When physicians routinely identify tobacco use and dependence in their patients, they are more likely to treat it. Recurring, brief, friendly, unambiguous physician advice to stop smoking significantly increases long-term nonsmoking rates by 17-fold (0.3% to 5.1%).1, 6 Adding only one medication increases the effect of physician advice another 2-fold (4.1% to 8.8%).102 By applying basic medical management principles such as those used for asthma, tobacco-dependence treatment can be an additional 5 to 8 times more effective.
This 3rd Edition of the CHEST Treatment of Tobacco Dependence Tool Kit is built on the evidence base provided by the U.S. Public Health Service Guideline for the treatment of tobacco use and dependence, the California Thoracic Society Position Paper, and the extensive clinical experience of the Members of this Committee treating tobacco dependence in their own clinical practice (aggregate number of patients diagnosed and treated for tobacco dependence one-on-one or in small groups by all Committee Members >> 20,000).
Based on the above evidence, one of the Tool Kit’s core recommendations is that pulmonary specialists need to be far more proactive in diagnosing and treating tobacco dependence in a non-judgmental, “no-fault” manner, using one or more effective medications, just as we do routinely with asthma. We need to move beyond “5-A” mnemonic, Ask, Advise, Assess, Assist, and Arrange (http://www.surgeongeneral.gov/tobacco/tobaqrg.htm), replacing it with the proactive medical-model approach described in this Tool Kit – ARMR: Assess and diagnose the patient, Recommend a treatment plan, Monitor the treatment plan’s outcome, Revise the treatment plan to improve its effectiveness, if necessary, and to reduce side-effects, if any.  ARMR acronym and concept developed by Reza Taheri, PharmD, Chair, Department of Pharmacotherapy & Outcomes Sciences, Loma Linda University School of Pharmacy, Linda H. Ferry, MD, Department of Preventive Medicine, Loma Linda University School of Medicine, and David P.L. Sachs, MD, Chair CHEST Tobacco-Dependence Tool-Kit Committee, at a meeting on May 6, 2008. This is precisely what we do with any other chronic medical disease, such as asthma or COPD.
You, the treating physician, should ASSESS and approach the patient in an objective, helpful manner, routinely quantify nicotine dependence using the Fagerström Test for Nicotine Dependence (FTND) and also routinely quantify Nicotine Withdrawal Symptoms (NWS), before you RECOMMEND any tobacco-dependence treatment. You should also measure NWS at each visit after starting treatment, in order to MONITOR the treatment plan for effectiveness and side effects. This kind of information will enable you to then rationally REVISE the patient’s treatment plan, including behavioral or pharmacologic components as necessary, to improve tobacco-dependence treatment effectiveness and reduce side effects, if any. This Tool Kit provides several instruments to measure the severity of Nicotine Withdrawal Symptoms that can be downloaded and printed for use in your practice. Select and routinely use the ones that work best in your practice.
Suppression of nicotine withdrawal symptoms should be your primary treatment objective. Failure to suppress nicotine withdrawal symptoms can make it much more difficult for a patient to stop cigarette use and remain nonsmoking. The only way to objectively and quantitatively monitor a treatment plan’s effectiveness is to quantitatively measure the patient’s nicotine withdrawal symptoms (see Nicotine Withdrawal Symptom Scale) at each visit. The pivotal importance of nicotine withdrawal symptom suppression is supported by four independent lines of evidence.
- At least two separate, randomized clinical trials have shown that 75%103 to 90%49 of tobacco users relapse within a mere 30 days, when trying to stop “cold turkey”-without any treatment.
- At least three separate clinical trials have identified craving for cigarettes104, 105 or other nicotine withdrawal symptom severity106 as the cause for this precipitous relapse within the first 30 days after Target Stop Date.
- At least two, non-randomized, open-label clinical trials have shown that relieving symptoms of nicotine withdrawal and mood disturbance with specific combinations of tobacco-dependence medications-at much higher-than-standard doses-improves treatment outcome and continuous non-smoking rates at the end of a 3-month treatment course,107,108 and even 9 months after treatment end.109
- At least one controlled trial showed that an abrupt, several-fold increase in nicotine withdrawal symptoms and craving for cigarettes occurred one to two days before relapse.110
The collective clinical-treatment experience of this Committee also supports the necessity of suppressing Nicotine Withdrawal Symptoms as completely as possible, from the Target Stop Date onward, to maximize treatment effectiveness.
A second and corollary recommendation of this Tool Kit is to start tobacco-dependence treatment even before the patient is in the classic “Action Phase” (see Prochaska JO, et al. for a description of the Transtheoretical Model for the Stages-Of-Change111) and entirely ready to stop smoking. This Tool Kit will provide specific, concrete steps that you, the treating physician, can take to help your patient “get to yes”.
