Don't quit on smokers: If at first they don't succeed...

As smoking continues to take a toll on the nation's health, physicians are provided an evidence-based guideline to help patients quit.

By Susan J. Landers — Posted Aug. 4, 2008

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Physicians and patients have been down this road before -- many times. The physician keeps bringing up the subject of smoking cessation. The patient tries to quit and fails, even though he or she knows that parting ways with those villainous cigarettes is long overdue. Still, the breakup is elusive.

And here the two sit again, confronting the question: Will the next attempt be successful, or is it time for the patient to surrender to the pull of nicotine once and for all?

A panel of health professionals led by Michael C. Fiore, MD, MPH, wants physicians and patients to focus on the first option -- trying again.

Dr. Fiore chaired the 24-member panel that developed "Treating Tobacco Use and Dependence: 2008 Update," a Public Health Service-sponsored clinical practice guideline released in May. The document is a revision of the well-respected 2000 edition.

"We lose almost half a million Americans every year to diseases caused by tobacco use," said Dr. Fiore, who directs the Center for Tobacco Research and Intervention at the University of Wisconsin School of Medicine and Public Health in Madison. "For primary care physicians, it is unequaled in terms of the burden it extracts from our patients' health."

It's well established that nearly three-quarters of smokers visit their physicians each year, making this stop No. 1 on the road to better health, noted Ron Davis, MD, immediate past president of the American Medical Association, who has long made smoking cessation a top priority.

The guideline was unveiled May 7 at the AMA's Chicago headquarters by Dr. Davis; C. Everett Koop, MD, ScD, who made smoking cessation a centerpiece of his tenure as U.S. surgeon general; and a host of other public health luminaries.

Dr. Davis called the guideline a "blueprint for physicians" that identifies pharmacologic and behavioral interventions that can help people quit smoking.

Try, try again

Research has documented the persistent nature of tobacco dependence and led to the first of the guideline's 10 recommendations: "Tobacco dependence is a chronic disease that often requires multiple attempts to quit."

"The chronic nature of tobacco use is something that needs repeating," said Carlos Roberto Jaén, MD, PhD, professor and chair of family and community medicine at University of Texas Health Science Center in San Antonio and vice chair of the PHS guideline panel.

Tobacco dependence shouldn't be treated as a single event, Dr. Jaén said. "Just like we shouldn't say to a diabetic, 'OK, control your sugar now, and we're done.' No one would think of doing that, but somehow we give ourselves permission to do that with smokers."

This mind-set is part of the problem. "Most people don't realize that it takes five, six or seven times for a lot of people to quit," said John Hughes, MD, a professor of psychiatry at the University of Vermont's College of Medicine in Burlington.

Thus follows guideline recommendation No. 2: "It is essential that clinicians and health care delivery systems consistently identify and document tobacco use status and treat every tobacco user seen in a health care setting."

For the physician who wonders how to fit this all-important advice into a 15-minute office visit, the document recommends a team effort. "I think the days of laying it all on the physician alone are unrealistic and less effective," Dr. Fiore said.

The guideline advocates a systems approach, starting with the medical assistant and extending to the pharmacist who delivers the prescribed medication. "Where you have maximal impact is where you have a number of people on the health delivery team who are engaged in helping the patient quit," he added.

The reception area itself can serve as a starting point, said Thomas P. Houston, MD, director of the Nicotine Dependence Program at McConnell Heart Health Center in Columbus, Ohio. Get rid of the magazines that carry ads for cigarettes, Dr. Houston advises.

Electronic medical records also can play a role by offering a prompt each time a patient who smokes is seen in a physician's office. "You may have to do some tinkering with the system so it brings up a prompt," he said.

A medication primer

The guideline provides an extensive review of seven medications that now are available to help patients forgo tobacco. There are five that contain nicotine -- in the form of gum, inhaler, lozenge, nasal spray and patch -- one that contains bupropion SR and another containing varenicline. All have been approved by the Food and Drug Administration.

The FDA is urging physicians who prescribe varenicline, marketed as Chantix, to monitor patients for mood and behavior changes, in light of the recent reports by Pfizer, the drug's manufacturer, of erratic behavior and drowsiness in some people.

When considering medications to prescribe, patient preferences should be included, the experts said. "Always ask if they have tried any medicines in the past and whether they have helped or not," Dr. Fiore said.

Watch the dose, cautioned Daniel F. Seidman, PhD, director of smoking cessation services at Columbia University Medical Center and clinical professor of medical psychology at the Columbia University College of Physicians and Surgeons in New York City.

"If you are going to start off replacing nicotine, you have to know how much nicotine they get from cigarettes," Seidman said. One cigarette equals one mg of nicotine. "So if they smoke a pack a day, start them off with one 21 mg patch a day."

Evidence also favors stacking or combining medications, according to the guidelines. That option may be particularly effective for heavy smokers, Dr. Houston said. "Think about the patch or bupropion as you would an asthma-controlling drug," he said. "Then on top of that you use a short-acting nicotine replacement product such as a lozenge, gum or inhaler like you would a rescue drug in asthma."

