Smoking CessationKristine Petrasko, BScPharm, CRE and Manjit Bains, BScPharm
PathophysiologyNicotine addiction involves a variety of physical, psy-chological and behavioural factors.1,2,3 Nicotine actsas a stimulant, increasing alertness and sense of well-being as well as heart rate and blood pressure. Due torapid delivery to the mesolimbic pleasure-reward sys-tem in the brain, nicotine is highly addictive. Withcontinued use, chemical and biologic changes occur inthe brain and tolerance develops very quickly. Nico-tine addiction is characterized by cravings for contin-ued smoking, a tendency to increase usage and pro-found physical and psychological symptoms elicited bywithdrawal. Table 1 describes various factors that rein-force nicotine addiction.
PrevalenceAbout 4.9 million Canadians (17% of the population)currently smoke.6 Nicotine addiction is the numberone cause of preventable death in Canada, killing over37 000 people every year, which is more than the num-ber associated with car accidents, suicides, homicides,AIDS and other substance abuse issues combined.6Now considered a chronic medical condition,7 tobacco
dependency is the inability to discontinue tobaccouse despite awareness of the various medical con-sequences.8 All forms of tobacco use have harmfuleffects. These include smokeless tobacco (chewingtobacco and “snuff”), pipe tobacco, cigars, hookahsand other non-cigarette forms.7,9
Health RisksOn average, 1 cigarette delivers 1–3 mg of nicotine tothe brain.2,10 Light or ultralight cigarettes may deliverthe same amount of nicotine as regular cigarettes,regardless of the reported nicotine content, and arenot safer than regular cigarettes.10 Many potentialfactors are involved, such as more intense inhalation(“compensation”) or inadvertent blocking of the ventholes on the cigarette filter by the lips or fingers duringsmoking.
The risks to health associated with smoking (see Table2) are attributable to not only the nicotine in tobacco,but also to at least 50 of the other 4000 chemicals intobacco smoke that are known carcinogens. Theseinclude: tar, arsenic, formaldehyde, ammonia andnickel.
Table 1: Factors Reinforcing Nicotine Addiction
Category Reinforcing Factors3,4,5
Physical Pleasure or “high” similar to other addictive psychomotor stimulants
Psychological Behavioural conditioning resulting from hand-to-mouth ritual repeated on average 250 timesa day for a pack-a-day smokerFear of weight gain associated with quitting
Social Routine activities associated with smoking such as waking up in the morning, talking on thetelephone, having a meal, spending time with family members or friends who also smoke;quitting does not eliminate these activities so they continue to act as triggers to smoke
Withdrawal Symptoms Dysphoric or depressed mood, irritability, anxiety, difficulty concentrating, restlessness,increased appetite/weight gain, gastrointestinal symptoms, headaches and insomniaSymptoms generally peak 24–72 hours after the last cigarette and subside after about 2weeksCravings can continue for years, but these are probably related more to behavioural andpsychological aspects of nicotine addiction than to physiological factors
In addition to the risk to the smoker, environmentaltobacco smoke (ETS) or second-hand smoke puts non-smokers at risk, accounting for over 1000 lung can-cer or cardiac deaths each year.6 Patients with chroniclung conditions may be most susceptible to ETS, withincreased risk of asthma or COPD exacerbations. How-ever, all nonsmokers are at risk for the effects of ETS,which also include eye and throat irritation, coughing,rhinitis, headaches and various types of cancer, partic-ularly lung cancer. In children it has also been linked toasthma, recurrent acute otitis media and sudden infantdeath syndrome.27
For those who do quit, there are immediate and longterm health benefits: reduced risk of heart disease,cancer, respiratory problems and infections. Quittingbefore the age of 50 results in a 50% reduction in riskof death in the next 15 years.28 The younger a person
is when quitting, the better their overall quality of life,with a significant decrease in mortality rate.29,30 Peoplewho stop smoking versus those who continue whenaged 25–34, 35–44, 45–54 and 55–64 lived longer by10, 9, 6 and 4 years of life, respectively.31 This high-lights the importance of assisting the younger smokerpopulations to quit, and more importantly, preventingthem from starting in the first place.
Patient AssessmentHealth professionals are in an ideal position not only tohelp patients who have already decided to quit smok-ing, but also to identify smokers and assist them inmak-ing the decision to quit. An assessment plan for smok-ing cessation is presented in Figure 1.Health professionals should take the initiative to pro-vide, at minimum, a brief intervention (3–5 minutes)
Table 2: Health Risks Associated with Tobacco Use
Category Potential Health Effects
Cancer Cancer of the lung, pancreas, kidney, bladder, lip, oral cavity and pharynx, esophagus and larynx areall increased 2–27 times for smokers compared to nonsmokers. Smoking accounts for about 30% ofall cancer-related deaths.11
Cardiovascular Smokers have 2–4 times higher risk of coronary artery disease, 1.5 times higher risk of cerebralthrombosis12 and increased risk of arteriosclerotic peripheral vascular disease.13 Smoking cessationis an effective means of cardiovascular risk reduction and should be assessed in addition to bloodpressure, lipid and blood glucose control.
