Smoking Cessation: What Works and What Doesn't?

There is strong evidence showing that even brief tobacco-cessation counseling and interventions are effective at promoting tobacco abstinence. In fact, said Sarah Mullins, MD, during her presentation,” BUTT Out: What Actually Works in Smoking Cessation,” Friday at the 2010 AAFP Scientific Assembly, interventions lasting less than three minutes have been shown to increase overall tobacco abstinence rates. Therefore, “every tobacco user should be offered at least a minimal intervention, whether or not he or she is referred to an intensive intervention,” Mullins said

She told that audience that several surveys have shown that more than 80% of physicians ask patients about smoking and advised them to quit, but fewer than one-third have recommended medications for their patients who smoke. Mullins said that physicians under-treat smokers and don’t use evidence-based treatments to help them quit for a variety of reasons, including because they are too busy, they lack expertise or knowledge about effective smoking cessation treatments, and there is little financial incentive for tobacco cessation counseling.

Mullins, who is a member of the AAFP Tobacco Cessation Advisory Committee, said that more than 70% of smokers want to quit, but only about 5% can quit on their own without any assistance. More than 90% of patients who try to quit without assistance from evidence-based programs relapse. Because more than 70% of smokers see a physician every year, this represents an excellent opportunity for physicians to apply proven, evidence-based approaches to tobacco cessation and help patients stop smoking and improve their overall health. “Even when patients are not willing to make a quit attempt, clinician-delivered brief interventions enhance motivation and increase the likelihood of future quit attempts,” Mullins said.

The evidence supports the use of pharmacotherapy in all smokers who are trying to quit, “except where contraindicated or for specific populations for which there is insufficient evidence of effectiveness,” Mullins said. Patients for whom smoking-cessation pharmacotherapy is not recommended include pregnant women, smokeless tobacco users, light smokers, and adolescents. When prescribing medication as part of a smoking-cessation plan, in addition to the medications’ contraindications, physicians should also consider their own familiarity with and knowledge of the medication, the patient’s preferences, and any patient characteristics that would affect prescribing choices (such as a history of depression or concerns over weight gain).

First-line pharmacotherapies for smoking cessation include a variety of nicotine replacement products such as the nicotine patch, nicotine gum and lozenges, and nicotine inhalers and nasal spray. Medications include buproprion SR and varenicline. Mullins said that patients who smoke more than 10 cigarettes a day who are prescribed a nicotine patch should start at a dose of 21 mg every 24 hours for four weeks, then receive 14 mg for two weeks, then 7 mg for two weeks. Side effects include skin irritation and sleep disturbance (if the patch is worn at night).

Patients prescribed nicotine gum should receive a 4 mg if they smoke more than 25 cigs a day. They should chew one piece every 1-2 hours for six weeks, moving to one piece every 2-4 hours for weeks 7-9, then one piece every 4-8 hours in weeks 10-12. Mullins said that patients should be reminded not to chew nicotine like regular gum; they should chew it briefly and then hold it in their cheek or gum. Nicotine gum should not be taken within 15 minutes of eating or drinking. The nicotine lozenge has a similar dosing schedule as nicotine gum. Patients should be cautioned to rotate lozenge placement in their mouth and to never chew or swallow this medication.

The starting dose for buproprion SR is 150 mg daily for three days, then twice per day for 7-12 weeks. Mullins said that patients and physicians should plan a smoking quit date 1-2 weeks after start of therapy with buproprion. The starting dose for varenicline is 0.5 mg daily for 1-3 days, then twice daily for 1-4 days, increasing to 1 mg twice daily until a quit date. This medication is contraindicated in patients with a history of depression (buproprion and nicotine replacement products are better choices for these patients). Patients with mental illness who are attempting to quit smoking will likely require medications, although patients with bipolar disorder or eating disorders shouldn’t receive buproprion. Mullins reminded the audience that these interventions are for heavy smokers and that medications have not been shown to be beneficial for light smokers (people who smoke fewer than 10 cigarettes per day). Nicotine replacement products are safe and effective in adolescent smokers, but there is little evidence that medications are beneficial.

Mullins said that long-term pharmacotherapy “is helpful with smokers with persistent withdrawal symptoms,” and that there do not appear to be any health risks associated with long-term use of nicotine replacement therapy. Combination therapy with a nicotine patch and nicotine gum or nasal spray increases long-term abstinence; combination patch/inhaler therapy is also effective. Studies have shown that therapy with a nicotine patch and buproprion is more effective than treatment with the patch alone. Mullins said that combining varenicline with nicotine replacement therapy is not recommended.

Counseling is the other key smoking-cessation intervention that physicians can use with patients who want to stop smoking. Mullins said that tobacco-cessation counseling is supported by the highest level of evidence in the guidelines and “is effective in improving tobacco quit rates among adults and adolescents.” She also noted that “the combination of counseling and medication is more effective for smoking cessation than either medication or counseling alone.”

The key to effective smoking-cessation counseling is the use of motivational interviewing, which uses empathy, reflective listening, and open-ended questions to encourage the patient to give voice to his or her reasons for wanting to quit smoking. During counseling, the physician can discuss why quitting is important to the patient, outline the risks associated with continuing smoking and the financial and health-related rewards of quitting, and the roadblocks and barriers to quitting that are specific to the patient. The important thing is to repeat the messages during future office visits; Mullins advised physicians to “think of tobacco use as a chronic disease” that requires consistent and repeated intervention.

Smoking cessation counseling should support self-efficacy in patients by helping them identify and build on past successes and offering the patient options for achievable small steps toward change. Counseling should teach patients practical problem-solving skills, help them identify “danger situations” that prompt them to smoke, and suggest coping skills to use with danger situations and how to avoid temptation.