The Biology of Nicotine Addiction
Tobacco dependence is a chronic medical condition prone to relapse and recurrence over time, particularly in the absence of effective medical management or if the patient does not adhere to the treatment plan. Cigarette use is the primary symptom of tobacco dependence. Nicotine dependence leads to neurophysiologic alterations of brain structure and function, including cell receptor abnormalities, neuronal development changes, and increased dendritic connections. Tobacco dependence causes a proliferation of nicotine receptor sites in the central nervous system. Some receptor abnormalities may be reversible in some patients but not in others. In either case, the CNS pathophysiology of tobacco dependence can be stabilized with effective pharmacotherapy. Uptake of nicotine increases CNS dopamine and norepinephrine synthesis and release, as well as increased synthesis and release of serotonin, b-endorphin, vasopressin, and glutamate, which cause feelings of pleasure, arousal, enhanced memory and intellect, increased problem-solving abilities, and reduced appetite.2, 112, 113 See The Biological Basis for Tobacco Use section, for more details on the biology of nicotine addiction and resultant tobacco dependence.
Nicotine Withdrawal Symptoms
Nicotine has a half-life of 2 hours, which is why tobacco-dependent people awaken with a significant urge to smoke. All nicotine is out of the body 8 hours after smoking the most recent cigarette. The physiological problem in stopping smoking is not having nicotine in the body and needing to get rid of it, as some people think. Rather, the physiological problem is that merely overnight, no nicotine is left in the circulation or the CNS. Consequently, sudden withdrawal from tobacco leaves brain nicotine receptor sites unfilled, thereby reducing CNS dopamine and norepinephrine levels, leading to craving for cigarettes and other nicotine withdrawal symptoms such as the ones listed below.
- Dysphoric or depressed mood
- Irritability, frustration or anger
- Difficulty concentrating
- Decreased heart rate
- Increased appetite or weight gain
These symptoms are real, not imagined, and are readily reversible in a dose-responsive fashion with nicotine itself, bupropion, and varenicline. Stopping smoking “cold turkey” is not a treatment for tobacco dependence and frequently is not effective. Allowing a patient to try cold turkey is sub-standard tobacco-dependence care. It should no longer be used or even considered as a treatment option, any more than we would regard “no treatment” as satisfactory for management of mild persistent asthma. You should offer pharmacotherapeutic treatment for all tobacco-dependent patients, and explain to all patients how the treatments can be helpful in reducing Nicotine Withdrawal Symptoms and increase the likelihood of remaining cigarette-free. Refer to the section on Pharmacologic Treatment for specific guidance and decision support.
A Chronic Disease
As discussed in The Scientific and Clinical Basis for the Tool Kit Recommendations section, the chronic nature of tobacco dependence demands a long-term treatment approach. Patient relapse and remission can be minimized, if not completely eliminated, when the physician and patient are attentive to medication needs and do not prematurely terminate all pharmacotherapy, particularly prn Rescue Medications. That said, treatment effectiveness and treatment response should not be judged only on the basis of permanent nonsmoking, but also on the progress and response to treatment over time. Relapse is a hallmark of any chronic medical disease and does not reflect the personal failure of either physician or patient. Rather, it indicates failure of the treatment plan and the need to revise it. The chronic, relapsing nature of tobacco dependence parallels that of asthma, hypertension, or any other chronic disease.
Patients with these disorders are treated with appropriate medications, support, and counseling. The same should be provided to patients with tobacco dependence.114-116 Timely revision of the treatment plan can reduce the probability of a lapse, or slip, progressing to full-blown relapse. Tobacco dependence, like any other chronic medical condition, requires periodic treatment-plan adjustments, such as a change of medication, dosage, or attention to behavioral factors that are also a part of any chronic medical disease.
Lapse vs. Relapse
“Relapse” denotes a return to full, baseline smoking rate, while “lapse” means smoking only 1, or a few cigarettes over 7 days, or less. Smoking a single cigarette, or even a few, does not define the patient as a smoker again. Try to determine the trigger (e.g., presence of unbearable nicotine withdrawal symptoms, sudden stress, alcohol consumption, presence of other smokers) and help the patient identify ways to treat, avoid, or effectively manage those trigger settings in the future. Make certain that nicotine withdrawal symptoms have been nearly or completely suppressed-90% suppression or better is your goal. Revise the patient’s treatment plan, if necessary, so that nicotine withdrawal symptoms are better controlled. Ask your patient what strategies have worked well in the past with that particular trigger. Reinforce those approaches. Offer your support and provide follow up. Encourage and be positive. Do not focus on the lapse, per se, but learn what caused it, how to more effectively treat that cause or prevent it in the future, and focus on the successes.
Approximate 1-3 months after the patient has stopped smoking, the treating physician, or another trained healthcare professional in that medical office, should have a straightforward discussion with the patient to let the patient know the highest risk settings for relapse, based on well-designed scientific studies. That way, your patient can plan ahead and have a relapse-prevention plan in place. When you begin the discussion of relapse-prevention strategies, your patient should not have smoked anything for at least 4-6 weeks and should not have been bothered by any nicotine withdrawal symptoms for at least 4-6 weeks.
Relapse in this setting is most likely to occur when your patient experiences:
- Stress (or other negative mood states)117-122
- Particularly when that stress occurs in the presence of another smoker
- And especially if these 2 conditions occur in the presence of mild alcohol consumption
2. Sudden or unexpected re-appearance of nicotine withdrawal symptoms
Relapse also commonly occurs when your patient is:
3. Celebrating or at a party
- Particularly when consuming modest amounts of alcohol
The patient can blunt the risk of relapse by engaging in proactive behavior:120-123
- Think something different
- Do something different
- Use nicotine Rescue Medication, e.g., nicotine nasal spray112
To facilitate relapse prevention, physicians should ask their patient open-ended questions and actively engage the patient in dialogue on:
- accrued benefits of stopping smoking,
- patient investment in and length of time the patient has been tobacco-free,
- possible resurgence of nicotine withdrawal symptoms and methods for managing them,
- problems encountered to date or anticipated threats to maintaining nonsmoking.