Respiratory Smoking leads to chronic obstructive lung disease including chronic bronchitis and emphysema,14 aswell as a higher incidence of lung and throat infections.15
Pregnancy andpostpartum
Smoking during pregnancy has been linked to increased risk of: intrauterine growth restriction(average 150 g lower birth weight at term); preterm and extremely preterm births; fetal and infantmortality; sudden infant death syndrome (SIDS); potential long-term effects such as increased risk oftype 2 diabetes, obesity, asthma, certain childhood cancers.16,17,18
Oral diseases Smoking increases the risk of oral diseases such as leukoplakia (white premalignant lesions on oralmucosa), impaired gingival bleeding, periodontitis and ulcerative gingivitis, as well as lip, mouth andthroat cancers that resulted in the deaths of 700 Canadians in 1996.19,20
Musculoskeletaleffects
Increased risk of lumbar disk disease and delayed bone healing.Decreased bone mineral density; though evidence of causality is lacking, bone loss associated withsmoking could be expected to predict an increased risk of hip fractures, especially in postmenopausalwomen.21,22,23
Delayed woundhealing
Wounds resulting from trauma, disease, or surgical procedures heal slowly in smokers. Smokersexperience a greater degree of complications as well as a higher incidence of unsatisfactory healingfollowing reconstructive surgeries.24
Endocrine Chronic smokers develop insulin resistance. There is also an increased risk of microvascularcomplications in smokers who develop insulin resistance.25
Sexual function Erectile dysfunction is twice as likely to occur in smokers than nonsmokers; exposure to second-handsmoke is also a significant risk factor for erectile dysfunction.12
Peptic ulcer disease Increased incidence of bleeding and perforated ulcers.
Dermatologic effects Premature aging of skin and wrinkling.26
Chapter 7: Smoking Cessation 53to assess smoking status and readiness to quit. Longerconsultations (30–90 minutes) are even more effec-tive.7,34,35,36
The following 3 assessment questions can be used toinitiate a discussion with a patient:1. Do you smoke?2. Have you ever considered quitting?3. Is now a good time?Assessing the patient's motivation to quit is based onthe Stages of Change model of behavioural change (seeFigure 1). The precontemplation stage describes thepatient who is not even thinking about quitting. In thecontemplation stage, the patient is considering quitting,typically in the next 6 months to a year. In the prepa-ration stage, the patient has made the decision to quitand is preparing to begin the process. Next is the actionstage where quitting actually occurs, followed bymain-tenance, where the patient has been abstinent for atleast 6 months and is working at remaining smoke-free.See Figure 1 and Nonpharmacologic Therapy for inter-vention strategies for each stage of the process.
If the degree of physical dependence is low (see Table3), the chances of successful smoking cessation aregood even with behavioural assistance alone. If thedegree of physical dependence is moderate to high, thepatient will likely require some form of pharmacother-apy (with or without behavioural assistance) to achievesuccess.7
Goals of TherapyThe ultimate goal of therapy is to achieve lasting smok-ing cessation. Pharmacists can help patients achievethis goal by:■ Supporting smokers moving from pre-contempla-
tive and contemplative stages of change to prepa-ration and then action stages of smoking cessation.
Questionsa 0 points 1 point 2 points 3 points Score
1. How soon after you wake up do you smokeyour first cigarette?
After 60 min Within 31–60min
Within 6–30min
Within 5 min___
2. Do you find it difficult to refrain from smokingin places where it is forbidden?
No Yes – –___
3. Which of all the cigarettes you smoke in aday is the most satisfying one (the hardestone to give up)?
Any otherthan firstone in themorning
First one in themorning
– –
___
4. How many cigarettes per day do yousmoke?
10 or less 11–20 21–30 31 or more___
5. Do you smoke more during the morningthan during the rest of the day?
No Yes – –___
6. Do you smoke when you are so ill that youare in bed most of the day?
No Yes – –___
Total: ___a For some nicotine replacement products, only question 1 or 4 is required to determine the appropriate initial dose.Score: <5 = low nicotine dependence; 5 = moderate nicotine dependence; 6–7 = high nicotine dependence; 8–10 = very high nicotine dependenceAdapted with permission from Heatherton TF, Kozlowski LT, Frecker RC, Fagerström KO. The Fagerström Test for Nicotine Dependence: a revisionof the Fagerström Tolerance Questionnaire. Br J Addict 1991;86:1119-27.
Chapter 7: Smoking Cessation 55Nonpharmacologic TherapyNonpharmacologic therapy for nicotine addictionincludes various behavioural interventions and alter-native therapies. Combining one or more of thesemethods may be sufficient for success in patients whoare light smokers. It is also the most appropriate optionfor patients in whom pharmacologic therapy is con-traindicated because of potential interaction with othermedications or because of other physical conditionssuch as severe heart disease or pregnancy.
Counselling approaches for patients at various stagesof change might include:
Precontemplation—Ask and Listen■ Encourage patients to discuss their smoking openly
and to think about quitting, e.g., “What do you likeand not like about smoking.”
■ Reinforce relevant health consequences of smoking,but avoid confrontational or judgmental commentsor body language.
■ When possible, use a personalized approach to ini-tiating a dialogue, e.g., “I am concerned about theeffect smoking is having on your asthma. Wouldyou be willing to discuss this at some point?”
■ Empower patients with belief in their ability to quit.■ Provide information and reassurance that you will
be available to help when they are ready.
Contemplation—Motivate and Assist■ Encourage patients to think about their own pros and
cons for smoking versus quitting. Help them under-stand that the benefits of quitting are well worth thechallenge.
■ Be understanding if patients express ambivalenceabout quitting or seem discouraged from failedattempts to quit in the past.
■ Provide encouragement and positive reinforcementof their desire to quit and reassurance about any per-ceived deterrents, e.g., “It is great that you are think-ing about quitting. That is the first step towardssuccess. I know you are concerned about gainingweight, but this is something that can be prevented. Ican certainly help you with this. Let me know whenyou are ready to talk more about it.”
Preparation—Show and Tell■ Help patients set a quit date (ideally within the next
2 weeks). The patient may choose to quit abruptlyon that day or to gradually reduce cigarettes smokedbefore the quit date.37
■ Use the Modified Fagerström Nicotine ToleranceScale (Table 3) to assess nicotine dependence, thenhelp select the most suitable smoking cessationmethod.
■ Address questions/concerns about smoking cessa-tion, e.g., nicotine withdrawal, nicotine replacementproducts, triggers, past quit attempts, weight gain.
