Basics
Description
Smoking, especially cigarettes, is a major health concern and requires regular screening and counseling.
Epidemiology
- Per the CDC in 2009:
- Adults that smoke tobacco: 20.6%
- Women: 17.9%
- Men: 23.4%
- Prevalence declined from 24.7% in 1997
- Per the CDC in 2003:
- High school students that smoke: 22%
- Middle school students that smoke: 8%
- Data vary for pregnant women, but from 11% to 22% of pregnant women smoke and in some parts of the US rates may be even higher.
General Prevention
Physician intervention for smoking cessation has shown to have a positive impact in cessation rates.
Associated Conditions
- Malignancy:
- Lung cancer is now the leading cause of cancer-related death in women.
- In the US, 71,080 women died of lung cancer in 2010 as opposed to 39,840 from breast cancer.
- Tobacco use is also associated with many other malignancies (head and neck, esophageal, bladder, cervical, and pancreatic).
- Cardiac: Coronary artery disease
- Smoking is associated with approximately a 6-fold increase in myocardial infarction compared to women who have never smoked.
- There is a decrease in myocardial events after quitting in both patients with and without prior cardiovascular events.
- Pulmonary: Chronic obstructive pulmonary disease
- Smoking cessation reduces the rates of decline in FEV1.
- Many smokers have a decrease in cough and sputum production in the first smoke-free year.
- Endocrine: Osteoporosis
- Tobacco use is a major risk factor for loss of bone density.
- Fertility:
- Smoking >10 cigarettes/day has been associated with impaired fertility.
- In addition, studies suggest that smoking can lead to premature aging of the ovary.
- Fetal effects:
- Increased risk of low birth weight and small for gestational age, spontaneous abortion, stillbirth, preterm premature rupture of membranes, placental abruption/previa, preterm delivery, congenital malformations
Diagnosis
History
Screening for smoking should be done regularly. The "5 A 's " are designed to help evaluate smokers:
- Ask: Systematically identify all tobacco users at every visit
- Advise: Strongly urge all tobacco users to quit
- Assess: Determine willingness to make a quit attempt
- Assist: Aid the patient in quitting
- Arrange: Arrange follow-up
Physical Exam
- Physical exam may be normal.
- If pulmonary obstruction occurs, may find:
- Prolonged expiration and wheezes on forced exhalation
- Hyperinflation
- Increased anteroposterior diameter of chest
- Decreased breath sounds
- Heart sounds often become distant.
- Coarse crackles at lung bases
- Concern for malignancy:
- Weight loss
- Hemoptysis
- Lymphadenopathy
Tests
Lab
Pulmonary function tests (PFTs):
- To detect lung disease that may be attributable to cigarette use
- May be useful to show patients documented evidence of the negative consequences of smoking when lung disease is detected
- Abnormal PFTs may provide motivation to quit.
Treatment
Medication
First Line
- Nicotine replacement therapy (NRT):
- Decreases the symptoms of nicotine withdrawal (insomnia, irritability, anxiety, dysphoria, and increased appetite with weight gain)
- There are a variety of forms available: Patch, gum, lozenge, inhaler, and nasal spray
- Doubles quit rates compared to placebo
- Dose is dependent on amount of nicotine used previously.
- Greater efficacy with concomitant use of long-acting forms (nicotine patch) with short-acting forms (gum, lozenge, inhaler, spray) as needed for cravings (1)[A]
- Shown to be safe even in patients with cardiovascular disease (2)[A]
- Bupropion:
- Antidepressant with action on norepinephrine and dopamine
- Approved for use in smoking cessation
- 150 mg sustained release tablet PO daily 3 days then 150 mg PO bid 7 " 12 weeks
- Doses should be at least 8 hours apart.
- Avoid dosing at bedtime as may cause insomnia
- Quit date should be 1 " 2 weeks after starting medication.
- Doubles quit rates compared to placebo
- Greater efficacy if used in combination with nicotine replacement (1)[A]
- Contraindicated in patients with a seizure disorder or eating disorder
- Varenicline:
- Partial agonist for a neuronal nicotinic acetylcholine receptor that plays a central role in nicotine addiction
- Dose and duration of treatment
- 0.5 mg PO daily on days 1 " 3 followed by 0.5 mg PO b.i.d. on days 4 " 7
- Then 1 mg PO b.i.d. for 12 weeks after a week of titration
- May continue for an additional 12 weeks of maintenance
- Quit date may vary but should be after initiation of medication to diminish neuronal pleasure of smoking.
- Major side effects include nausea, insomnia, and headache.
- May be slightly more effective than NRT or bupropion (1)[A]
- FDA issued a black box warning in 2009 for both bupropion and varenicline for concern over serious mental health effects including depressed mood, behavior changes, and suicidal thoughts.
Second Line
- Clonidine and nortriptyline considered second-line therapies (3)[A]
- Electronic cigarette or vapor cigarette is a battery-powered device that provides inhaled doses of nicotine.
- Not currently FDA approved due to its reclassification as a drug/device instead of a tobacco product and lack of studies supporting its safety
- Concern over variety chemicals found in the smoke and the lack of manufacturing standardization
- Generally considered less harmful than cigarette smoking
Additional Treatment
General Measures
- After screening for smoking, the patient 's readiness to quit should be assessed. They may fall into the following categories:
- Precontemplative: Patient is not ready or interested in quitting.
- Contemplative: Patient is considering quitting in the future.