Relapse is most likely when patients experience internal or external conditions that make them vulnerable. The chief internal cause of relapse is persistence or re-appearance of uncontrolled and intolerable nicotine withdrawal symptoms, including craving.104-106 The most common external causes of relapse are being in a high-stress situation or while drinking alcohol or both.117, 124Additionally, lines of evidence indicate that relapse is more likely to occur when the patient encounters lack of support from health-care professionals, family, or friends, experiences weight gain, feels deprived, or becomes depressed or dysphoric. If the patient identifies lack of support as a threat, practitioners should consider how that can be addressed or remedied. For example, make sure all office staff from front-office staff, to you, to back-office staff are fully supportive. If some on your staff are not supportive and think cigarette smoking is merely a character flaw and that the tobacco-dependent patient is just bringing this all on himself or herself and this kind of patient is just wasting everybody’s time and wasting medical resources, this should be correctable by appropriate in-service education. If the staff member refuses to read or learn from relevant scientific material or attend and learn from internal or external educational opportunities, such as the Annual CHEST International Scientific Assembly or that of the Society for Research on Nicotine and Tobacco, then that staff member should be transferred to a position that involves no patient contact or should be terminated. You would not tolerate a similar negative attitude that was impairing your office’s care of an asthmatic or diabetic. You should not tolerate it in situations involving a tobacco-dependent patient under your care.
If you learn that the patient’s family or friends are not supportive or are belittling the patient, work with your patient to develop ways to help those close to the patient to be helpful and supportive.
You may also consider referring the patient to appropriate treatment counseling or support groups in their area (see General and Referral Resources). However, before making such a referral, make certain that such a referral will, in fact, be helpful and not undermine the patient’s efforts. For example, some widely available, national groups clearly state that use of any medication, particularly nicotine medications, to improve stopping smoking is a sign of weakness and a character flaw on the patient’s part and that such medications should not be used. You or one of your staff should be able to determine the philosophy and practical aspects of such a referral by talking with someone at such a referral source that would be involved with your patient or by checking that referral source’s Web site.
You should, of course, schedule follow-up visits or telephone calls from you or one of your office nurses to provide additional support, to make certain that nicotine withdrawal symptoms continue to be completely suppressed, and to make certain that your patient is not prematurely tapering or stopping tobacco-dependence medications.
If you uncover an underlying depression or other psychiatric states or find such a state emerging after you have commenced an adequate tobacco-dependence treatment plan, you should increase pharmacotherapy and refer your patient to a psychiatrist knowledgeable in treating psychiatric illness in the context of discontinuing tobacco use.
In all cases where your patient has lapsed or relapsed, DO NOT stop use of tobacco-dependence medications, such as nicotine patch. If your patient has lapsed or relapsed, this is prima facie evidence of an inadequate and insufficient treatment plan that you and your patient must revise, precisely as you would do if an asthmatic patient under your care had a breakthrough asthma attack. Also, use this opportunity to provide encouragement for any positive movement toward complete elimination of tobacco use.
Although nicotine withdrawal symptoms are at their peak 24-72 hours after stopping smoking, gradually decreasing over the next 4 weeks, they can last many months, remaining strong 6 or more months after stopping smoking.84 In some patients, one or more nicotine withdrawal symptoms can remain strong and disabling for years to life. The time for withdrawal symptoms to resolve is variable from one patient to another, and not predictable a priori, even for a given patient. Time until symptom resolution can only be determined as tobacco-dependence treatment progresses. Moreover, not all tobacco-dependent patients experience the same withdrawal symptoms.
Your patients need to know that using pharmacotherapy to maintain continued suppression of nicotine withdrawal symptoms is crucial for tobacco-dependence treatment to be effective and enables them to stop smoking without the pain and discomfort that inadequately treated nicotine withdrawal symptoms cause. The patient education guide You Deserve to Stop Smoking Comfortably contains further helpful information.
The Pharmacologic Treatment section of this Tool Kit provides you with information you should share with your patients before they begin to use of any tobacco-dependence medications. You can provide necessary behavioral management using the principles provided in the Communication and Patient Education Tools section. Other potentially valuable resources you should consider include your state’s Quit Line and well-run group-counseling or support programs, such as those provided by the American Lung Association’s Freedom From Smoking Clinics Program, the Hawai’i Tobacco Education & Assistance Program, or the UCSF (University of California, San Francisco) Tobacco Education Center. Similarly, determine if there are specific local resources or a clinical psychologist in your area who could amplify your care of the tobacco-dependent patient. Some pulmonary specialists and members of your College have recruited a clinical psychologist, trained in tobacco-dependence behavioral management, specifically to provide the necessary behavioral management and support. You can also provide your patients with the General and Referral Resources for local, state, and national contacts. Before any referral, though, you or one of your office professionals should thoroughly evaluate the program(s) you are considering using as referral options for your patients, to make certain your patients will not receive messages that conflict with the behavioral and pharmacological management principles in this Tool Kit.