■ Prior to quitting, encourage patients to avoid smok-ing in places where a great deal of time will be spentsuch as in the car or at home in order to help min-imize the behavioral and psychological aspects ofsmoking.38
■ Suggest avoiding triggers by removing smokingparaphernalia (e.g., ashtrays, lighters) from thehome and vehicles and cleaning areas to remove thesmell of smoke.
■ Suggest strategies to deal with cravings, e.g.,remembering the reasons for quitting smoking,distractions such as exercise, relaxation, takingdeep breaths, low calorie snacks and seeking socialsupport.
■ Encourage patients to identify and inform individ-uals they will count on for support during the quitprocess, e.g., family, friends, co-workers.
■ Inform patients of community resources availableto assist with smoking cessation such as quit lines.(See Table 4).
Action—Congratulate■ Provide positive feedback and praise for taking the
important step of quitting.■ Ask patient how they have been doing since you last
saw them, e.g., “How are you dealingwith cravings?Have you had any setbacks since we last spoke andif so how did they affect you?”
■ Reinforce coping strategies that were successful orsuggest new ones if necessary.
■ Reassess medication use and suggest changes asappropriate.
■ Continue to provide support and follow-up periodi-cally.
Maintenance—Support■ Continue to provide positive reinforcement.■ Work on preventing relapse and encouraging long-
term self-management.■ Remind patients of their own reasons for quitting
and help demonstrate their success and progress,e.g., “You know, you have barely needed your blueinhaler in the last few months. This tells me that
your asthma is under much better control since youquit smoking.”
Relapse—Don't Give Up■ Remind patients that this situation should be consid-
ered a “learning experience” rather than a failure.■ Find out what stage of change they are currently in
and assist them with getting back into the prepara-tion stage.
■ Identify triggers for relapse and discuss strategiesfor prevention.
■ Help patients identify personal strengths and weak-nesses and formulate a new plan of attack.
■ Motivate and encourage them to try again no matterwhat, e.g., “Quitting smoking is one of the most dif-ficult things to do and it often takes a few attemptsbefore a person becomes completely smoke-free.With each attempt you are getting that much closerto quitting permanently. If you are willing to tryagain, we can discuss.”
Behavioural Modification ProgramsAn estimated 1 in 5 smokers who are preparing tostop smoking actually seek formal help with quitting.Although smokers can become involved in self-helpprograms, health professionals should be providinginformation on behavioural interventions for all smok-ers, regardless of the patient's motivation to quit. Foreffective recruitment strategies, see Suggested Read-ings .
Even brief advice to quit from a primary care physi-cian during a routine consultation has been effective inincreasing the number of smokers who remain absti-nent for at least 6 months. Person-to-person coun-selling over 4 or more sessions is especially effective.In general, greater contact between the patient and theprogram provider leads to greater success.7,39
Regardless of their level of nicotine dependence,encourage patients to participate in a behaviouralmodification program. Light smokers may be able toachieve lasting abstinence using behavioural modifi-cation alone, while moderate to heavy smokers benefitmore from the addition of pharmacologic therapy. ACochrane systematic review demonstrated that inter-ventions combining pharmacotherapy and behaviouralsupport increase success rates in smoking cessationcompared to usual care.40 This further validates theimportance of recommending patients to engage inbehavioural modification programs in addition to phar-macotherapy.
Even the simplest type of behavioral modificationprograms may be beneficial. Self-help in the form ofelectronic aids such as internet sites and mobile tele-phone text messages designed to assist individuals tostop smoking is effective in increasing the likelihoodof long-term cessation.41,42
Many self-help materials, individual and group pro-grams and counselling programs are available to bothhealth care professionals and patients. A list of pro-grams in each province is available on the HealthCanada and Canadian Lung Association web sites (seeTable 4).
To provide optimum support for smoking cessation,health care professionals need proper training.43 The“5 A's Approach” is a universally adopted tool phar-macists can utilize as part of a smoking cessation pro-gram. The 5 A's consist of: ask, advise, assess, assistand arrange. Pharmacists and other health care profes-sionals can be trained in this approach via several pro-grams including QUIT and TEACH (see Table 4).
