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Tobacco Use

Basics

Description

- 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

- 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]

- 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

- 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

- 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

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 diseaseSmoking 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 diseaseSmoking 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: OsteoporosisTobacco 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 exhalationHyperinflationIncreased anteroposterior diameter of chestDecreased breath soundsHeart sounds often become distant.Coarse crackles at lung bases
  • Concern for malignancy:Weight lossHemoptysisLymphadenopathy

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 sprayDoubles quit rates compared to placeboDose 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 dopamineApproved for use in smoking cessation150 mg sustained release tablet PO daily 3 days then 150 mg PO bid 7 " 12 weeksDoses should be at least 8 hours apart.Avoid dosing at bedtime as may cause insomniaQuit date should be 1 " 2 weeks after starting medication.Doubles quit rates compared to placeboGreater 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 addictionDose and duration of treatment0.5 mg PO daily on days 1 " 3 followed by 0.5 mg PO b.i.d. on days 4 " 7Then 1 mg PO b.i.d. for 12 weeks after a week of titrationMay continue for an additional 12 weeks of maintenanceQuit 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 safetyConcern over variety chemicals found in the smoke and the lack of manufacturing standardizationGenerally 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 quitPrepare for quit dateIdentify triggers and develop alternate planAvoid situations and places that triggered smoking in the pastInform friends and family of plan for their support and assistanceBe aware of nicotine withdrawal and how it can be treatedPatient education regarding potential weight gainExercise and healthy diet should be discussed.
  • Counseling:CognitiveThe 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 motivationBehavioralBehavioral 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 counselingCan be associated with a 22% quit rateLimited 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.govwww.smoking-cessation.orgwww.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.