A basic understanding of the science of nicotine addiction and tobacco dependence provides the foundation for a rational pharmacotherapeutic approach to treating tobacco dependence. Because numerous pharmacotherapies exist and have been shown to be effective, physicians should prescribe these to their tobacco-dependent patients, except in the presence of contraindications, which are very rare. Six (6) first-line pharmacotherapies have been proven to reliably increase long-term non-smoking. Two (2) second-line pharmacotherapies can be effective options in the unlikely event that the first-line medications are not effective or cause intolerable side effects. Refer to the sections labeled Quick Reference Guide to Pharmacotherapy and Stepwise Tobacco-Dependence Treatment Guide for more detailed information on formulating your own pharmacotherapy approach.
The Necessity of Using the Fagerström Test for Nicotine Dependence (FTND), Assessing Nicotine Withdrawal Symptoms (NWS) Regularly, and Assessing for Previous and Treatment-Emergent Depression
You cannot plan your pharmacotherapy plan for your patient without measuring nicotine dependence (see Fagerström Test for Nicotine Dependence (FTND)). You cannot determine your treatment plan’s effectiveness for your patient, including the pharmacotherapy component, without measuring nicotine withdrawal state (see Nicotine Withdrawal Symptom (NWS) Scale). It is axiomatic in medical practice that you have to measure the right variable-FEV1 to diagnose the severity of COPD, for example, or blood pressure, if you are diagnosing and treating hypertension. If you don’t measure blood pressure initially, you have absolutely no way of even determining whether or not your patient is hypertensive, and if hypertensive, how severely. Initial disease severity determines your initial treatment plan and what, if any, further diagnostic tests are needed
The same is true in tobacco dependence diagnosis and treatment. The Fagerström Test for Nicotine Dependence (FTND) is analogous to measuring the FEV1 the first time you see a COPD patient. In fact, the FTND is the single most important diagnostic test in diagnosing severity of tobacco dependence. All else comes after that. You need to make an initial measurement of FTND on each tobacco-dependent patient. Recent data show that the FTND for nearly three quarters of your tobacco-dependent patients will be high enough to place them at Step 3 (Severe) or Step 4 (Very Severe) disease severity.125 (See Stepwise Tobacco-Dependence Treatment Guide, Table #1 & Table #2 and Pharmacologic Treatment, Medication Prescribing Examples #1, 2, and 4). That means, just based on the FTND, 75% of your patients are going to need pharmacotherapy appropriate for tobacco-dependence severity of Step 3 or 4 (see Stepwise Tobacco-Dependence Treatment Guide, Table #2). That means they will need to be prescribed multiple concomitant medications, both controller and reliever medications. This can only be done by you, the chest physician.
The number of cigarettes smoked per day is not a suitable proxy for the FTND. Its coefficient of variation is too high. Moreover, as the price of cigarettes has been increasing, patients have become much more efficient at extracting more nicotine from each puff and from each cigarette. Thus, in 2009 it is common to see patients who smoke 15-18 cigarettes per day, but have a high serum cotinine (> 300 ng/mL) and a high FTND (> 5/10 points). Ideally, you should obtain baseline measurement of both serum cotinine and the FTND while your patient is still smoking. While serum cotinine is the only accurate biomarker of 24-hour nicotine intake,126 the FTND is a good proxy for measuring serum cotinine. Think of the FTND as the poor man’s biomarker of nicotine intake. The FTND is the only physiologically validated question-based measurement of nicotine dependence.
However, you cannot use the FTND to determine how effective your treatment plan is, as you can by repeated measurement of blood pressure after initiating hypertension treatment. A quick look at the FTND tells you why: All 6 questions assume the individual is smoking.The questions in the instrument have no meaning at all after the patient has stopped smoking.
The FTND Scoring Instructions provides you the information you need to have to score and interpret the FTND. The FTND is a physiologically validated, linear scale producing a score from 0 to 10 points.127, 128 A score of 0 out of 10 points means your patient has no physiological dependence on nicotine, while 10/10 points means your patient suffers from the severest degree of nicotine dependence. Less than 1% of your patients will have an FTND score of 0 points, while 5%-7% will have a score of 10 points. Over the last 15 years, the FTND has shown a shift toward more severe nicotine dependence. Whereas 15 years ago 50% of patients were highly nicotine dependent and 50% low, more than 75% are high-nicotine dependent now.113, 125 The linearity of the FTND means that if your patient has an FTND score of 10 out of 10 points, that patient is 10% more physically dependent on nicotine than your patient with an FTND score of 9/10 points. Your patient with an FTND score of 9/10 points is 10% more physically addicted to nicotine than your patient with an FTND score of 8/10 points, and so on.
