AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Background

Cigarette smoking is a major preventable cause of disease worldwide, and it is the major cause of premature death in North America. In 1912, Adler first suggested that inhalation of cigarette smoke might be a cause of lung cancer. Since then, knowledge about the adverse health effects of smoking has accumulated. The important causes of mortality are atherosclerotic vascular disease, cancer, and chronic obstructive pulmonary disease (COPD). Smoking also can contribute to other diseases, eg, histiocytosis X, respiratory bronchiolitis, obstructive sleep apnea, idiopathic pneumothorax, low birth weight, and perinatal mortality.

Tobacco addiction, the second-leading cause of death in the world, is a culprit for approximately 5 million deaths each year or 1 in 10 adult deaths. Currently, about 1.3 billion smokers live in the world; most (84%) live in developing countries (Esson, 2004). With the present smoking trends, tobacco will kill 10 million people each year by 2020 (WHO, 2005). Through direct healthcare costs and loss of productivity from death and illness, tobacco will cost governments an estimated US $200 billion per year. A third of these costs will be borne by the developing countries. Many factors have led to increased global smoking rates. These include trade liberalization; direct foreign investment; global marketing; transnational tobacco advertising, promotion, and sponsorship; and international tobacco smuggling.

Research investigating why people smoke has shown that smoking behavior is multifaceted. Factors influencing smoking initiation differ from those of smoking behavior maintenance. Nicotine dependence, genetic factors, and psychosocial factors influence maintenance of smoking behavior.

Nicotine meets the criteria of a highly addictive drug. Nicotine is a potent psychoactive drug that induces euphoria, serves as a reinforcer of its use, and leads to nicotine withdrawal syndrome when it is absent. As an addictive drug, nicotine has 2 very potent issues: it is a stimulant and it is also a depressant. For example, one smoker talked too lovingly about her cigarettes who are called her "best friend." They got her going in the morning, and they chilled her out during the day.

Nicotine in cigarette smoke affects mood and performance and is the source of addiction to tobacco. While cigarette manufacturers have publicly denied that nicotine is an addictive drug, recent documents disclose that they have known and used the addictive properties of nicotine since the 1950s. Unfortunately, this misinformation led to the false belief that nicotine use is a habit and not an addiction.

All health care professionals should be aware of the risks of tobacco smoking, understand tobacco addiction, and assist patients with smoking cessation. For additional resources, visit Smoking.

Pathophysiology

Nicotine releases hormone noted in the following paragraphs that act on various receptors in the brain. Nicotine use results in more efficient processing of information and reduction of fatigue. In addition, nicotine has a sedative action, reduces anxiety, and induces euphoria. Nicotine effects are related to absolute blood levels and to the rate of increase in drug concentration at receptors.

Nicotine stimulates the hypothalamic-pituitary axis; this, in turn, stimulates the endocrine system. Continually increasing dose levels of nicotine are necessary to maintain the stimulating effects. With regards to dependence, some experts rank nicotine ahead of alcohol, cocaine, and heroin. A teenager who smokes as few as 4 cigarettes might develop a lifelong addiction to nicotine.

Small rapid doses of nicotine produce alertness and arousal, as opposed to long drawn-out doses, which induce relaxation and sedation. Nicotine has a pronounced effect on the major stress hormones. Nicotine stimulates hypothalamic corticotropin-releasing factor (CRF), and it increases levels of endorphins, adrenocorticotropic hormone (ACTH), and arginine vasopressin in a dose-related manner. Corticosteroids also are released in proportion to plasma nicotine concentration.

Nicotine alters the bioavailability of dopamine and serotonin and causes a sharp increase in heart rate and blood pressure. Nicotine acts on brain reward mechanisms, indirectly through endogenous opioid activity and directly through dopamine pathways.

The association between depression and smoking is well established. A lifetime history of major depression is more than twice as common in people who smoke compared to people who do not smoke. A history of major depressive disorder is associated with a decreased ability to quit smoking and an increased likelihood of smoking relapse. Increased relapse rates of major depression after smoking cessation also have been described. In subjects with a history of major depression, smoking may be an attempt to decrease negative affect, and following a quit attempt, they are likely to experience greater symptoms of nicotine withdrawal compared to smokers without a history of depression. Therefore, in patients who are attempting to quit smoking, inquiring about present or past symptoms of depression and anxiety is advisable, and specific therapy may be indicated.