Some patients may be prescribed three medications. "This could be an option for heavy smokers who have relapsed 10 times," he said.

Also, inhalers and nasal sprays may be more helpful for heavier smokers, Dr. Houston added. "Nasal spray gives the quickest uptake of nicotine, and the inhaler has the hand-and-mouth action going on and gives a pretty good dose of nicotine."

Some smokers may worry about trading one addiction for another and be hesitant to use nicotine replacement products. "But nicotine isn't the bad guy. The bad guy is the smoke in tobacco," said Seidman, who also co-edited the book Helping the Hard-Core Smoker: A Clinician's Guide.

Counseling is vital

Medications are only part of the solution, Seidman added. Physicians and patients also should discuss the relapse triggers that inevitably will occur. "Even if it's as simple as asking them if they have a plan to handle the other smokers in their lives. That would be helpful," he said.

Counseling and medication are most effective when used in tandem, according to the guideline. "Probably the biggest finding from the guideline in 2008 is the expansion of advice and evidence for clinicians around the counseling of patients who use tobacco," Dr. Fiore said.

The new guideline recommends using Motivational Interviewing, a counseling strategy designed to persuade patients to try to quit. "Sixty percent of smokers say, 'You know doc, I know it's bad, but I'm just not ready to quit yet,' " he said. This technique is designed to transform the patient who is reticent at the beginning of a session into someone who at least is thinking about quitting by the end of it.

"We don't beat them over the head with a club," Dr. Houston said. "You try to help the patient understand the problem, and recognize their own strength in dealing with it and their self-motivation to go forward."

Despite all the help available, smoking cessation is hard work for patient and physician alike -- both can become discouraged, Dr. Fiore noted. "Smokers may feel they are weak-willed and fail to view nicotine as the powerful drug that it is."

But physicians already are aware of the need for persistence. "Anyone who has worked with an overweight or diabetic patient knows that, over time, we encourage patients to make healthy lifestyle choices. The guideline helps to use some of those similar strategies to move a smoker along," Dr. Fiore added.

Or as Mark Twain said, "Habit is habit and not to be flung out of the window by any man, but coaxed downstairs a step at a time."

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The top 10

Tobacco cessation experts highlighted these points in their clinical practice guideline:

  1. Tobacco dependence is a chronic disease that often requires repeated intervention and quit attempts.
  2. It is essential that clinicians and health care delivery systems consistently identify and document tobacco-use status and treat every tobacco user seen.
  3. Tobacco dependence treatments are effective across a broad range of populations.
  4. Brief tobacco dependence treatment is effective.
  5. Individual, group and telephone counseling are effective and their effectiveness increases with treatment intensity. Two components of counseling are particularly effective: Practical counseling with problem solving as well as skillstraining and social support delivered as part of treatment.
  6. Numerous effective medications are available for tobacco dependence. The seven first-line treatments include bupropion SR; varenicline; and nicotine gum, inhaler, lozenge, nasal spray and patch.
  7. The combination of counseling and medication is more effective than either used alone.
  8. Telephone quit line counseling is effective. Its use should be promoted.
  9. If a tobacco user is unwilling to try to quit, motivational treatments that express empathy and help patients build on past successes have been shown to be effective.
  10. Tobacco dependence treatments are clinically and highly cost effective as compared to other clinical interventions. All insurance plans should cover the counseling and medications identified as effective in the guideline.

Source: "Treating Tobacco Use and Dependence: Clinical Practice Guideline, 2008 update," U.S. Dept. of Health and Human Services, May 7 (link)

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Genetic considerations

Whether bupropion or various forms of nicotine replacement therapy help individual patients stop smoking may depend on their genes, according to a new study.

Researchers identified distinct clusters of genetic markers associated with the likelihood of success or failure of the two popular smoking cessation treatments. The study was in the June Archives of General Psychiatry.

"Our results provide the first genome-wide evidence that the genetics of successful smoking cessation with bupropion are different from the genetics of successful smoking cessation with [nicotine replacement therapy]," said George Uhl, MD, PhD, chief of the National Institute on Drug Abuse's molecular neurobiology research branch in Baltimore.

The researchers first identified clusters of gene variants that were present more frequently in the successful quitters. They also found that the variants were different in those who were successfully treated with bupropion than in those who were helped by nicotine replacement therapy.

"These findings suggest we may be able to improve the success rate for smoking cessation by using results of simple DNA tests," said Dr. Uhl.

The study used a technique known as genome-wide association scans to compare DNA extracted from the blood of 550 cigarette smokers who were either successful or unsuccessful in quitting using bupropion or a nicotine replacement therapy, such as the patch or nasal spray.

The researchers concluded that molecular genetics could help match the types and/or intensities of anti-smoking treatments with the smokers most likely to benefit from them.

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