The Early Recognition and
Systematically identify all tobacco users at every visit.Implement an office-wide system that allows for inquiry and
documentation of tobacco use for every patient at every visit
|ADVISE- Strongly urge
all smokers to quit in a clear, strong and personalized
|ASK- Ask every smoker
if he or she is willing to make a quit attempt at this
|ASSIST- Aid the
patient in quitting
Help patient with the development of a quit
Encourage nicotine replacement therapy and/or bupropion if
there are no contraindications
Give key advice on successful
follow up contact in person or via telephone
Modified from Fiore, MC, Bailey, Cohen
JJ, et al. Smoking Cessation. Clinical Practice Guideline Number 18. AHCPR
Publication No. 96-0692, Rockville, MD, Agency for Health Care Policy and
Research, Public Health Service, U.S. Department of Health and Human
Nicotine is a powerfully psychoactive drug, and users become physically
and psychologically dependent. Addicting drugs, including tobacco, have
the following characteristics:
Recent research into tobacco addiction has focused on the effects of
nicotine on the brain. Cigarette smoke delivers sudden jolts of nicotine
to the brain within 7 seconds of its inhalation. This rapidly increases
levels of the neurotransmitter dopamine in brain tissue, leading to a
feeling of pleasure and a sense of well being. These pleasurable feelings
are transient—lasting only a few seconds. As nicotine levels fall, the
smoker experiences intense craving, often described as the “nicotine fit”.
Symptoms of withdrawal include:
Nicotine replacement therapy and bupropion have been approved for
treatment of tobacco addiction. Both drugs used alone or in combination
have been shown to increase quit rates when compared to placebo.
Nortriptyline and clonidine have also been found to be beneficial but have
not been approved by the FDA for the indication of smoking cessation.
Nicotine is the substance in tobacco known to cause dependence.
Nicotine replacement therapy (NRT) can reduce the severity of withdrawal
symptoms and cravings in patients abstaining from tobacco and has been
shown to double quit rates compared to placebo. NRT can potentially reduce
exposure to carbon monoxide, carcinogens, and the more than 4000 other
compounds found in tobacco. Pure nicotine delivered in proper doses is
safe and effective in treating patients with tobacco addiction and in
patients with stable cardiovascular diseases.
In the United States, five delivery systems are available for NRT:
Transdermal Nicotine Systems:
systems are available over the counter and deliver a fixed dose of the
drug over 16 to 24 hours. Dosages vary from 7mg to 21mg. Heavily addicted
smokers may fail NRT because they are unable to achieve nicotine blood
levels sufficient to suppress withdrawal symptoms. Nicotine blood levels
achieved by the 21mg patch are 40% to 50% of the levels found in a subject
smoking 30 cigarettes daily (one and a half packs a day). Therefore, this
dose of nicotine may not be sufficient to decrease the patient’s nicotine
requirement. The use of combined NRT delivery methods should be considered
if there are no medical contraindications (See next page). The
nicotine patch is usually removed at bedtime, but in heavily addicted
patients, early morning cravings may be avoided by leaving the patch on
during the night. Side effects include:
Redness and pruritus at the site of
The dose is usually reduced every 4 to 6 weeks. The physician may
safely combine nicotine patches with other NRT products. supplementing the
patches with nicotine gum, nicotine inhaler, nicotine spray or nicotine
Nicotine gum was the first
NRT product approved by the FDA and is available over the counter in doses
of 2mg and 4mg. The higher dose is usually required initially. When
nicotine cravings are felt, the gum is chewed until a tingling sensation
in the mouth is noted, after which the gum is “parked” between the cheek
and gum until the cravings return, then the process is repeated. When used
in conjunction with an intense behavioral modification program, quit rates
have doubled when compared to placebo. Many patients have difficulty
chewing the gum, especially those with dentures.
Nicotine Nasal Spray
Nicotine nasal spray
(Nicotrol NS®) is an aqueous solution of nicotine delivering approximately
0.5 mg of nicotine to the nasal mucosa with each spray. The usual dose is
one spray in each nostril every 1 to 2 hours. Absorption is rapid, with
venous concentrations of 2 to 12 ng/ml of nicotine achieved in 4-15
minutes – mimicking the levels reached by the smoking of one cigarette.
(7-17 ng/ml). This may abort craving in heavily addicted patients. The
maximal recommended dose is 40 mg per 24 hours. Nasal irritation is
common, affecting 80% to 90% of users. Other side effects include
sneezing, lacrimation and cough. Clinical trials have shown favorable quit
rates, but the dependence and abuse potential is greater when compared to
other NRT products (but still lower than cigarettes).
The Nicotrol® Inhaler (nicotine
inhalation system) consists of a mouthpiece and plastic cartridges, each
containing 10 mg of nicotine. One cartridge is inserted into the
mouthpiece, and nicotine is released by inhaling. The majority of the
nicotine is deposited in the oral mucosa, and maximum blood levels are
achieved more slowly when compared to the nasal spray or cigarettes. The
most common side effects are cough and irritation of the mouth and throat.