Frequency

United States

In 1965, 52% of men and 34% of women were cigarette smokers. Presently, the incidence of cigarette smoking has decreased to 28% and 24%, respectively. The incidence of smoking is highest in blacks, blue-collar workers, less-educated persons, and persons in the lower socioeconomic strata.

• The trend is decreasing in more educated persons. Forty percent of men with less than 12 years of education, 35.9% of high school graduates, and 17.4% of college graduates smoke. Of women, 30.7% with less than 12 years of education, 29.6% of high school graduates, and 15.1% of college graduates smoke.
• Economic status also is related to smoking behavior. Of men with an income of $10,000-20,000 per year, 36.3% smoke, as opposed to 23.2% of men who make $50,000 or more per year. Of women who had a family income of $20,000 or less per year, 29.8% smoke, as opposed to 19.5% who make $50,000 or more per year.
• In 1983, a comparison was made between white-collar workers, of whom 27.9% smoked, and blue-collar workers, of whom 42.7% smoked.
• Twenty-five percent of pregnant women who smoke quit during pregnancy; yet 80% resume smoking after childbirth.
• Recent surveys show that 20% of teenage girls smoke, and 15% of teenage boys smoke.

International

Worldwide, approximately 1.1 billion people smoke. In China, more than 70% of men older than 25 years smoke. Smoking is more prevalent in developing countries and is continuing to increase. Prevalence of smoking in North America is decreasing, currently approximately 25% of North Americans smoke.

Mortality/Morbidity

The health consequences of this addiction are enormous. Tobacco smoking is responsible for 1 of every 5 deaths and is the most common cause of cancer-related deaths in the United States. Children smoke 1.1 billion packs of cigarettes yearly. This accounts for more than $200 billion in future health care costs.

Tobacco accounts for more than 85% of all deaths due to lung cancer. Approximately 10 million people in the United States have died from causes attributed to smoking since the Surgeon General's first report in 1964; 2 million of these were from lung cancer alone. Furthermore, tobacco also has been identified as the leading cause of emphysema, COPD, bronchitis, and heart disease.

• Laryngeal cancer is uncommon; however, in 1988, it accounted for 1.1% of cancer-related deaths in men and 0.3% of cancer-related deaths in women. Oral cancer accounted for approximately 2.1% of male cancer-related deaths and 1.2% of female cancer-related deaths in 1988. Cigarette smoking and tobacco chewing are major causes of this disease. Esophageal cancer accounted for 2.6% of male cancer-related deaths and 1% of female cancer-related deaths. Approximately 50% of overall esophageal cancer mortality is due to cigarette smoking.
• Bladder cancer accounted for 2.4% of male cancer-related deaths and 1.3% of female cancer-related deaths in 1988; approximately one third of these deaths were related to cigarette smoking. Pancreatic cancer accounted for approximately 5% of cancer-related deaths in 1990; one third of these deaths were associated with cigarette smoking.Kidney cancer accounted for 2.3% of male cancer-related deaths and 1.8% of female cancer-related deaths. Smoking has been established as an independent risk factor for uterine cervical cancer. Anal cancer in both heterosexual men and women also was due largely to cigarette smoking. Interactions between viral factors and tobacco exposure increase cancer risk.
• Nonsmokers exposed to environmental tobacco smoke have a significantly higher risk of developing cancers and pulmonary diseases. Concentrations of toxins and carcinogens are higher in sidestream smoke. Children exposed to secondhand smoke develop a variety of respiratory disorders and morbidity.

Race

The smoking rate in the United States is higher among blacks than whites and is steadily increasing in Hispanics. In 1987, 39% of the black male population were smokers, compared to 30.5% of white men; 28% of black women were smokers, as opposed to 26.7% of white women. In addition, 30% of Hispanic men and 18% of Hispanic women were smokers.

Sex

In the United States, approximately 28% of men and 24% of women smoke.

