Smoking Cessation: Where to Begin?

APRIL 25, 2018
Anyssa Garza, PharmD
Cigarette smoking remains the leading preventable risk factor for cancers and cardiovascular and respiratory diseases, leading to 480,000 deaths each year across the United States.1,2

Smoking causes more deaths every year than alcohol use, firearm-related incidents, HIV, illegal drug use, and motor vehicle injuries combined, translating to the cause of nearly 1 in 5 deaths.2

Evidence of Concern
The CDC this year reported a 5.4% decrease in US adults who smoked in 2016 compared with 2005. However, 38 million Americans still smoke.3

Although the CDC has reported some progress, cigarette smoking is not declining at the same rate across the board. There are several populations that are not seeing the same progress, including males between ages 25 and 64; those who are uninsured or insured through Medicaid; those living below the poverty level; those of certain races; those who have a disability; those who are bisexual, gay, or lesbian; and those who lived in the Midwest or South.3

The CDC has called for population-based interventions, such as anti-tobacco media campaigns, increased access to tobacco cessation counseling and medications, smoke-free laws, and tobacco price increases.3

The good news is that more than half of people who smoke want to quit. In 2015, nearly 7 in 10 (68%) adult cigarette smokers said they wanted to stop, according to the CDC.4

In 2015, the US Preventive Services Task Force (USPSTF) issued a final recommendation statement that applies to adults and pregnant females. The final recommendation is titled Behavioral and Pharmacotherapy Interventions for Tobacco Smoking Cessation in Adults, Including Pregnant Women.

The recent publication, an update from 2009, recommends that health care providers ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and pharmacotherapy options approved by the FDA for smoking cessation to help them quit (Grade A).5,6

The task force found evidence showing that behavioral interventions alone or in combination with pharmacotherapy as well as pharmacotherapy interventions, with or without behavioral counseling interventions, substantially improve the achievement of tobacco cessation in nonpregnant adults who smoke. The task force also found evidence to support the use of 2 types of nicotine replacement therapy (NRT). Compared with using only 1 type of NRT, using 2 has been shown to moderately improve the achievement of tobacco smoking cessation. The investigators also found that the addition of NRT to bupropion sustained release (SR) provides an additional benefit compared with bupropion SR alone.5,6

The task force recommends that health care providers ask all pregnant women about tobacco use, advise them to stop using tobacco, and provide behavioral interventions, such as counseling, to help them quit (Grade A).5,6

For more details on the recommendations, refer to Table 1.5,6



The First Step: Recognition
A very common method of recognition is to record a patient’s smoking status as one would a vital sign or to use the “ask, advise, refer,” approach. This method helps health care providers ask patients about tobacco status, advise them to quit, and refer them to evidence-based smoking cessation interventions. Another approach is to follow 5 A’s:5,6
  1. Ask about smoking.
  2. Advise the person to quit through clear, personalized messages.
  3. Assess the willingness to quit.
  4. Assist in quitting.
  5. Arrange follow-up and support.
The task force said that because many pregnant women may be reluctant to disclose that they smoke, asking them in the form of multiple choice may improve disclosure.5

Effective Behavioral Interventions
There is a positive dose-response relation between counseling intensity and smoking cessation rates. Multiple sessions are recommended, according to the Public Health Service Guidelines. In fact, more than 4 in-person counseling sessions is the goal. Cessation rates may come to a halt after 90 minutes of total counseling time.5 For additional information on behavioral interventions, refer to Table 2.5

Table 2. Effective Behavioral Interventions for Smoking Cessation5
Intensity and Duration Strategy and Resources Method
Both type of physician advice interventions (<20 minutes in 1 visit and >20 minutes >1 follow-up visit) effectively increase the proportion of adults who quit smoking and remain smoke-free for 6 months.

Brief, in-person behavioral counseling (<10 minutes) effectively increases the proportion of adults who quit smoking and remain smoke-free for 12 months.
 
Effective counseling interventions provide support and training in practical problem-solving skills. Problem-solving skills training includes helping those looking to quit smoking:
  • Recognize smoking triggers
  • Develop coping skills to overcome barriers
  • Develop a plan to quit
Provide information about smoking and successful quitting.