AcupunctureAcupuncture therapy for smoking cessation is based onthe Chinese science of energy pathways in the body. Itinvolves special needles placed at strategic points underthe skin of the nose or ear. Evidence of effectiveness insmoking cessation is not available; most studies werepoorly conducted, yielding unreliable results.44,45,46
Aversion TherapyAversion therapy is based on the concept that asso-ciation of an unpleasant sensation with smoking canreduce the desire to smoke. Techniques have includedmild electric shock, breath-holding, rapid smoking,unpleasant taste, noise or smell and imagined stimuli.Good evidence to support aversion techniques is lack-ing; rapid or excessive smoking has shown the mostpromise. Because of the potentially harmful effect onthe heart and lungs, this method is not recommendedas a smoking cessation strategy.44,46
HypnosisHypnosis is a deep, relaxed state of attention duringwhich people are more responsive to suggestions. Hyp-notherapy for nicotine addiction attempts to change aperson's habits and attitudes to cigarettes. The thera-pist's skill and experience are very important, as are thepatient's susceptibility to hypnosis and desire to quit.Although there are reports of success with this method,a Cochrane review concluded there was insufficient
Program Name Description Contact Information CostOne Step at a Time—A Smoker's Guide to Quitting
Self-help program for patients—includesbooks (For Smokers Who Want to Quit andFor Smokers Who Don't Want to Quit) and apamphlet for assisting others who wish to quit
Canadian Cancer Society1-888-939-3333www.cancer.ca(also available through the Smoker'sHelpline service)
Freea
On the Road to Quitting—A Guide to Becoming aNonsmoker
A 40-page self-help guide and online programto assist smokers with the quitting process
Health Canada smoking cessationweb sitewww.hc-sc.gc.ca/hc-ps/tobac-tabac/quit-cesser/index-eng.php
Freea
Smokers' Helpline Service provided by trained counsellors toassist patients who are seeking help withsmoking cessation. Telephone assistance,on line and print materials available in Frenchand English
www.smokershelpline.caToll free telephone numbersprovided for each province andterritory
Freea
Centre for Addiction andMental Health (CAMH)
Online information for the public on tobaccouse. HCP education programs such as theTEACH project
www.camh.ca1-416-535-8501 (Ext. 1600)
Freea
Canadian Action Networkfor the Advancement,Dissemination and Adoptionof Practice-informed TobaccoTreatment (CAN-ADAPTT)
Mainly for HCPs; user can post onlinequestions to panel experts or colleagues.Quick reference to guideline updates
1-416-535-8501 (Ext. 7427)www.nicotinedependence-clinic.com/English/CANADAPTT/Pages/Home.aspx(affiliated with CAMH)
Freea
QUIT—Quit Using and InhalingTobacco
Training program that provides usefulresources and tools for practisingpharmacists. Live workshops and an onlinelesson are available
Canadian Pharmacists Association1-800-917-9489www.pharmacists.ca
b
a Shipping costs may apply for large orders.b Fee for live and online workshops; resources free for participants.Abbreviations: HCP = health care professional; TEACH = training enhancement in applied cessation counselling and health
evidence to consider hypnotherapy effective for smok-ing cessation.47 If this method is tried, advise patientsto combine it with behavioural modification or coun-selling. Follow-up counselling and support or combin-ing the therapy with other smoking cessation methodsmay also improve the success of hypnotherapy.44,46,48
Laser TherapySimilar to the application of acupuncture, laser ther-apy uses laser beams which are directed at certain keypoints on the body surface. This stimulation of keypoints purportedly triggers a release of endorphins andrelieves nicotine cravings. No reliable studies supportthis therapy.44,45,46
Clove and Herbal CigarettesImitation cigarettes containing ingredients such ascloves and various herbs are available. However, theseproducts may also contain tar, carbon monoxide andvarious other toxins. Clove cigarettes may actually
contain up to 70% tobacco, providing nicotine and thesame toxins as all-tobacco cigarettes.49,50
Electronic CigarettesElectronic cigarettes look and behave like cigarettes,but they contain a battery-powered mechanism to heatand vapourize a liquid chemical mixture composed ofvarying amounts of nicotine, propylene glycol, otherchemicals and/or impurities. The vapour produced andglowing tip resemble the smoke and burning tip of anactual cigarette, whichmay satisfy the behaviours asso-ciated with smoking (handling of cigarette, inhaling ofsmoke) in addition to nicotine addiction. Advocatesof e-cigarettes praise them as a clean drug deliverydevice, although the chemical safety is questionable.For example, propylene glycol is a known irritant andthe long term effects on the lungs are unknown at thistime.51 Additionally, the FDA conducted a preliminaryanalysis on samples of e-cigarettes from leading brandsand found known carcinogens and toxic chemicals.52Although the analysis conducted was preliminary, it
illustrates the lack of research on these products and theneed for additional data on safety and effectiveness.
Electronic cigarettes are currently marketed and soldin Canada and are also available via the internet. How-ever, since the production is not regulated, some elec-tronic cigarettes contain nicotine while others containvarying levels of other chemicals. It is important tonote that only those products without nicotine or healthclaims can be legally imported and sold in Canada.53Over 400 brands of electronic cigarettes are available.52There is world wide debate concerning electronic ciga-rettes, since the potential benefit of smoking cessationmay outweigh the potential risks. Health Canada doesnot recommend using electronic cigarettes due to lackof safety information regarding exposure to vapourizedpropylene glycol (among other chemicals used in theproducts) and their unknown long term effects.54
Pharmacologic TherapyPharmacologic therapy for smoking cessation can bedivided into 2 broad categories: nicotine replacementtherapy and non-nicotine therapies.
The purpose of pharmacologic therapy is to reduce thephysical effects of nicotine withdrawal (see Table 1),which peak within 72 hours and may continue inter-mittently for several weeks. In some patients, phar-macologic therapy is also needed to reduce the psy-chological effects of withdrawal (cravings), which canlast up to several years, or as some ex-smokers willattest, indefinitely.4,5 While many patients may bene-fit from pharmacologic therapy, patients who are onlymildly addicted may not require it to quit successfully.Pharmacotherapy may be contraindicated for certainpatients because of potential drug or disease interac-tions.
Abstinence rates associated with various smokingcessation pharmacotherapy are presented in Table 5.Use caution when comparing abstinence rates amongtreatments, as there is insufficient data regarding directcomparisons. Placebo success rates average around13% in smoking cessation pharmacotherapy trials.
Nonprescription TherapyNicotine replacement therapy (NRT), designed toreplace the nicotine found in cigarettes, is the mainstayof nonprescription therapy for smoking cessation.
In Canada, NRT medications are considered Sched-ule U products (unscheduled) and can be obtainedfrom a pharmacy without a prescription. Availabledosage forms include chewing pieces (gum), lozenges,inhalers, mouth sprays and transdermal patches (seeTable 6). Although nasal sprays and sublingual tabletsmay be available in the US, they are not available inCanada.
Table 5: Estimated Six-month AbstinenceRates for Smoking CessationPharmacotherapy7,55
InterventionEstimated AbstinenceRates at 6 Monthsa,b,c
Nicotine gum 19%
Nicotine patch 23.7%
Nicotine inhaler 24.8%
Nicotine lozenge 19.9%
Bupropion 24.2%
Bupropion plus nicotine patch 28.9%
Nicotine patch plus as-neededinhaler or gum or lozenge(average)
29.7%
Varenicline 1 mg BID 33.2%
Varenicline 0.5 mg BID 25.4%a Average quit rates following usual course of therapy.b Longer duration of therapy may result in slightly higher abstinencerates.
c Abstinence rates for placebo average 13%.