Age

Studies reveal that the average age of first-time smokers is 14.5 years and the average age of daily smokers is 17.7 years. Approximately 20% of high school seniors smoke.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

History

• Nicotine addiction is classified as nicotine use disorder according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). The criteria for this diagnosis include any 3 of the following within a 1-year time span:
• • Tolerance to nicotine with decreased effect and increasing dose to obtain same effect
  • Withdrawal symptoms after cessation
  • Smoking more than usual
  • Persistent desire to smoke despite efforts to decrease intake
  • Extensive time spent smoking or purchasing tobacco
  • Postponing work, social, or recreational events in order to smoke
  • Continuing to smoke despite health hazards
• Nicotine withdrawal is classified as a nicotine-induced disorder according to the DSM-IV-TR. Symptoms include difficulty concentrating, nervousness, headaches, weight gain due to increased appetite, decreased heart rate, insomnia, irritability, and depression. These symptoms peak in the first few days but eventually disappear within a month.
• Symptoms of nicotine toxicity, otherwise known as acute nicotine poisoning, include nausea, vomiting, salivation, pallor, abdominal pain, diarrhea, and cold sweat.
• A previous history of depression, use of antidepressants in the past, and onset of depression during previous quit attempts should be obtained.

Physical

• Physical effects of nicotine use include increased heart rate, accelerated blood pressure, and weight loss.
• Physical effects of nicotine withdrawal and smoking cessation include weight gain due to increase in appetite, decreased heart rate, and improvement in the senses of taste and smell.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Other Problems to be Considered

Fetal growth retardation
Atherosclerotic vascular disease
Cancer
Histiocytosis X
Respiratory bronchitis
Obstructive sleep apnea
Idiopathic pneumothorax
Low birth weight
Perinatal mortality

TREATMENT

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical Care

Smoking may begin as a voluntary habit, but eventually it becomes an addiction. Health professionals can contribute powerfully to motivate their patients to attempt and sustain cessation by offering encouragement, advice, and assistance. For patients who are not yet ready to attempt quitting, such advice can move them further toward that point. A willingness to help and to provide assistance is very important in motivating cigarette smokers in attempting to quit. The reassurance that a knowledgeable health professional stands ready to offer guidance and support is immensely beneficial to individuals addicted to nicotine. Understanding the benefits and limitations of the available medications provides an important foundation for such a successful smoking cessation program.