- Determination: Patient is actively planning to quit or has started to try.
- Action: Patient is actively trying to quit or quit <6 months ago.
- Maintenance: Patient quit >6 months ago.
- Behavioral changes:
- Providing even brief advice about quitting smoking increases the likelihood that a smoker will successfully quit and remain a nonsmoker in the future.
- Suggested interventions:
- Quit date: Choose a day in the future to quit
- Prepare for quit date
- Identify triggers and develop alternate plan
- Avoid situations and places that triggered smoking in the past
- Inform friends and family of plan for their support and assistance
- Be aware of nicotine withdrawal and how it can be treated
- Patient education regarding potential weight gain
- Exercise and healthy diet should be discussed.
- Counseling:
- Cognitive
- The goal of cognitive therapy is to reframe the way a patient thinks about smoking.
- Smokers are taught techniques of distraction, positivism, relaxation, and mental imagery.
- Offered encouragement and motivation
- Behavioral
- Behavioral therapy teaches patient to avoid stimuli that trigger smoking, such as stress, alcohol, and associating with other smokers.
- Other interventions include altering the usual smoking routine, preparing for cigarette cravings, and addressing withdrawal.
- Intensive counseling
- Can be associated with a 22% quit rate
- Limited counseling (<3 minutes) is associated with a 13% quit rate.
(See "Substance Abuse " chapter)
Complementary and Alternative Medicine
- Acupuncture: A 2002 Cochran review of 22 studies comparing acupuncture to sham acupuncture showed no difference in quit rates.
- Hypnotherapy has not been shown to reliably affect rates of quitting.
- Telephone quit lines: Many states have numbers where patients can easily access advice and treatment programs for quitting.
- National websites provide additional education and support.
- www.smokefree.gov
- www.smoking-cessation.org
- www.becomanex.org
Ongoing Care
Follow-Up Recommendations
Patient Monitoring
Follow-up for continued patient screening and support should be provided.
- NRT classified as class D in pregnancy, but no strong evidence that NRT during pregnancy associated with higher risk of adverse perinatal events (4)[B]
- American College of Obstetrics and Gynecology recommends NRT in pregnancy when counseling has failed and risks of NRT are less than risks of smoking (4)[B].
- Possible increase in risk of congenital anomalies with use of bupropion in first trimester of pregnancy
- No safety data on varenicline in pregnancy
References
1Fiore MC, Jaen CR, Baker TB 2008. Clinical practice guideline " Treating tobacco use and dependence: 2008 update. Available at: www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf2Joseph AM, Norman SM, Ferry LH. The safety of transdermal nicotine as an aid to smoking cessation in patients with cardiac disease. N Engl J Med. 1996;335:1792 " 1798. [View Abstract]3Hughes JR, Stead LF, Lancaster T. Antidepressants for smoking cessation. Cochrane Database Syst Rev. 2004;4:CD000031.4Crawford JT, Tolosa JE, Goldenberg RL. Smoking cessation in pregnancy: why, how, and what next. Clin Obstet Gynecol. 2008;51(2):419 " 435. [View Abstract]
Additional Reading
1Abbot NC, Stead LF, White AR. Hypnotherapy for smoking cessation. Cochrane Database Syst Rev. 1998;2:CD001008.2Bernstein IM, Mongeon JA, Badger GJ. Maternal smoking and its association with birth weight. Obstet Gynecol. 2005;106:986 " 991. [View Abstract]3Ford C, Zlabek JA. Nicotine replacement therapy and cardiovascular disease. Mayo Clin Proc. 2005;80:652 " 656. [View Abstract]4Lancaster T, Stead LF. Physician advice for smoking cessation. Cochrane Database Syst Rev. 2004;4:CD000165. [View Abstract]5Nides M. Update on pharmacologic options for smoking cessation treatment. Am J Med. 2008;121(4 Suppl 1):S20 " S31. [View Abstract]6 Quick Reference Guide for Clinicians: Treating tobacco use and dependence. Available at: http://www.surgeongeneral.gov/tobacco/tobaqrg.htm7Schroeder SA. What to do with a patient who smokes. JAMA. 2005;294:482 " 487. [View Abstract]8White AR, Rampes H, Ernst E. Acupuncture for smoking cessation. Cochrane Database Syst Rev. 2002;2:CD000009. [View Abstract]
Codes
ICD9
- V15.82 Personal history of tobacco use
- 305.1 Tobacco use disorder
- 649.03 Tobacco use disorder complicating pregnancy, childbirth, or the puerperium, antepartum condition or complication
ICD10
- O99.330 Smoking (tobacco) complicating pregnancy, unsp trimester
- T65.224A Toxic effect of tobacco cigarettes, undetermined, init
- Z72.0 Tobacco use
- T65.224D Toxic effect of tobacco cigarettes, undetermined, subs
- T65.224S Toxic effect of tobacco cigarettes, undetermined, sequela
SNOMED
- 110483000 tobacco user (finding)
- 427189007 maternal tobacco use (finding)
- 212899006 toxic effect of tobacco and nicotine (disorder)
Clinical Pearls
- Smoking cessation should always be a major health care goal as quitting can have a significant impact on disease.
- Smokers who receive optimal pharmacological treatment together with counseling have greatly improved odds of obtaining long-term abstinence.
- Pharmacological therapy may be associated with significant side effects, especially for smokers with a history of mental illness.
- Relapse rates are high for smokers who quit during pregnancy.