Nicotine replacement therapy increases the rate ofsmoking cessation by 50–70 percent.56 The successof NRT is independent of dosage form, concurrenttherapy and setting.In general, the incidence of adverse effects is low pro-vided the patient receives adequate counselling on theappropriate use of the product. It is important to con-sider that some contraindications may be relative ratherthan absolute contraindications, requiring clinical judg-ment in the decision-making process. Given the sig-nificant risks of continued smoking, the risk/benefitratio for pharmacotherapy may be favourable even inpregnant patients or those with heart disease. Thesepatients can often be successfully and safely managedwith NRT or other pharmacotherapy under guidance oftheir physician or specialist. This concept will be fur-ther discussed under Special Considerations.57,58
Initial strength:Nicorette (see Table 3): 2 mg ifscore is ≤6, 4 mg if ≥7Thrive: 4 mg if ≥25 cigarettes/day,2 mg if <25 cigarettes/dayInitial dose: 10–12 pieces per daypo. May increase to 20 pieces perday if neededPlace 1 piece of gum in the mouth.Bite down once or twice then parkit between the teeth and gums forabout 1 min. Repeat when thedesire to smoke arises, up to onceper min for up to 30 min, thendiscard pieceAt weekly intervals, reduceby 1 piece/day over 3 mo, aswithdrawal symptoms allow.Continue for maximum of 6 mo
Life-threateningarrhythmia; severeangina pectoris; historyof recent stroke;temporomandibularjoint disease; within2 wk following myocardialinfarction.Relative contra-indications: pregnancy,smoking while usingthis medication (nicotinetoxicity), breastfeeding,age <18 y.Caution inhyperthyroidism,pheochromocytoma,insulin-dependentdiabetes, active pepticulcer, uncontrolledhypertension.
Caution patients not to chewlike regular gum (increasedside effects).Avoid use of acidicbeverages and foods(coffee, fruit juices, softdrinks, alcohol) whilechewing and 15 minbefore as this decreasesabsorption.Favourable dosing flexibilitycompared to patch.
nicotinebitartratedihydratelozengesThrive
Initial strength: 1 mg if <20cigarettes per day, 2 mg if ≥20cigarettes per dayDosing frequency: see nicotinepolacrilex lozenges; maximum15/day po for 2 mg strength,25/day po for 1 mg strength
20–60 min See nicotine polacrilexgum.
See nicotine polacrilexgum.
Caution patients not toswallow or chew lozenges(increased side effects).Avoid acidic beverages andfoods (e.g., coffee, fruitjuices, soft drinks, alcohol)during and 15 min prior tousing the lozenge as thisdecreases absorption.Favourable dosing flexibilitycompared to patch.See nicotine polacrilexlozenges.
Table 6: Nicotine Replacement Therapy for Smoking Cessation (cont'd)
For product selection, consult Products for Minor Ailments. Smoking Cessation Products.
Drug Dose Peak Adverse Effects Contraindications Comments
nicotinepolacrilexlozengesNicorette
Use initial strength of 2 mg if firstcigarette of the day >30 min afterwaking, 4 mg if ≤30 minWeeks 1–6: Dissolve 1 lozengein the mouth Q1–2H PRN forwithdrawal symptoms (maximum15 lozenges/day)Weeks 7–9: Use 1 lozenge Q2–4HPRN poWeeks 10–12: Use 1 lozengeQ4–8H PRN poDiscontinue when the dose hasbeen reduced to 1–2 lozenges/dayUse beyond 6 mo is not generallyrecommendedLozenges should be allowed toslowly dissolve and moved fromone side of the mouth to the otherperiodically
20–60 min See nicotine polacrilexgum.
See nicotine polacrilexgum.
See nicotine bitartratedihydrate lozenges.
nicotine inhalerNicorette
Initial therapy: Use at least 6cartridges/day (maximum 12 perday) for the first 3–6 wk. Begin totaper slowly over the next 6–12wk. Discontinue once usage isdown to 1–2 times per day (after 3mo ideally). Use may be continuedwith tapering dosage up to 6 mo.Use for >6 mo not recommendedInhalers should be puffed similarlyto a cigarette (~5–10 min at a time)
15 min Mainly mild local irritation,cough, throat irritation,pharyngitis, stomatitis,rhinitis. Headache,dyspepsia, nauseamay also be present.Side effects are usuallytransient and decreasewith continued use.
See nicotine polacrilexgum.
Each 10 mg cartridgedelivers 4 mg of nicotine(of which about 2 mg issystemically absorbed);approximately equivalent to20 min of puffing.Nicotine vapour is absorbedthrough the buccal liningof the mouth, not from thelungs.Colder ambienttemperatures decreaseabsorption rate.Cartridge can be used forup to 24 h once punctured.
Apply patch to nonhairy, clean, dryskin site in upper arm or hip; use adifferent site each day; avoid usingthe same site more than onceweeklyApply upon waking and wear16–24 h per day, depending onproductGeneral dosing instructions involve6 wk of use of highest strength(21 mg for Nicoderm or Habitrol,15 mg for Nicorette) followedby 2 wk at the intermediatestrength then 2 wk at the loweststrength. Consult individualproduct monographs for details
See nicotine polacrilexgum.Generalized skindisorders (severeeczema or psoriasis)Relative contra-indications: pregnancy;mild atopic or eczema-tous dermatitis.Hypersensitivity to topicaladhesives or nicotine.