Complementary practices include motivational interviewing, assessing readiness to change, and the option of more intensive counseling or offering referrals. 
Behavioral counseling can be done by any of the following methods:
  • In-person (both group and individual counseling have been found to be effective)
  • Telephone (>3 telephone calls) can be done by professional counselors or health care providers who are trained to offer advice over the telephone.
Printed self-help materials that are tailored to the individual, providing information that goes beyond a description of the negative health effects of smoking are effective.

Data on nontailored print materials and computer/mobile programs are mixed, but some study results are promising.

Pharmacotherapy
Data have shown that the rate of smoking cessation may increase from 10% (placebo or no pharmacotherapy) to 17% in those using any form of NRT. For those using bupropion SR, the rate of smoking cessation may increase from 11% (control) to 19%. For those using varenicline, the rate of smoking cessation may increase from 12% (control) to 28%.5

Behavioral Support Plus Pharmacotherapy Interventions
Combining behavioral support and pharmacotherapy interventions may increase the rate of smoking cessation from 18% with pharmacotherapy alone to 21%.5

Electronic Nicotine Delivery System (ENDS)
No ENDS manufacturers have applied for or received approval to market their product to help with smoking cessation.5 

A study from 2013 surveyed physicians about ENDS and its role in smoking cessation. Two-thirds of the physicians surveyed said they think that e-cigarettes were helpful in smoking cessation, and 35% had recommended them to patients who were looking to quit smoking tobacco. A more recent survey showed that 56% of e-cigarettes users reported using e-cigarettes to help them decrease or quit cigarette use.5

Based on a small survey done between 2010 and 2013, the use of e-cigarettes with conventional cigarettes may be higher than believed. It was estimated that 9.4% of those who reported smoking conventional cigarettes reported using e-cigarettes concurrently, and 76.8% of those who reported using e-cigarettes reported smoking conventional cigarettes concurrently.6 Justifiably, there have been concerns regarding the potential for harmful ingredients in e-cigarettes. What complicates matters further is the lack of regulation and the fact that there are many variations of available devices and cartridge fluids. As a result, the toxicity and safety of e-cigarettes is difficult to determine.6

With the increased popularity of e-cigarettes and positive perception, the USPSTF reviewed the available evidence. In its most recent recommendation publication, the task force determined the evidence on the use of e-cigarettes as a smoking cessation option to be insufficient.5 Additional research is warranted to gain a better understanding of how e-cigarettes and conventional cigarettes used concurrently may affect attempts at smoking cessation, as well as how e-cigarettes affect the initiation of smoking.6
 
Anyssa Garza, PharmD, BCMAS, received her doctor of pharmacy degree from the University of Texas at Austin. She is the vice president of Content and Patient Education Programs at Digital Pharmacist and an adjunct assistant professor at The University of Texas at Austin College of Pharmacy.

References
  1. Verbiest M, Brakema E, van der Kleij R. National guidelines for smoking cessation in primary care: a literature review and evidence analysis. NPJ Prim Care Respir Med. 2017;27(1):2. doi: 10.1038/s41533-016-0004-8.
  2. CDC. Health effects of cigarette smoking. cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smoking/index.htm. Updated May 15, 2017. Accessed January 15, 2018.
  3. CDC. Smoking is down, but almost 38 million American adults still smoke [news release]. Atlanta, GA: CDC Newsroom; January 18, 2018. cdc.gov/media/releases/2018/p0118-smoking-rates-declining.html. Accessed January 28th, 2018.
  4. CDC. Fast facts. cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm. Updated February 20, 2018. Accessed March 9, 2018.
  5. Siu Al; US Preventive Services Task Force. Behavioral and pharmacotherapy interventions for tobacco smoking cessation in adults, including pregnant women: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2015;163(8):622-634. doi: 10.7326/M15-2023.
  6. US Preventive Services Task Force. Final recommendation statement. Tobacco smoking cessation in adults, including pregnant women: behavioral and pharmacotherapy interventions. uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions1#consider. Accessed January 1, 2018.


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