• Assess smoking history, level of addiction, and the health status of the patient (see Image 1). After the assessment, intervene with education and advice.
• Educate patients about the benefits of smoking cessation and the cessation process. Provide a description of the expected withdrawal syndrome. Continue with a discussion of the possible cessation methods, which include physician counseling, nicotine replacement, antidepressant medications, behavioral training, group therapy, hypnosis, and quitting "cold turkey."
  • More than 90% of patients who attempt to quit smoking stop cold turkey.
  • Professional group therapy or counseling achieves a 60-100% initial cessation rate and a 1-year cessation rate of approximately 20%.
  • Hypnosis and acupuncture are popular programs that might encourage renewed attempts by people who failed other techniques, but they are no different from placebo.
  • Verify successful cessation by measuring cotinine or carbon monoxide levels.
• A cigarette delivers 1.2-2.9 mg of nicotine, and the typical one pack-per-day smoker absorbs 20-40 mg of nicotine each day, raising the plasma concentrations to between 23-35 ng/mL. Nicotine produces increased expression of brain nicotine receptors, changes in regional brain glucose metabolism, the release of catecholamines, tolerance, and physiologic dependence. Nicotine addiction results from positive reinforcement (with the administration of nicotine) and withdrawal symptoms that start within a few hours of the last cigarette. The time to first cigarette and total cigarettes per day are the two strongest predictors of nicotine addiction. The nicotine dependence and nicotine withdrawal could be treated by the following (Fiore, 2000; Henningfield, 2005):
  • Other forms of nicotine delivery
  • Drugs that selectively target one or more of the underlying mechanisms
  • Behavioral treatments, acupuncture, and other therapies
• Nicotine replacement therapy
  • Nicotine replacement therapy works by making it easier to abstain from tobacco by partially replacing the nicotine previously obtained from tobacco. At least 3 mechanisms by which NRT could be effective include (1) reducing either general withdrawal symptoms, thus allowing people to learn without cigarettes; (2) reducing the reinforcing effects of tobacco-delivered nicotine, (3) providing some psychological effects on mood and attention states.
  • Nicotine replacement medications should not be viewed as stand-alone medications that make people stop smoking. Reassurance and guidance from health professionals can be critical to achieve and sustain abstinence. Six types of nicotine replacement products are on the market. These include nicotine transdermal patch systems; nicotine nasal spray; and nicotine delivery through the oral mucosa including gum, lozenge, sublingual tablet, and vapor inhaler. Common adverse events that are common to all NRT products include dizziness, nausea, and headache.
• Transdermal nicotine patches
  • Nicotine patches deliver nicotine through the skin at a relatively steady rate. Currently, 4 patch formulations are on the market; they vary widely in their design, pharmacokinetics, and duration of wear (ie, 24- and 16-h wear). For some products, progressively lower doses can be used to provide weaning over a period of several weeks or longer to enable gradual adjustment to lower nicotine levels and ultimately to a nicotine-free state. Smokers who use more than 10 cigarettes per day should use the 21-mg/day patch for the first 6 weeks, move to the 14-mg/day strength for 2 weeks, then use the 7-mg dose for the final 2 weeks. Nicotine patches have higher compliance than other NRT products but may not adequately protect against craving provoked by smoking-related stimuli. For breakthrough cravings not adequately controlled by transdermal nicotine alone, acute therapies may be added.
  • A study tested the efficacy of nicotine patches in combination with behavioral therapy for the treatment of adolescent spit tobacco addiction. The usual care group's spit tobacco cessation rate was 11.4%; placebo patch, 25.0%; and active patch, 17.3%. The cessation rates for active and placebo patch were not significantly different, proving that behavioral intervention is twice as successful and that nicotine patch did not offer additional improvement (Stotts, 2003).
• Acute dosing forms
  • The amount and timing of these products can be titrated by the user, thus allowing the use of NRT medications as rescue medication for cravings. Ongoing craving in a quitter is associated with acute episodes of more intense craving called breakthrough craving. Provoked by situational stimuli, such as seeing someone smoke, or experiencing emotional upset, are associated with very high risk of relapse.
  • These therapies may also be used when a situation is expected to produce a craving, such as a demanding meeting, rush-hour traffic, commute, or social situation with cigarette smokers.
• Nicotine gum
  • First available in the 1980s, nicotine polacrilex (nicotine gum) is available without a prescription. The gum is available in doses: 2 mg and 4 mg, delivering approximately 1 mg and 2 mg of nicotine. Users are instructed to use a piece of gum every 1-2 hours for the first 6 weeks, then to reduce use to one piece every 2-4 hours for 3 weeks, and one piece every 4-8 hours for 3 weeks. In highly dependent smokers, the 4-mg gum is superior to the 2-mg gum. Since about 50% of the nicotine in gum is absorbed, a fixed schedule of 10 pieces per day, a smoker receives about 10 mg or 20 mg of nicotine per day using the 2-mg or 4-mg gum, respectively.
  • The slow absorption of nicotine from gum doses does not produce the extremely high levels of nicotine. Acidic beverages interfere with buccal absorption of nicotine; patients should avoid acidic beverages (eg, soda, coffee, beer) for 15 minutes before and during chewing gum. Nicotine gum chewing may cause jaw soreness; therefore, the smoker should chew the gum to release nicotine, then move the gum between the cheek and gum for a minute or so. Gum can also cause a mild burning sensation in the mouth and throat, which may be undesirable.
• Lozenge: Available in 2- and 4-mg formulations since 2002, nicotine from the lozenge is absorbed slowly through the buccal mucosa. The lozenge should not be chewed, and the amount of nicotine absorbed per lozenge is somewhat higher than that delivered by gum.