Assess patient in first 2 wkto ensure smoking has beendiscontinued. If patient stillsmoking discontinue patchand refer to physician.Check product monographre. wearing patch duringstrenuous exercise—variesby product.Used patches should befolded so that medicatedsides are facing inwardand discarded safely out ofreach of children or pets.Manufacturers do notrecommend cutting patchesas this may damage thedelivery device.Patients who experienceinsomnia from the 24–hourpatch may benefit fromremoving the patchat night and using animmediate-release productfirst thing in the morning,then applying a new patch.
nicotinemouthsprayNicoretteQuickMist
Use 1 or 2 sprays every 30–60min po. Maximum dose:2 sprays/episode, 4 sprays/h,64 sprays/daySpray must be primed with first useor after 2 days of not using
16 min Altered sense of taste,headache, hiccoughs,nausea and vomiting,dyspepsia, oral soft tissuepain, stomatitis, salivaryhypersecretion, burninglips, dry mouth.
See nicotine polacrilexgum.Precautions: Unstablecardiovascular disease,diabetes mellitus, GIdisease, uncontrolledhyperthyroidism,pheochromocytoma,hepatic or renalimpairment.
Each spray delivers 1 mg ofnicotine.Mouthspray absorbedthrough buccal mucosa.Avoid acidic beverages andfoods (coffee, fruit juices,soft drinks, alcohol) duringuse and 15 min beforeuse as this may decreaseabsorption.
Combination NRTFor heavy smokers who continue to suffer withdrawalsymptoms while using a single nicotine patch, totaldaily doses of nicotine may be increased up to 35mg per day for smokers previously using 21–40 cig-arettes a day, and up to 40 mg per day for smokerspreviously using more than 40 cigarettes a day, withreported safety and improved efficacy.59,60,61 This maybe achieved by using additional patches or chewingpieces or the combination of both. Using more than 1patch or doses >21 mg requires physician supervision.Combining the nicotine patch with as-needed gum,inhaler or lozenges can be more effective than theindividual products,7,55,56 possibly because it providesa steady baseline level of nicotine with “boluses” forflexibility and treatment of cravings.
Prescription TherapyA number of therapeutic agents have been investigatedfor use in nicotine addiction. See Table 5 for reportedquit rates for various single and combination therapies.Bupropion is effective for smoking cessation.7,62Contraindications include a history of seizures,anorexia or bulimia nervosa and concurrent MAOItherapy. More common adverse effects include drymouth and insomnia. Less common are hypertension,arthralgia, myalgia, dizziness, tremor, somnolence,bronchitis, pruritus, rash and taste perversion.63 Somepatients may develop agitation-like behavioural oremotional changes, which may increase the rare riskof harm to themselves or to others. Close patientmonitoring is advised for all patients, but especially inthose with underlying psychiatric illness.63,64
As with other pharmacotherapeutic agents for smokingcessation, bupropion should be used in combina-tion with behavioural programs to assist the quittingprocess, and can be used during pregnancy if benefitoutweighs the risk.63,64 A combination of NRT andbuproprion may be more effective than buproprionalone.56
Varenicline, an alpha4beta2-nicotinic receptor par-tial agonist, has higher quit rates compared to otheravailable agents.7 Advise patients about common sideeffects such as nausea, vomiting, headache, insomnia,abnormal dreams and dizziness.Concerns regarding potential cardiovascular risks ofvarenicline,65,66 prompted Health Canada to review itscardiovascular safety.67 However, newer data suggestsno significant increase in cardiovascular adverse eventsassociated with varenicline use.68,69Until further data is
available, exercise caution before initiating vareniclinein patients with cardiovascular concerns.Safety concerns have also been raised regarding neu-ropsychiatric symptoms in patients with underlyingpsychiatric disorders. Though severe behaviouralchanges (severe agitation, hostility, suicidal ideation)are rare, psychological symptoms should be carefullyassessed in all patients before starting vareniclineand at each visit. Assessment should include askingpatients if any adverse psychological effects occurredon previous quit attempts.64,70
Varenicline is not recommended in combinationwith NRT due to an increase in side effects (nausea,headache, dyspepsia) without an increase in effi-cacy.7,64 Varenicline is also contraindicated duringpregnancy as there is evidence of reproductive toxicityin animal studies, though no human pregnancy dataare available as yet.71
Nortriptyline may be as effective as buproprion forsmoking cessation,62 making it a suitable second-lineoption. Clonidine is somewhat effective but of limiteduse because of significant side effects.7,72,73
Special ConsiderationsPregnancyNonpharmacologic choices are always first-line forpregnant patients as behavioral therapy has proveneffective for smoking cessation in pregnancy.74 Evi-dence is insufficient to determine if NRT is effectiveor safe for promoting smoking cessation in preg-nancy.75However, those with moderate to high nicotinedependence will likely require some form of pharma-cotherapy.7 One must balance the risks and benefitsof continuing to smoke compared to using NRT. Theproducts are not officially approved for use in preg-nancy and NRT may have potential risks to the motherand fetus.7,76 However, cigarette smoking during preg-nancy would likely have far greater risks includingexposure to nicotine and the 4000 other chemicals intobacco smoke. Therefore, most experts believe thatif nonpharmacologic and/or behavioral strategies fail,interventions with NRT would be justified and canbe attempted with close physician supervision.64 It isimportant to incorporate behavioural interventions andto use the lowest effective dose of NRT. Initiation ofsmoking cessation is important during the earlier stagesof pregnancy (ideally within the first 16 weeks).64
If NRT is to be used in pregnancy, choose an imme-diate-release form of NRT such as the gum, lozengeor inhaler rather than a continuous dosage form such
Chapter 7: Smoking Cessation 63as the patch. Use the lowest effective dose, for theshortest possible time, to reduce fetal exposure to nico-tine. If a patient is highly addicted to nicotine, use ofthe patch may be a more favourable option. In thesecases, a 16-hour patch may be preferable to a 24-hourpatch (or a 24-hour patch can be applied for 16 hoursand removed at night) to reduce fetal nicotine expo-sure.64 Close supervision and monitoring is essentialfor all pregnant patients and should involve the patient'sphysician.