Knowing the severity of your patient’s tobacco dependence enables you to plan a rational, appropriate treatment plan, just as you would with hypertension. For example, if you had a new hypertensive patient in your office and you knew from the data your nurse or medical assistant entered in the chart for that visit that the patient’s blood pressure was 180/110, you would think in a very different direction regarding diagnostic work-up and initial treatment plan than if the blood pressure were 125/85. You would treat both. But the treatment intensity would be greater and the initial duration of intense treatment longer in the first case than the second. Likewise, you need to plan a more intensive and longer-duration initial treatment plan for tobacco dependence in a patient with a high FTND score, say 8, 9, or 10 points, compared to a patient with a score of only 2 or 3 points out of 10. Knowing the FTND score enables you to adequately conceptualize and frame your patient’s treatment plan. The USPHS Clinical Practice Guidelines Update 2008 recommends that physicians prescribe at least one, and preferably more than one, of the first-line treatments listed in the Quick Reference Guide to Pharmacotherapy section to all patients who smoke.
The 2008 USPHS Guidelines recommends prescribing more than one first-line tobacco-dependence medication because the evidence shows that this generally produces better treatment outcome. Those with an FTND score of 5-6 points or higher will likely need two first-line medications and for a longer duration of time-6 to 12 months-or even longer. Patients who score below 6 points may only need one first-line medication and may only need it for 3-6 months to achieve permanent cure. Pay particular attention to those with a lower FTND score but whose prior tobacco-dependence treatment was not effective; whatever elements their treatment plan contained before, strengthen them this time around. Remember, they have relapsed-that is why they are smoking now. Therefore, their previous tobacco-dependence treatment plan was inadequate. Also, review the Factors that May Affect Treatment Choices (below) for other diagnostic criteria that would point to the need for treating a patient more intensively.
The Quantitative Nicotine Withdrawal Symptom (NWS) Scale
While you cannot assess your treatment plan’s effectiveness by re-measuring the FTND, you can monitor how effective your treatment plan is for your patient by measuring the suppression of nicotine withdrawal symptoms. And that you can do by using the Nicotine Withdrawal Symptom (NWS) Scale to quantitatively measure nicotine withdrawal symptom severity at baseline, while your patient is still smoking, and then at each visit thereafter. Nicotine Withdrawal Symptom (NWS) Scale Instructions, Scoring, and Use provides you the information you need to use, score, and interpret your patient’s changes in nicotine withdrawal symptoms. Fundamentally, your treatment plan, and particularly its pharmacotherapy component, needs to suppress all nicotine withdrawal symptoms and keep them suppressed. If your patient’s nicotine withdrawal symptoms are not close to fully suppressed at any time after stopping smoking, your patient will need treatment-plan change, more aggressive treatment, including increasing the dose(s) and/or combination(s) of medications, and closer follow-up, until NWS are well-suppressed. Nicotine withdrawal symptoms can cause relapse to smoking.
Those who smoke cigarettes have a greater risk of depression and the more they smoke, the greater the depression risk. The same is true of suicide. Thus, as part of the basic medical history and physical exam for any new tobacco-dependent patient, the treating physician must also obtain an adequate history of depression, suicidal behavior, panic attacks, anxiety, and post-traumatic stress disorder (PTSD). Depression, in particular, also needs to be regularly assessed throughout treatment for tobacco dependence and especially after treatment has ended. The easiest and simplest way of doing so is to administer a simple, standard screening tool while the patient is in the waiting room. The tool most psychiatrists recommend for use in a medical office is the Beck Depression Inventory®-II, or BDI®-II. This validated test takes only a few minutes for the patient to complete, readily identifies suicidality, and takes only about 10 seconds for the physician or staff to score. It is sensitive to detecting changes in depression or suicidality, so it is ideal to use in the medical context of treating tobacco dependence, where 5-10% of patients will demonstrate treatment-emergent depression or suicidality, if their pharmacotherapy for tobacco dependence is not adequate.
Although never studied systematically, the clinical experience of the CHEST Tool Kit Committee Members indicates that once a patient’s tobacco dependence has stabilized, the patient has been 100% tobacco free for at least 3-6 months, and the patient is not suffering from any nicotine withdrawal symptoms, then medication dose should be tapered, one medication at a time, to determine the lowest dose and the fewest number of medications necessary to continue tobacco-dependence control. The ultimate goal is to determine whether or not the patient can taper off all medications, with tobacco dependence remaining fully controlled. This approach, also developed applying principles we use in treating asthma, is described more fully in Pharmacologic Treatment.
Behavioral Management Principles
Providing appropriate behavioral management for your patients increases the likelihood of successfully terminating tobacco use. The more intense the behavioral treatment, the greater its effectiveness. Person-to-person treatment is more effective than group therapy, and the longer the duration, the better the results. Key behavioral management principles are straightforward and simple. As presented in the Patient Management Tools, they involve: (1) having the patient identify triggers to smoke; (2) developing action plans for each trigger (e.g., how to handle stress-a dysphoric mood-without a cigarette, how to deal with wanting a cigarette after a meal-a conditioned-response situation, or how to turn down a proffered cigarette from a friend-skills training); and (3) anticipating relapse and how to manage that.