• Inhaler
• • Currently marketed as a prescription medication in the United States, the inhaler consists of a mouthpiece and a plastic cartridge containing nicotine. When the inhaler is "puffed," nicotine is drawn into the mouth of the smoker and satisfies the behavioral aspects of smoking, namely, the hand-to-mouth ritual.
  • Each inhaler cartridge contains 10 mg nicotine, of which 4 mg can be delivered and 2 mg are absorbed. Nicotine is not delivered to the bronchi or lungs, but rather it is deposited and absorbed in the mouth, like nicotine gum. Most people use between 6 and 16 cartridges a day, the recommended duration of treatment is 3 months, after which patients may be weaned by gradual reduction over the following 6-12 weeks.
• Nasal spray: Marketed as a prescription medication, the nasal spray delivers nicotine more rapidly than other NRTs and delivers acute craving relief. The multidose bottle with a pump delivers 0.5 mg of nicotine per 50-µL squirt. Each dose consists of 2 squirts, one to each nostril. The dose of nasal spray should be individualized for each patient based on the patient's level of nicotine dependence. Most patients are started with 1 or 2 doses per hour, which may be increased up to the maximum of 40 doses per day.
• Sublingual tablet: A small nicotine tablet has been developed but is not yet available in the United States. The product is designed to be held under the tongue, where the nicotine in the tablet is absorbed sublingually. The levels of nicotine obtained by use of the 2-mg tablet and 2-mg nicotine gum are similar. It is recommended that smokers use the product for at least 12 weeks, after that the number of tablets used is gradually tapered.
• Use of pharmacotherapies for tobacco harm reduction: Smoking cessation treatments with NRT enable smokers to cease tobacco use and subsequently to withdraw from nicotine altogether. However, for some smokers, withdrawing from smoking completely may be difficult. In those individuals, there may be benefit by continuing to use NRT for longer periods, even indefinitely, to prevent relapse to smoking. This strategy is currently used in methadone maintenance programs for heroin-dependent patients, where patients may be maintained on daily doses of methadone for years. Although nicotine is not entirely without risk, nicotine maintenance is clearly safer than cigarette smoke-delivered nicotine with its numerous toxins. Therefore, indefinite NRT to prevent resumption of smoking may be considered for some individuals.
• Bupropion (Zyban)
  • Bupropion acts by alleviating some of the symptoms of nicotine withdrawal, which includes depression. One clinical trial demonstrated that highly nicotine-dependent smokers who receive bupropion are more likely to experience a decrease in depressive symptoms during active treatment. Like NRT products, bupropion has been endorsed by the US Clinical Practice Guideline as a first-line therapy (Fiore, 2000).
  • Bupropion has been shown to approximately double rates of cessation compared with placebo, and the medication is equally effective for men and women. It has also been shown that bupropion combined with nicotine replacement medications may increase cessation rates relative to bupropion alone. The recommended and maximum dose of bupropion is 300 mg/day, given as 150 mg twice daily. Dry mouth and insomnia are the most common adverse events associated with use. A very small risk of seizure exists, which can be reduced by not prescribing the medication to persons with a history of seizure or a predisposition toward seizure.
• Varenicline (Chantix) is a partial agonist selective for alpha4, beta2 nicotinic acetylcholine receptors. Action is thought to result from activity at a nicotinic receptor subtype, where its binding produces agonist activity while simultaneously preventing nicotine binding. Agonistic activity is significantly lower than nicotine.
• Other medications: Besides NRT products and bupropion, nortriptyline and clonidine are endorsed by the US Clinical Practice Guideline as second-line therapies.
• Nortriptyline: As a second-line therapy, studies have demonstrated the potential efficacy of nortriptyline for smoking cessation in smokers without history of major depression. Nortriptyline in combination with transdermal nicotine was also shown to enhance the cessation rates above levels seen with transdermal nicotine alone. The tricyclic antidepressant doxepin has also been shown in a small human study to improve cessation rates. The most commonly encountered side effects associated with nortriptyline include fast heart rate, blurred vision, urinary retention, dry mouth, constipation, weight gain or loss, and low blood pressure on standing.
• Clonidine: An alpha-2-noradrenergic agonist used to treat hypertension, clonidine has been shown to diminish symptoms of both opiate and alcohol withdrawal symptoms. In one study of heavy smokers who had failed in previous quit attempts found that those treated with clonidine had twice the rate of abstinence as those treated with placebo at the end of the 4-week treatment, and the effect persisted for the 6-month follow-up period. Although clonidine may be efficacious in the treatment of nicotine addiction, the conditions under which it is most appropriately used are not well defined. The most common side effects of clonidine are constipation, dizziness, drowsiness, dryness of mouth, and unusual tiredness or weakness.
• Combination products
  • To improve smoking cessation, medications can be combined, such as passive nicotine delivery (eg, transdermal patch) with another medication that permits acute nicotine delivery (eg, gum, nasal spray, inhaler). Combining the nicotine patch (which may prevent the appearance of severe withdrawal) with acute dosing forms (which can provide relief in trigger-to-smoke contexts) may provide an excellent treatment option over either therapy alone (Kornitzer, 1995).
  • Bupropion in combination with a nicotine patch appears to be more efficacious than a nicotine patch alone, possibly because the two medications act via different pharmacologic mechanisms. Despite the possibility of increased efficacy concluded in the Clinical Practice Guideline, these therapies should be prescribed under the direction of an experienced physician or the specialty clinic (Jorenby, 1999).

