smoking%20cessation
SMOKING CESSATION
Ask, Advise to quit and Assess are the steps in approaching patients regarding smoking cessation.
All patients should be asked if they use tobacco and should have their tobacco status documented on a regular basis.
Patient with nicotine dependence is characterized by smoking within 30 minutes of waking, consuming >10 cigarettes/day and had withdrawal symptoms in previous attempts of quitting smoking.
Smokers should be strongly urged to quit at every physician encounter. 
Advice should be clear, personalized, supportive and non-judgmental.
Determine the willingness of smoker to make a quit attempt.

Principles of Therapy

  • Choice of therapy should be based on patient’s past experience, preference, medical conditions, and potential side effects

Pharmacotherapy

First-Line Medications

Nicotine Replacement Therapies (NRT)

  • Involves the use of a product that contains nicotine to replace the nicotine previously provided by smoking
    • Helps patients unwilling or unable to stop smoking to lessen their cigarette consumption
  • Should be given to patients for 8-12 weeks and gradually reduced with maximum duration of 12 months
    • Generally started when patient stops smoking to prevent adverse effects resulting from higher than usual nicotine concentrations
  • Safe and can be used in all groups of smokers including adolescents; use with caution in patients with unstable cardiovascular disease
    • It is well tolerated and toxicity is rare and short lived; blood nicotine levels from NRT are less than those from cigarette smoking
  • Behavioral support may be added to increase overall success rates but it is not required for NRT to be effective
  • Available in different forms (such as gum, inhaler, lozenge, nasal spray and patch)
    • There is no difference in efficacy among the various forms of NRT
    • All NRT forms can increase abstinence rate by 50-70%
  • Long-term use of some forms of NRT may help some people to remain abstinent
  • Considerations in providing NRT
    • Dose should be based on cigarette consumption prior to smoking cessation
    • Types of NRT to be used will be based on patient’s preference, side effects, and previous attempts
    • Replacement or adaptation doses available
    • NRT may be safely used in patients with stable cardiovascular disease
    • Contraindicated in patients who have recently suffered a cardiovascular event or have poorly controlled disease
    • Instead of longer-acting patches, oral NRTs are recommended

Varenicline

  • A partial neuronal α4 β2 nicotinic receptor agonist that is developed specifically for smoking cessation that targets the nicotinic acetylcholine receptor
  • Helps in alleviating symptoms of craving and withdrawal, and prevents inhaled nicotine from activating the α4 β2 receptor to cause the pleasure and reward response
  • Should be given to patients for at least 12 weeks and continued until 12 months
  • Patient should be advised to stop smoking within 1-2 weeks after starting the treatment
  • May be used in patients with stable cardiovascular disease, monitor for neuropsychiatric side effects
    • Avoid in patients with seizure risk, ie brain metastases
  • Based on a number of studies, Varenicline was found to be superior to NRT and Bupropion in achieving continuous abstinence but efficacy diminishes after 6 months, thus have limited role in relapse prevention

Bupropion HCl

  • An oral non-nicotine preparation that has been shown to be effective in treating nicotine withdrawal in cigarette smokers wishing to quit through inhibition of dopamine-norepinephrine reuptake
  • Should be given to patients 1-2 weeks prior to and up to 3-6 months after quit date
  • Patient should be advised to stop smoking in the second week of treatment
  • May be an option for patients who are not pregnant, with no current or history of seizures or closed-angle glaucoma, and not on monoamine oxidase inhibitors (MAOI) or Tamoxifen
  • Safe to use in patients with stable cardiovascular disease, monitor for neuropsychiatric side effects
  • Has lower effectivity than Varenicline as shown by clinical trials and is likely to be the 1st-line therapeutic option in cases where Varenicline is inappropriate or for smokers with depression or schizophrenia
  • Bupropion may have a limited role in relapse prevention

Combination of Pharmacotherapies

  • Indicated for patients with:
    • Failed attempt with monotherapy
    • Nicotine withdrawal
    • Breakthrough cravings
    • High level of dependence
    • Multiple failed attempts
  • Two forms of NRT
    • Patch plus another form of NRT (eg patch + spray, patch + lozenge)
    • Combination may be used safely and effectively than a single form of NRT
  • Varenicline plus NRT
    • May improve smoking abstinence rates at 6 months
  • Bupropion plus NRT
    • Combination of Bupropion and NRT has not shown significant increase in quit rates compared to NRT alone
  • Bupropion plus Varenicline
    • A randomized trial showed higher rates of abstinence with Bupropion and Varenicline combination therapy compared with Varenicline monotherapy and combination was well tolerated

Second-Line Medications

  • Eg Nortriptyline, Cytisine, Clonidine
  • Should be considered only if 1st-line medications have failed or are contraindicated
    • Evaluate for correct medication usage if initial therapy failed
  • Patients should be assessed for specific contraindications, precautions and side effects
    • May try lowering dose or switching to an alternative agent if with intolerable side effects

Other Medications

  • There were no significant effects found on the following antidepressants: Fluoxetine, Paroxetine, Sertraline, Moclobemide, or Venlafaxine
  • Antinicotine vaccines are currently undergoing clinical studies, with varying results

Non-Pharmacological Therapy

Quit Plan

  • Help the patient with a quit plan
    • Set a quit date, which is ideally within 2 weeks
  • In lower-resource settings, quitlines may also be used as an adjunctive therapy 
  • Family, friends and co-workers should be informed about plans of quitting, and understanding and support should be requested
  • Anticipate challenges in the quit plan especially during the first few weeks, such as nicotine withdrawal symptoms, weight gain
  • Remove tobacco products from environment
  • Prior to quitting, avoid smoking in places where much time is spent
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