Another important part of the treatment plan is encouraging your patient to discuss the tobacco-dependence treatment plan with immediate family and close friends and obtain their support-social support. Finally, depending on the extent of behavioral management you and your professional staff provide your patients, you may want to recommend that your patients use the phone number for a well-run telephone quit line-available in most states-and other types of support outside of your office, such as tobacco-dependence treatment counselors or support groups (refer to the General and Referral Resources section). However, the treating physician should personally, or have one of the practice’s nurses, carefully evaluate specifically what counseling and education will be provided from these referral services and resources to make certain the patient will not hear conflicting or contradictory messages from a telephone quit line, treatment counselor, or support group. Because content in these external programs differs from state to state and because they can change rapidly, content review by CHEST is unfortunately not possible, which is why the physician (or staff) at the local level must do this. For example, many, if not nearly all, Nicotine Anonymous programs tend to regard all nicotine, whether from cigarettes or in a medication to help treat tobacco dependence, as “bad” and something to be overcome.129, 130 This is a value system that is not compatible with the extensive data supporting rational pharmacotherapeutics and effective medical management of tobacco-dependence. Tobacco smoke kills, nicotine medications do not.
Programs that many patients find helpful and are generally readily available include those offered by the American Lung Association, local health departments, hospitals, and other voluntary health agencies; individual counseling from a medical provider or tobacco-treatment specialist; media resources (e.g., books, manuals, audiotapes and videotapes, and internet resources); and telephone counseling or hotlines. Some patients may also be able to benefit from workplace tobacco-dependence treatment programs. The treating physician or a trusted, knowledgeable staff member should evaluate the content and approach of all such potential referral resources, for the reasons already discussed, before having the patient consider the value of these methods of social and behavioral support.
Lung Age-Its Value In Diagnosis and Treatment of Tobacco Dependence
A particularly valuable part of both medical management and improving motivation regarding stopping smoking is telling your tobacco-dependent patients their lung age, as determined from their FEV1.131 Multiple studies have shown that this simple maneuver, by itself, significantly improves tobacco-dependence treatment outcome.132, 133 Once a patient has stopped smoking, then the patient is going to want to know whether lung function and lung age have improved. The studies cited above show that your patient’s knowledge of this information, independent of any other treatment component, including pharmacotherapy, improves stop smoking rates. Based on the rate of change in lung physiology and function, as reported in the Lung Health Study,134-136 the CHEST Tool Kit Committee recommends obtaining spirometry on an annual basis as part of tobacco-dependence treatment.
The CHEST Tool Kit Committee recommends routinely measuring the patient’s Lung Age in diagnosing and treating tobacco-dependent patients and discussing this information with the tobacco-dependent patient.
The Multimodality Approach
An estimated 70% of users want to quit, but only 3% per year succeed in quitting permanently using the cold-turkey approach.49 Providing the patient with the pharmacologic treatment and the behavioral management principles (see above), in addition to standard physician advice, improves the treatment plan and increases treatment effectiveness. Those who are dependent on nicotine but wish to quit can increase their chances of success by 2- to 3-fold, if not more, by combining behavioral and pharmacologic therapy. Randomized clinical trials show that pharmacologic treatment of tobacco dependence with monotherapy, combined with standard, office-based behavioral support, will enable 50% of patients to remain nonsmokers at the end of a short, 6- to 12-week treatment course. Use of varenicline plus basic office-based behavioral management can boost 3-month, end-of-treatment non-smoking rates to as high as 65%,73 while more individualized pharmacotherapy can boost 3-month, end-of-treatment non-smoking rates to as high as 80%.58 Longer-duration treatment of 6 to 12 months from Target Stop Date (TSD) generally produces substantially and significantly better and long-term (6-month to 1-year), post-treatment, non-smoking rates.69, 73, 137-139 Individualized, combination pharmacotherapy, including higher-than-standard nicotine medication doses, can boost 9-month, post-treatment non-smoking rates overall107, 108, 139 and, in patients smoking > 40 cigarettes/day, to as high as 45%.107 Longer-duration pharmacotherapy treatment produces better results than shorter treatment. Some patients will need treatment indefinitely to prevent resumption of tobacco use.2, 112, 113, 139
Most clinical trials to date, unfortunately, were designed from the scientifically inaccurate premise that tobacco dependence was merely a “bad habit” only requiring a relatively short treatment. As a profession, we have never designed asthma or COPD treatment trials measuring the major dependent outcome variable, for example FEV1, 9 months or 1 year after bronchodilator treatment ends. Similarly, no sound scientific basis exists for measuring the primary outcome variable in tobacco-dependence treatment trials-stopping cigarette use-after treatment has ended; relapse is the norm.