Consultations

Patients may be referred for group therapy or behavioral counseling. If an affective disorder is suspected, evaluation by a psychiatrist may be indicated.

Diet

Patients who quit smoking tend to gain weight; therefore, encourage patients to follow a low-calorie diet and exercise regimen during and after cessation.

Activity

While attempting smoking cessation, exercise has been shown to help curb weight gain and to help alleviate nicotine withdrawal symptoms.

MEDICATION

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Two types of medications are available as part of a smoking cessation program. Types include nicotine replacement therapy in the form of cutaneous patches, inhaled or nasal delivery, or chewing gum and the non–nicotine-containing tablet bupropion. These medications ameliorate withdrawal symptoms while the smoker deals with behavioral aspects of smoking cessation.

Nicotine chewing gum, if chewed correctly, increases quit rates up to 2-fold. At 1 year, the abstinence rate with the patch is 20%. At 4 years, the abstinence rate is 12.4% compared to 4.5% with placebo.

Drug Category: Nicotine replacement therapy (patches)

Nicotine patches are sold under the following trade names: NicoDerm, Nicotrol, and Habitrol. The dosing schedule of each is a graduated decrease of drug over 9-12 wk.

Drug Category: Nicotine replacement therapy (chewing pieces)

These are marketed in 2 strengths (2 mg and 4 mg). An individual who smokes 1 pack per day should use 4-mg pieces. The 2-mg pieces are to be used by individuals who smoke less than 1 pack per day. Instruct the patient to chew hourly and for their initial cravings for 2 wk, then gradually reduce amount chewed over the next 3 mo.

Drug Category: Nicotine replacement therapy (nasal spray)

Provides nicotine delivery through nasal mucosa

Drug Category: Nicotine replacement therapy (inhaler)

Delivers nicotine through oral mucosa.

Drug Category: Antidepressants

The drug bupropion is used as a non–nicotine-containing aid to smoking cessation. Acts by enhancing the central nervous nonadrenergic function. A recent study demonstrated a 23% sustained cessation rate with bupropion tablets at 1 year, compared to a 12% sustained cessation rate with placebo. Bupropion also is effective for patients in whom nicotine replacement therapy fails.

Drug Category: Nicotinic acetylcholine receptor partial agonists

Bind to nicotine receptors and elicit mild nicotine central effects to ease withdrawal symptoms. Also decrease stimulatory effect from consuming nicotine products by blocking nicotine receptors.

FOLLOW-UP

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Further Outpatient Care

• Long-term follow-up is recommended because individuals who successfully quit smoking are at high risk for relapse. The health care deliverer should make provisions for support, measurement of progress, and a mechanism to deal with relapse. For motivated patients who have failed smoking cessation, consider referral to an expert for the treatment of a relapse.

Deterrence/Prevention

• More than 90% of first-time use of tobacco occurs before high school graduation. Because the average age at first use is 14.5 years, smoking prevention must start early.
• Approximately 40% of teenagers who smoke eventually become addicted to nicotine.
• Social attitudes and policies toward smoking can have a major impact on smoking behavior. Physician associations, public health organizations, and consumer groups should lobby for the following:
• • Restriction of access to tobacco products for minors
  • Restriction of smoking in public places
  • Restriction of advertisements
  • Increased prices through taxation
  • Increased awareness about the harmful health effects of smoking

Patient Education

• Patient education with regard to the health effects of smoking should occur with all patients who smoke. Patients should be provided with a variety of options and advice that will allow them to escape the harmful effects of tobacco use and the highly addictive drug, nicotine.
• For excellent patient education resources, visit eMedicine's Public Health Center and Lung and Airway Center. Also, see eMedicine's patient education article Cigarette Smoking.

MISCELLANEOUS

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical/Legal Pitfalls

• Relapse during the first year after achieving smoking cessation occurs in approximately 50% of patients, irrespective of therapeutic regimen.
• The changes in the central nervous system, eg, neurone genetics, cell structure, and cell function, induced by smoking do not reverse with pharmacological therapy.
• Highly nicotine-dependent smokers may require an initial therapy for 6 months or longer. Some individuals may require low-dose maintenance therapy for years.
• Controlled studies are required to help guide management of relapses and prolonged tapering periods. Immediately restarting nicotine medication might be helpful if a relapse occurs.
• According to Gro Harlem Brundtland, the director of the World Health Organization, "A tax increase is the single most important intervention by governments to curb tobacco consumption." A 10% tax increase worldwide could inspire 42 million people to stop smoking and would prevent approximately 10 million premature deaths.