The inhaler should be avoided in patients with history of asthma. Some
patients prefer this system, because the hand-to-mouth activity mimics
These lozenges also contain 2 mg
nicotine polacrilex. Up to 20 lozenges can be safely dissolved under the
tongue over a 24 hour period. One lozenge per hour is a common dosing
Combining NRT Systems-Compliance
None of the NRT
systems are as effective as the cigarette in delivering nicotine to the
brain. Heavily addicted patients may not achieve adequate blood levels
using a single NRT system. Combining NRT products has been shown to be
effective and safe. The combination of transdermal nicotine patches with
nicotine gum provides steady state levels of nicotine and a jolt of
nicotine to treat break-through cravings. Compliance with NRT products is
highest with the nicotine patch and lowest with the nicotine inhaler.
Bupropion SR (Zyban)
Bupropion was originally
marketed in the United States as an antidepressant drug with dopaminergic
and noradrenergic activity. In clinical trials some of the test subjects
treated for depression noted a decrease in their desire to smoke, leading
investigators to explore the usefulness of the drug in the treatment of
tobacco addiction. Studies with patients who had failed in efforts to quit
have revealed that bupropion SR (Zyban), either alone or in combination
with NRT, significantly achieved higher short-term and long-term quit
rates when compared to placebo.
Bupropion SR should be started at least two weeks before the quit date
with a dose of 150 mg a day for three days and then twice daily. The doses
should be separated by at least eight hours and the second dose should be
given no later than 6:00 PM. Bupropion SR is contraindicated in patients
with a history of seizure disorder or uncontrolled hypertension. The drug
should be continued for up to 6 months to maintain abstinence. Side
effects include insomnia, dry mouth and agitation.
Many smokers avoid quitting or relapse because of weight gain. Weight
gain ranges from 2.3 to 4.5 kg (5 to 10 lb), but some individuals gain
considerably more. Patients should be counseled to follow a healthy diet
and to start a regular exercise program to help minimize weight gain.
Patients should not try to lose weight and stop smoking at the same time.
The physician should point out that a modest weight gain is a small price
to pay compared to the benefits that are derived from stopping
It is clear that smoking cessation diminishes the risk of developing
COPD, slows the accelerated decline in pulmonary function due to cigarette
smoking, and improves symptoms in patients with COPD. Every tobacco user
should be offered treatment to quit. The process begins by identifying all
smokers in your practice, not just those with smoking-related diseases.
You should motivate each patient to quit by asking at each encounter about
his/her tobacco habits and pointing out the advantages of quitting.
Performing spirometry to identify early COPD can be a great motivator and
should be done on all smokers. However, if spirometry results are normal,
reinforce with those patients that they are one of the lucky ones who do
not yet have a significant loss of lung function. This may occur if they
continue to smoke, but more importantly, they remain at an increased risk
for having a heart attack, stroke, and/or lung cancer. Treatment should
routinely include counseling as well as pharmacotherapy. Combinations of
NRT products are safe and effective, and frequently are required to reduce
craving in heavily addicted patients. NRT added to bupropion SR, combined
with behavioral therapy, achieves the highest smoking cessation rates.
Smokers frequently try acupuncture or hypnosis for tobacco dependence, but
scientific merit is lacking to support these treatments.
Research is ongoing to find more effective pharmacotherapy in the
treatment of nicotine addiction. Studies are currently underway to develop
an ”anti-nicotine vaccine”. This experimental drug is injected into the
patient, and the antibodies subsequently produced prevent nicotine
molecules from reaching the brain, blunting the nicotine high. Another
approach is being evaluated that decreases dopamine levels in the brain.
The anti-convulsant drug Vigabatrin, marketed in Europe, decreases
dopamine levels and has shown promising results in nicotine addiction.
Rigotti Nancy A, Treatment of Tobacco Use
and Dependence, New England of Medicine, Vol. 346, No. 7, February 14,
2002 pp 506-512. An excellent, concise review clinical approach to
treatment of tobacco abuse.
ATS Guidelines: cigarette smoking and health
1999, Comprehensive review of tobacco use and treatment.
Raw. M, McNeil, A, Weat, R. Smoking
cessation guidelines for health professionals. A guide to effective
cessation interventions for the health care system. Thorax; 1998; 53
(supplement 5: S1.) Provides a simple behavioral approach for smoking
cessation endorsed by the British Thoracic Society and out lines the “5
A’s” approach of smoking cessation for office practices.
Bohadana A, Nilsdson F, Rasmussen T, et al:
Nicotine Inhaler and Nicotine Patch as a Combination Therapy for Smoking
Cessation: a randomized, double-blind, placebo trial. Archives of
Internal Medicine. 2000;160:3128-34. A comparison of the nicotine inhaler
and patch, suggesting roughly equal effectiveness.
Fiore MC, Bailey WC, Cohen SJ, et al.
Treating Tobacco Use and Dependence. Rockville, MD. Department of Health
and Human Services, Public Health , Public Health vice, 2000. A
comprehensive review of strategies useful in smoking cessation.
Nicotine Replacement Therapy for Patients
With Coronary Artery Disease. Working Group for the Study of Transdermal
Nicotine in Patients With Coronary Artery Disease.. New England Journal of
Medicine, 1996; 335:1792.Evidence that use of nicotine replacement is safe
in patients with coronary artery disease.
Physicians Desk Reference, 2000. Contains a
listing of smoking cessation products.