This article originally ran in FloridaMD magazine in the January 2014 issue.

Physicians are well aware that cigarette smoking is the leading preventable cause of mortality. It is also well known that when smokers stop smoking they reduce their risk of developing and dying from tobacco-related diseases. Surveys have indicated that approximately 70% of smokers want to quit smoking and over 40% of smokers have tried to quit smoking in the past 12 months. However, less than 7% of smokers who make an unassisted attempt to quit smoking remain abstinent after 12 months.

Currently, it appears that behavioral counseling combined with pharmacotherapy will produce the best results in smoking cessation.

The guidelines of the United States Preventive Health Services recommend that the smoking status of every patient be assessed and documented at every healthcare encounter. This has been shown to increase the likelihood of smoking cessation discussions between patients and physicians and to increase smoking cessation rates. It is important to assess the patient’s desire to stop smoking as well as the methods of previous quit attempts and their effectiveness. More dependent smokers have smoked for many years, smoke more cigarettes per day and smoke within 30 minutes of waking up. The degree of nicotine dependence can help predict the difficulty that the patient will have in smoking cessation and help predict the intensity of treatment that may be necessary.

Nicotine is a potent psychoactive drug that causes both physical dependence and tolerance. The nicotine withdrawal syndrome can include symptoms of insomnia, irritability, anxiety, difficulty concentrating, restlessness, increased appetite or weight gain  as well as dysphoric mood. It is important for smokers to know what to expect during a smoking cessation attempt and how to respond if these symptoms occur. Certain situations can increase the risk of relapse such as having other smokers in the household (or at the workplace) or getting into stressful situations. Smoking is also often associated with alcohol use.

Many smokers will relapse and wind up making several attempts to quit smoking before they ultimately achieve success. It is important to remind our patients about this to help them try to learn from each quit attempt.

The average weight gain for people who quit smoking is 2-5 pounds in the first two weeks, followed by an additional 4-7 pounds over the next 4-5 months. Remind your patient that the benefits of smoking cessation outweigh the risk of this degree of weight gain. The patient should identify a “quit date,” which should typically be within two weeks of the decision to attempt to quit smoking. Low tar and low nicotine cigarettes are not recommended. It is helpful for the smoker to notify their family, friends and co-workers about their plan to quit and ask for their support.

There is limited scientific data to support hypnosis and acupuncture for smoking cessation; however, there are certainly anecdotal accounts of benefit in some patients.

Nicotine replacement therapies can be used in combination. For example, a nicotine patch can provide a constant low level of nicotine and can be used in conjunction with a nicotine gum as needed for cravings. Other options include a nicotine spray, inhaler, and lozenge. The nicotine patch should be titrated to the patient’s nicotine use. Typically, the 7 mg patch would be recommended for somebody who smokes a half pack of cigarettes per day, a 14 mg patch would be recommended for somebody who smokes a pack of cigarettes per day and a 21 mg patch would be recommended for somebody who smokes more than one-and-a-half packs of cigarettes per day. The nicotine patch could then be tapered over time.

Chantix (Varenicline) is a partial neuronal nicotinic receptor agonist, it prevents the stimulation of the mesolimbic dopamine system by nicotine.

It is started at 0.5 mg once a day for three days, then 0.5 mg twice a day for four days followed by 1 mg twice a day, starting at day 7. The individual should stop smoking one week after starting therapy with Chantix. If the patient has quit smoking after 12 weeks of Chantix, an additional 12 weeks of therapy can be initiated. Common side effects of Chantix include nausea and abnormal dreams. For most patients, the nausea is tolerable. If the nausea becomes intolerance, the patient can decrease the Chantix dose to the highest dose that they can tolerate.

There have been a small number of people who have developed suicidal thoughts or aggressive/erratic behavior during treatment with Chantix. It has been difficult to determine with certainty whether these behaviors are related to Chantix therapy or smoking cessation itself. There is an exciting trial ongoing locally regarding use of Chantix in patients with psychiatric conditions. The study should provide further information regarding the safety of Chantix use in this setting. For more information about this trial, you can contact Dr. Patricia Brown at 407-425-3670 or by e-mail at pbrown@cnshealthcare.com. The FDA issued an advisory in 2011 that in patients who have preexisting cardiac conditions, Chantix may increase the risk of acute coronary syndrome.

Another pharmacologic option to help our patients to achieve smoking cessation is Wellbutrin. The typical dose is 150 mg of Wellbutrin XR for three days and then 300 mg of the extended release Wellbutrin thereafter.

Wellbutrin therapy can be combined with nicotine replacement therapy.

Wellbutrin can cause insomnia and dry mouth and is not recommended for patients with pre-existing seizures, history of head trauma, anorexia nervosa or bulimia or excessive alcohol consumption. Like Chantix, Wellbutrin therapy should be started one week before the patient’s “quit date”.

Patients who smoke but are not willing to quit should be motivated using the”5 R technique.” This includes:

1. Relevance, which involves explaining to the patient why smoking cessation would be particularly relevant in their condition.
2. Risks, in which the patient identifies potential negative consequences of continued tobacco use that are particularly meaningful to them
3. Rewards of smoking cessation such as saving money, improved health, improved sense of smell/taste, etc.
4. Road blocks, which involves understanding your patients’ specific concerns about smoking cessation (withdrawal symptoms, fear of failure, weight gain, enjoyment of tobacco, etc.)
5. Repetition involves continued discussions with the patient at every clinic visit.

For patients who want to quit smoking, the “5 A Method” can be used:

1. Asking the patient about tobacco use at every visit.
2. Advising patients to quit smoking in a clear, strong and personalized manner.
3. Assessing the patient’s willingness to quit smoking.
4. Assisting the patient in smoking cessation.
5. Arranging follow up to assess the success of the patient’s smoking cessation attempt.

Potential resources to help smokers include:

American Lung Association website (http://www.lungusa.org) as well as http://www.quitnet.com, and http://www.ahectobacco.com, as well as the telephone hot line at 1-800-QUIT-NOW