Effective treatment can be considerably higher when tobacco dependence is addressed in a manner similar to a chronic disease such as asthma. In asthma management, we think of medications as being “Controllers”, i.e., controlling airway pathology, or “Relievers”, i.e., relieving acute breakthrough asthma symptoms, such as cough, wheezing, chest tightness, or shortness of breath. Controller Medications also have a longer time to effect, while Relievers, or Rescue Medications, have a relatively fast onset of action. Similarly, tobacco-dependence medications can be thought of as being Controllers, controlling underlying CNS neuropathology, or short-acting Relievers, relieving acute, breakthrough, nicotine withdrawal symptoms, such as craving for a cigarette. Bupropion, nicotine patch, and varenicline are Controller-type medications; whereas the nicotine inhaler, lozenges, nasal spray, and gum are Reliever agents for immediate relief of breakthrough withdrawal symptoms. Bars, et al. reported a series of patients treated for only 3 months but with 1-year follow-up quit rates of 39% among those treated with combination nicotine medications,107 and, remarkably, as high as 43% for those who had smoked >40 cigarettes/day, pre-treatment.107 The use of bupropion seemed to increase compliance with the nicotine medications. In a review of five published studies, Sweeney, et al. examined the effectiveness of the nicotine combination therapy (nicotine patches used in conjunction with other nicotine delivery modes) compared to nicotine monotherapy.140 This strategy also appears more effective than use of a single nicotine medication, and predictably doubles the treatment success rates compared to placebo. Several other recent clinical trials have confirmed significantly higher cessation rates with aggressive combination strategies.69, 141, 142
There are a number of alternative-medicine methods advocated by some for assisting the tobacco user to stop. These include hypnosis; acupuncture; laser treatment, which is merely a high-tech version of acupuncture; homeopathic medication; and herbal medication, amongst others. Published reports of a large series of consecutive patients treated with hypnosis would suggest it might be effective, but hypnosis has yet to be studied in a randomized, controlled fashion.1More evaluation research is needed before hypnosis can be recommended.1
Except for acupuncture, none of the other alternative-medicine approaches have ever been adequately tested scientifically.1 In contrast, acupuncture has been tested in multiple, randomized, sham-acupuncture controlled trials, but has not been shown to be effective.1 So-called laser treatment merely uses laser stimulation, instead of acupuncture needles, at acupuncture sites. Laser treatment has never been scientifically tested in any way. Because published scientific studies have not found acupuncture to be effective, there is no reason to think that laser treatment would be any more effective. No scientific studies support the use of homeopathic medications, herbal medication, or other alternative approaches.
A “Reduction Toward Cessation” Approach
Complete cessation is the ultimate therapeutic goal. However, tobacco-dependent patients who are not quite ready to stop may benefit from pre-cessation treatment with nicotine patch in order to move toward eventual nonsmoking. Rose et al. demonstrated that a two-week “head start” treatment with nicotine patch prior to the target stop date more than doubles the chances of stopping smoking completely.143
Even if a patient is unable to quit entirely, reducing tobacco use, while using any of the first-line tobacco-dependence medications (see Quick Reference Guide to Pharmacotherapy and Stepwise Tobacco-Dependence Treatment Guide), demonstrably reduces the risks and provides real medical benefits.144 Although restriction in the number of cigarettes smoked has been hypothesized to lead to compensatory smoking (i.e., more intensive smoking in an effort to obtain the same level of nicotine intake), decrease in tobacco use has been associated with a reduction in mortality risk even when controlling for age and smoking rate.145 The dose-response relationship between smoking and disease was examined in a Swedish study of cardiovascular risk.146This reduction in use was shown to result in improvements in levels of CO, hemoglobin, fibrinogen, and red and white blood cells. However, the Committee to Assess the Science Base for Tobacco Harm Reduction is more cautious. Although concluding that reducing exposure to many tobacco toxicants is feasible and can result in decreased disease incidence, the greatest benefit is associated with completely stopping smoking. This conclusion is based on the assumption (yet to be proven) that reduction in the number of cigarettes consumed does not lead to compensatory increase in exposure resulting from the method of use (e.g., long, deep drags to increase nicotine levels and possibly inflated exposures to other toxicants). Tobacco reduction is advised for those who absolutely cannot or will not stop smoking completely.147 Reduction could be achieved by reducing the number of cigarettes smoked per day or the amount of each cigarette smoked.
Factors that may affect treatment choices.
If smoking is the behavioral manifestation of complex disturbances in the biology of mood and motivation, it stands to reason that clinicians should expect to experience significant variability in treatment requirements and outcome among their patients. The treating physician can easily screen for several important indicators, alerting the physician that a particular patient may require more intense therapy. Though few specific treatment predictions can be made in response to these indicators, as a general rule, the presence of one or more of the following conditions should prompt a considered, individualized, and more intensive approach to pharmacotherapy, including treatment for longer than 3 or 6 months and use of combination pharmacotherqpy.