BreastfeedingAlthough nicotine is excreted in breast milk duringNRT, the risk to the infant is less than the risk fromsecond-hand smoke, such as increased risk of sud-den infant death syndrome, respiratory infectionsor asthma.7,64 Intermittent use of immediate-releaseforms of NRT are preferred in breastfeeding mothers.Encourage the mother to breastfeed just before usingthe NRT product, to minimize infant exposure to nico-tine.76
Cardiovascular DiseaseIt is dangerous for patients with cardiovascular diseaseto continue to smoke. Smoking can activate coagu-lation pathways in the body, promoting thrombosisformation and increased risk of myocardial infarction.Nicotine can also cause vasoconstriction as well asincreased heart rate and contractility.2 Despite this,many experts now believe that short-term use of NRTis safer than smoking, although there are risks involvedwith the use of NRT products. Evidence suggests thatNRT is generally safe in patients with stable cardiovas-cular disease.77,78 Caution and physician supervisionare recommended, particularly within 2 weeks follow-ing myocardial infarction or in patients with unstableangina or serious arrhythmias.7,79 The transdermalpatch may be preferable to immediate-release dosageforms because of more consistent nicotine plasmaconcentrations.
Children and AdolescentsFor many years, tobacco use has been a major con-cern in the pediatric population.7 Experimentationwith nicotine and drugs is beginning at much earlierages (11–17 years) and it is not uncommon for nico-tine dependence to occur rapidly in this population.Primary prevention is key and health care practition-ers must deliver strong tobacco use prevention andcessation messages to this group and their parents.80According to the 2008 Treating Tobacco Use and
Dependence guideline update, adolescents are inter-ested in quitting. A survey of about 5000 eleventhgrade students revealed that approximately 79% wouldbe willing to discuss or acknowledge their smokinghabit if they were asked about it.7 This sets the stagefor health care providers to engage in tobacco usediscussion—simply by asking the 3 main assessmentquestions (see Patient Assessment). Though manypatients may not be ready to quit at the first visit, ask-ing about tobacco use and sending a strong message ofabstinence and/or cessation to young patients and theirparents is important in the prevention of tobacco usein this young population.The current recommendation for smoking cessa-tion treatment of adolescent smokers is primarilybehavioural. Avoid incentive programs utilizing prizesaimed to prevent smoking uptake, as they are noteffective.81 Although NRT has been shown to be safein this population, it is generally not recommended,and counselling is the most effective. There is littleevidence that pharmacotherapy is effective in promot-ing long-term abstinence rates in younger patients.7Pharmacologic therapy (including NRT) in patientsunder 18 years of age should be initiated and moni-tored by their physician. Recommend Health Canada's“Quit4Life” program to this age group (see Table 4).
Smokeless TobaccoCounselling is effective for treating patients who usesmokeless tobacco products, and should be consideredfirst-line.7,82 If behavioural therapies are insufficient(e.g., for moderately-highly addicted patients), vareni-cline may increase smokeless tobacco abstinencerates.82 Evidence is insufficient to support the use ofbuproprion and NRT for smokeless tobacco cessa-tion.82 Dosage conversion information is not availablefor initiating NRT.
Drug InteractionsCigarette smoking can affect the metabolism of manydrugs. One of the major lung carcinogens founds intobacco smoke is polycyclic aromatic hydrocarbon(PAH). PAH, not nicotine, is responsible for inductionof hepatic enzymes CYP1A1, 1A2, and possibly 2E1.83Thus drug interactions only occur with the cigarettesmoke and not with NRT. The clearance of drugs suchas caffeine, clozapine, diazepam, estrogens, fluvox-amine, methadone, nifedipine, olanzapine, rasagiline,theophylline, trifluoperazine and warfarin may beincreased in smokers. Conversely, when patients quitsmoking, increased monitoring and dosage reductionmay be required once drug metabolism is no longer
affected by smoking. Refer patients to their physicianif they are taking drugs that may be affected by smok-ing and are planning to quit. Reduction of caffeineintake is advised to minimize caffeine-induced palpi-tations and other side effects after quitting.
Monitoring of TherapyBecause of the large behavioural component of nicotineaddiction, monitoring of therapy is crucial to the suc-cess of smoking cessation therapy. Ideally, the patientreceives ongoing monitoring for a period of time by aclinician or therapist involvedwith a smoking cessationprogram (see Table 7). If this service is not providedby the program, the pharmacist or other treating healthprofessional should offer it.Relapse rates are high, particularly at the beginningof smoking cessation, with 66% reportedly relapsingwithin 48 hours and 76% within the first week, when
patients attempt to quit on their own.7 Follow-upshould begin within the initial week following the quitdate, particularly if the patient is receiving NRT, toavoid adverse effects from excessive nicotine levels.Follow-up counselling should be provided regularly,e.g., every month for 3 months, then at 6 and 12months. In general, more counselling time yieldshigher abstinence rates.7 Additional monitoring shouldbe considered for patients who are at high risk, e.g.,highly nicotine-addicted patients with history of manyprevious smoking cessation attempts, patients experi-encing severe psychosocial stress, those with comorbidsubstance abuse disorders or history of depression orschizophrenia, patients taking concomitant medicationthat interacts with nicotine or cases where smokingcessation is medically urgent. A suggested schedulefor more intensive monitoring might involve follow-upevery 2 weeks for the first 3 months, then at 6, 9, 12,18 and 24 months.