Special Concerns

• Tobacco use is the greatest potentially remedial problem throughout the world, and it is the number-one preventable cause of death in the developed world. Physicians have a particularly important role as patient advocates in health promotion, discouraging smoking initiation, encouraging and assisting smoking patients to quit, and participating in social efforts designed to curb smoking at various levels.
• The gains in understanding the neuropathology of nicotine addiction have already opened new frontiers, including effective nicotine replacement and oral therapy. Greater therapeutic advances are anticipated in the next few years.
• Smoking and weight gain
  • Concerns about weight gain following smoking cessation are a well-known barrier. Smokers with weight concerns are more likely to relapse. Smoking for weight control reasons has been associated with being female, smoking more cigarettes per day, lower motivation to quit smoking, body image dissatisfaction, and higher Fagerström (Dale, 1998).
  • Interventions designed specifically for weight-concerned smokers such as on-site exercise program improved smoking abstinence rates and delayed weight gain. Cognitive-behavioral therapy to reduce weight concerns improved smoking cessation success and reduced weight gain.
  • NRT can have an additional, positive effect on weight gain as another significant barrier to smoking cessation. NRTs can attenuate postcessation weight gain, although upon termination of nicotine replacement use, weight continues to increase to the level of exsmokers who used placebo (Allen, 2005).
• Smoking and depression
• • An association between nicotine addiction and depression is well established.
  • Previous studies also have demonstrated that dependent smokers have lower monoamine oxidase A and B activity than nonsmokers. Smokers with a past history of major depression also were found to have significantly lower resting plasma norepinephrine levels. Past history of depression also was found to be more frequent in female smokers.
  • Reports of severe major depressive episodes after smoking cessation indicate that the onset of severe depressive symptoms ranges from 2 days to 6 weeks after abstinence from smoking.
  • In some cases, depression after smoking cessation was resolved with the use of nicotine replacement therapy or the use of antidepressants; in others, depressive symptoms dissipated after a relapse to smoking. The significant predictors of major depressive episodes were having a history of major depression and experiencing elevated withdrawal symptoms at the end of treatment.
  • Obtaining information about any history of depressive symptoms is important, and when such a history is present, remaining alert to the possible onset of depression even weeks after smoking cessation treatment has ended also is important.
  • Antidepressants such as fluoxetine and sertraline may be a useful cessation aid for smokers with prior major depression, and other authors have suggested that smokers with prior major depression benefit from mood management counseling and nortriptyline as cessation aids. Whether these treatments also prevent the onset of postcessation depression remains to be examined. It also remains to be known whether effective management of withdrawal symptoms prevents postcessation depression.

MULTIMEDIA

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Media file 1:  Smoking cessation strategies for physicians.
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Media type:  Image

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

• Allen SS, Hatsukami D, Brintnell DM. Effect of nicotine replacement therapy on post-cessation weight gain and nutrient intake: a randomized controlled trial of postmenopausal female smokers. Addict Behav. Aug 2005;30(7):1273-80. [Medline].
• Benowitz NL, Jacob P 3rd. Nicotine metabolism in nonsmokers. Clin Pharmacol Ther. Oct 1990;48(4):473-4. [Medline].
• Benowitz NL. Sodium intake from smokeless tobacco. N Engl J Med. Sep 29 1988;319(13):873-4. [Medline].
• Bergen AW, Caporaso N. Cigarette smoking. J Natl Cancer Inst. Aug 18 1999;91(16):1365-75. [Medline].
• Croghan IT, Offord KP, Evans RW, et al. Cost-effectiveness of treating nicotine dependence: the Mayo Clinic experience. Mayo Clin Proc. Oct 1997;72(10):917-24. [Medline].
• Cromwell J, Bartosch WJ, Fiore MC, et al. Cost-effectiveness of the clinical practice recommendations in the AHCPR guideline for smoking cessation. Agency for Health Care Policy and Research. JAMA. Dec 3 1997;278(21):1759-66. [Medline].
• Dale LC, Schroeder DR, Wolter TD. Weight change after smoking cessation using variable doses of transdermal nicotine replacement. J Gen Intern Med. Jan 1998;13(1):9-15. [Medline].
• Dewar AL, Esson L, Entwistle C. Prior learning assessment. Putting experience to the test. Can Nurse. May 2002;98(5):28-31. [Medline].
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Article Last Updated: Apr 13, 2006