising to quit) e) Arrange for follow-up 2) for patients unwilling to quit, enhance motivation (5 R's) [8] a) non-confrontational strategies (motivational interviewing) b) expore Relevance of smoking cessation to patient' life c) assist in identifying Risks of smoking d) assist in identifying Rewards of smoking cessation e) discuss Roadblocks or barriers to stopping f) Repeat motivational intervention each visit 3) referral to smoking cessation program advised - nicotine gum or patches should be prescribed prior to &/or with referral (GRS11) [3] - smoking cessation & varenicline more important than depression screening in patients with manifestations of depression [8] - bupropion appropriate for smoking cessation in patients with depression [68] 4) both behavioral & pharmacotherapy interventions (nicotine replacement therapy, bupropion sustained release, & varenicline) to reduce tobacco use are recommended for nonpregnant adults (USPSTF) [64] - behavioral interventions & pharmacotherapy together are more effective than either alone [64] - for patients with serious mental illness, a combination of varenicline plus cognitive behavioral therapy may improve sustained smoking cessation at 6 months & 1 year [24] 5) cognitive behavioral therapy *** - behavioral therapy to reduce tobacco use is recommended for pregnant women [64] - 1st line during pregnancy regardless of previous unsuccsessful attempts [68] 6) pharmaceutical agents a) varenicline* (Chantix) - as single agent, varenicline is more effective than bupropion or nicotine [8,50,63,69] - has not been studied in elderly (GRS11) [3] - varenicline plus bupropion - outperforms varenicline alone in men & heavy smokers [30] - varenicline plus nicotine patch better than varenicline alone (49% vs 23% at 24 weeks) [31] - leads to higher smoking cessation rates among smokers who say they're not quite ready to quit (32& vs 7%) [34] - varenicline (0.5 mg QD to 1 mg BID) - smoking cessation 31% for varenicline vs 21% for placebo at 52 weeks [53] - only after unsuccessful behavioral therapy during pregnancy [68] b) nicotine (conflicting reports) 1] effective - increases rate of success 50-70% [35] - number needed to treat (NNT) = 15 [35] - pharmaceutical of choice in elderly [3] 2] nicotine patch* more effective than gum [3] 3] combining two nicotine products with different patterns of nicotine delivery is safe & more effective than using a single nicotine product first line [8,29] - nicotine patches (21-mg patches tapered to 7 mg by 8 weeks) plus - nicotine gum or - nicotine lozenges (ok in patients with dental disease) - nicotine patch plus nicotine spray - nicotine combination as effective as varenicline [69] 6] contraindicated in pregnancy [11] - nicotine patch of no benefit in pregnant women [12] 7] nicotine patches before a targeted smoking cessation date (nicotine preloading) probably deters use of varenicline, a more effective smoking cessation drug [56] 8] early nicotine withdrawal may increase pain reactivity [57] 9] a 3-week abstinence game plus nicotine replacement therapy helped 1 in 5 smokers quit who were not ready to quit at baseline [67] 10] not contraindicated following myocardial infarction - may be started in hospital [1] 11] of no value [10] c) antidepressants 1] bupropion* (Wellbutrin, Zyban) alone or in combination with nicotine patch [4] - bupropion appropriate for smoking cessation in patients with depression [68] - avoid bupropion with history of seizures - avoid combination with nicotine during in pregnancy - safety in pregnancy unclear - may be good choice in patients with depression [3] - may be associated with suicidal ideation [8] - only after unsuccessful behavioral therapy during pregnancy [68] 2] combination of bupropion & varenicline improves smoking cessation at 12 & 26 weeks, but not 52 weeks [23] 3] tricyclic antidepressants - doxepin, nortriptyline 4] SSRI of no benefit for smokng cessation [8] d) clonidine e) cytisine may be better than nicotine replacement therapy 7) electronic cigarettes - more effective than over-the-counter nicotine replacement [27] - 18% vs 10% at year [60] - e-cigarette for smoking cessation controversy [46] - availability of e-cigarettes associated with more success in smoking cessation [49] - use of e-cigarettes intermittently & concurrently with other cessation aids not useful for smoking cessation [52] - evidence is insufficient to support use of e-cigarettes to reduce tobacco use [64] - electronic cigarettes are similar to varenicline & better than nicotine gum for smoking cessation [71] - electronic cigarettes plus counseling better than counseling alone [72] * varenicline, bupropion, & nicotine patch do not increase cardiovascular risk in smokers * review [66] Notes: 1) physician training in smoking cessation skills & interventions may be useful (13% vs 5% success rate for patient smoking cessation [2]) 2) salivary nicotine metabolites (point of care test) may provide incentive for patients to quit [7] 3) screening for carotid stenosis with carotid ultrasound not sufficient motivation for smoking cessation [11] 4) interventions for adolecents not successful [15] 5) both gradual & abrupt smoking cessation have poor success rates, 14-15% 6) smoking cessation programs that begin during hospitalization & continue after discharge increases the odds of success [8] 7) financial incentives double smoking cessation succcess rates [37] including among pregnant women [33] - patient navigation + financial incentives improve smoking cessation among low income, minimally educated patients NNT=10 [51] - $600 improves 6 month smoking cessation rate (up to 3%) [55] - neither free medication nor free electronic cigarettes improves 6 month smoking cessation rate (<= 1%) [55] 8) more intense smoking cessation interventions by physicians after lung cancer screening are associated with greater likelihood of smoking cessation (65% vs. 58% of smokers) [38] 9) smoking cessation after myocardial infarction associated with better health care outcomes vs continuing to smoke [40] 10) abrupt smoking cessation more likely to be successful than gradual cessation [42] 11) 1 minute smoking cessation intervention in the emergency department increased abstinence at 6 & 12 months [62] 12) specifically, smoking cessation is more important than reducing alcohol intake in a 38 year old woman who smokes 10 cigarettes per day & drinks 2 alcoholic beverages most nights [8]

Related

smoking; cigarette smoking; tobacco smoking

General

life-style clinical procedure

References

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