Table 7: Monitoring of Therapy for Smoking Cessation
Smoking Patient reports no smoking. Patient: dailyHealth professional:monthly × 3 mothen at 6 and 12 mo
Inquire as to smoking level, provide encouragementand support.If patient has a relapse, discontinue nicotinereplacement therapy until patient is ready to quit again;encourage patient to reset a quit date; discuss possiblereasons for relapse and help patient strategize abouthow to be more successful with the next quit attempt;be empathetic and avoid scolding the patient.
Desire tosmoke
Patient reports level ofdesire decreasing to minimal(or none) by end of therapy(3–6 mo); cravings maynever completely end forsome.
As above Intense craving may require additional treatment(e.g., bupropion) or switch to varenicline.Encourage behavioural changes to decrease desire;empathize with patient's difficulty and stronglyencourage perseverance.
Nicotinewithdrawalsymptoms
Patient on NRT reportsreduction in withdrawalsymptoms (see Table 1)within 25 min to 24 h ofinitiating therapy.
As above If symptoms are bothersome, consider increasing dose,switching or adding an alternative method of NRT.Remind patients that the most difficult period is thefirst 2–14 days. Recommend additional behaviouralinterventions if necessary.
As above If minor side effects occur, suggest ways to modify(e.g., for belching, hiccoughs and GI upset with gum,advise slower chewing) or consider switching to analternative method of NRT.If serious adverse effects occur (e.g., hypertension,nicotine toxicity) consider reducing dose ordiscontinuing medication and/or switching to alternative(e.g., bupropion or varenicline).
Patient reports minimal orno weight gain over the6–12 mo following quitting.
Patient: weeklyHealth professional:3, 6, 9, 12, 18 and24 mo
Encourage healthy eating habits, exercise, havinghealthy snacks available to deal with cigarette cravings(e.g., carrot sticks) to prevent or minimize weight gain.Reassure patient that slight weight gain is less harmfulto their health than continued smoking.
Stress Patient reports minimaladditional stress due tosmoking cessation over6–12 mo following quitting.
Patient: dailyHealth professional:3, 6, 9, 12, 18 and24 mo
Assess for evidence of excessive stress (reported bypatient, or other physical or behavioural signs such asweight loss, nervous habits, GI symptoms, headache).Suggest behavioural therapy (deep breathing,muscle relaxation, positive self-talk) or refer to stressmanagement program.Encourage exercise and other distracting activities.Treat stress-related symptoms as needed (referto physician, recommend appropriate medicationto reduce stress or treat stress-related physicalsymptoms).
Mood Patient reports minimalmood changes due tosmoking cessation.
Patient: dailyHealth professional:3, 6, 9, 12, 18 and24 mo
Assess for any signs of depressive illness, severeagitation or mood changes (with or withoutmedications). Family and/or caregivers should beinformed and alerted to watch for these changes orsymptoms.
Abbreviations: NRT = nicotine replacement therapy
Resource Tips
Canadian Council for Tobacco Control.Available from: www.cctc.ca.
Canadian Lung Association. Available from:www.lung.ca. Note: World “No Tobacco Day” isMay 31st each year. Partner with your local LungAssociation for more resources (such as pamphletsand handouts) to assist you with a display or clinicday venue.
Physicians for a Smoke-Free Canada. Available from:www.smoke-free.ca.
Quit4Life (Health Canada). Available from:www.quit4life.com.
Suggested Readings
Fiore MC, Jaen CR, Baker TB et al. Treating tobaccouse and dependence: 2008 update. Rockville: USDepartment of Health and Human Services; 2008.
The Lung Association. Making quit happen: Canada'schallenges to smoking cessation. 2008. Availablefrom: www.lung.ca/_resources/Making_quit_happen_report.pdf.
Mallin R. Smoking cessation: integration of behavioraland drug therapies. AmFamPhys 2002;65:1107-14.
Selby P. Smoking cessation. In: Repchinsky C, ed.Therapeutic choices. 6th ed. Ottawa: CanadianPharmacists Association; 2011. p. 153-67.
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Quitting Smoking — What You Need to KnowCongratulations on deciding to quit smoking! Whetherthis is your first time quitting, or you have tried to quitbefore, follow these tips to be successful.■ Set a quit date. It should be within the next 2 weeks.
Avoid a time when you will be under stress.■ Think about why you want to quit and all the good
things that you expect as a result of quitting.■ If you have tried to quit before, you have probably
learned some valuable tips of what not to do thistime. Think about what was most difficult last timeand why you gave up trying. Think about the thingsyou need to avoid this time.
■ Decide what kind of support will be most helpfulover the next 6 months to a year. For example,you can join a smoking cessation group or plan tomeet regularly with a health professional (such as apharmacist, nurse or doctor).
■ Tell your family and friends that you are quitting.Ask them to help you to stick to your plan. If theysmoke, ask them to respect your decision to quit andto not smoke in front of you. Think of things you cando to avoid smoking while with them.
■ Choose someone you knowwho does not smoke andask them to help you to quit.
■ Make a diary for a few days to keep track of whenand why you smoke.
■ Think of ways to avoid situations when you usuallysmoke.
■ Think of things you can do instead of smoking (forexample, chewing gum, sippingwater, playing cardsor calling a friend).
■ It is possible to gain weight while quitting. You canavoid this by healthy eating foods and increasingdaily activity. Keep healthy snacks around for timeswhen you get the urge to nibble.
■ Keep busy with healthy activities like walking or anexercise program. Starting a new activity will helpto break old habits connected with smoking.
■ If you are taking medication to help you to quit fol-low the instructions carefully. Be sure to ask yourpharmacist any medication-related questions.
■ If you are using nicotine replacement therapy, youshould either not smoke at all or reduce smoking asmuch as possible, to avoid side effects.
■ Smoking (and quitting) can affect your metabolism.After you quit, reduce your caffeine intake to pre-vent side effects, and talk to your pharmacist or doc-tor about other medicines you may be taking, in casethe dose needs to be adjusted.
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