- High FTND Score-FTND scores of 6 or greater148or Fagerström Tolerance Questionnaire (FTQ) scores of 7 or greater149, 150 have inferior treatment results during treatment, when treated with merely standard-dose pharmacotherapy and also have greater risk of relapse 6 to 9 months after treatment end. (The FTQ is the predecessor version of the FTND.) Patients with the most severe nicotine dependence generally benefit from more aggressive nicotine withdrawal symptom control, including higher doses of nicotine replacement, combination pharmacotherapy, or aggressive use of nicotine Rescue Medications in response to acute situational, or cue-induced, craving for cigarettes.107
- High Daily Cigarette Consumption-In addition to affecting the FTND score, the absolute number of cigarettes smoked daily independently and proportionately increases the risk of relapse. However, it is far less accurate than the FTND, in its totality. In addition, though not readily available in the office, smoking topography (i.e., the intensity of smoking, including number of puffs per cigarette, the volume of the puff, the duration of the puff, and the inter-puff interval) proportionately affects outcomes, especially in the young smoker.151
- High Serum (or Salivary) Cotinine Level–Cotinine has a 20-hour half-life.126 Serum cotinine is the only biomarker of 24-hour nicotine intake and, fortunately, is a highly accurate measurement (r=0.82; P<0.001).126 Therefore, it is the “gold-standard” for quantifying nicotine dependence. Several lines of published evidence from randomized, double-blind, placebo-controlled, clinical trials show that it is an inversely proportional and independent predictor of tobacco-dependence treatment effectiveness.58, 152, 153The higher the serum cotinine level while smoking, the less effective tobacco-dependence outcome, unless the patient is provided with higher medication dose.57, 58, 150, 152-154Also, data available tend to consistently show that standard or fixed-dose medication treatment plans produce poorer treatment outcomes the higher the measured cotinine level and can be substantially and significantly improved by increasing nicotine medication dose to attain a greater percent of cotinine replacement from treatment relative to smoking,57, 58, 154 or simply by a higher medication dose in highly nicotine-dependent cigarette users, defined as having a high (or higher) serum cotinine level.57, 58, 150, 154, 155 Serum cotinine is a potentially valuable predictor of the need for more intensive or longer-duration medical management but is underutilized in clinical tobacco-dependence treatment. Some, but not all, members of the Tool Kit Committee recommend routine, quantitative measurement of baseline serum (or saliva) cotinine levels to biologically determine nicotine dependence and, when using nicotine medications, measuring serum cotinine level at least one more time after the patient is on stable nicotine medication dose(s), to improve treatment effectiveness by attaining a percent cotinine replacement of ≥ 100% from medication treatment compared to cigarette smoking.58, 153
- Psychiatric Co-Morbidity–More than 50% of patients with underlying, previously diagnosed Major Depressive Disorder are regular cigarette users. Patients with depressive or anxiety symptoms smoke more than the population at large, and find it more difficult to stop tobacco use without medical intervention. Unfortunately, while they are not smoking, they are also more likely to suffer an exacerbation of their psychiatric symptoms.156 Clinicians should consider using bupropion to treat tobacco dependence in these patients, including those on preexisting selective serotonin reuptake inhibitors.157
- Separately from the above, feelings of deprivation and loss of motivation are common following stopping smoking. The physician should probe to ensure that the patient is not using tobacco periodically to self-treat this problem, and emphasize that even a single puff will increase the urge to smoke and make stopping more difficult. Patients should be encouraged to reward themselves for incremental successes. Patients who are depressed or have negative affect state should be evaluated for severity and, if significant, provided with counseling, prescribed appropriate medications, or referred to a psychiatric or psychological specialist.
- Also, other recent studies clearly show that depressive risk and risk of successfully committing suicide, in those not even trying to stop smoking, is significantly and linearly proportional to the number of cigarettes smoked per day.158-160 In other words, separate from other factors, the 2 pack-per-day cigarette smoker is significantly more likely to commit suicide than the 1 pack-per-day smoker. While it is not clear whether or not this is merely an association or a causal relationship, that is not really relevant to those of ua who have cigarette smokers in our practice. We need to know that our patients who smoke more are more likely to commit suicide.
- Concurrent Substance Abuse–Contrary to widely held beliefs, substance abusers are in fact interested in stopping smoking, motivated to do so, and willing to accept treatment.161 In fact, substance abuse treatment outcomes seem to be improved with concurrently stopping tobacco use.162 In the typical clinical setting, it is important not to underestimate the likelihood that a substance-abusing patient will make a stop attempt with physician guidance. When they do however, they may well require additional support to maximize their likelihood of stopping tobacco use. With cocaine dependence in particular, treatment outcomes appear to be interdependent, with stopping smoking improving the likelihood of stopping cocaine use, and vice-versa.163-165
- Female Gender–While research results are mixed regarding the influence of gender on tobacco-dependence treatment outcomes, many studies show that women do less well than men with a standardized, fixed treatment regimen,150, 166-169 and, as a consequence, may well benefit from more individualized and/or longer-duration medical management. While data are inadequate to draw firm conclusions, it appears that women may experience a smaller treatment effect in response to nicotine patch than do their male counterparts. However, it is important to note that this effect-difference may not hold true for other nicotine medication types167and some non-nicotine medications, e.g., varenicline,170 but does hold true for bupropion.150 In addition, women frequently cite concern over weight gain as a powerful disincentive to quitting. In fact, women who stop smoking are at higher risk for major weight gain (> 13kg) as a result: 13.4% for women compared to 9.8% for men.171Therefore, clinicians should consider treatment with bupropion, given its effectiveness in women at risk for relapse and in minimizing weight gain.62, 172
- Risk For Weight Gain–Weight gain is not necessarily an inevitable consequence of stopping smoking. In fact, one third of smokers who stop experience some degree of weight loss. Instead, clinicians should view weight gain (>5% of baseline) as a sign of poor control over the compulsion to smoke, prompting a reassessment of the pharmacologic and behavioral support methods being employed. A considerable amount of work is currently underway investigating novel pharmacologic approaches to preventing weight gain, including central nicotine antagonists and cannabinoid antagonists. Until these become available, however, physicians should respond to weight gain by evaluating whether higher doses or combinations of pharmacotherapeutics are warranted or also whether changes in behavioral management, such as increasing exercise or reducing calorie intake, should be discussed with the patient. Nicotine medications combined with bupropion SR resulted in less weight gain than placebo or either treatment alone (1.1kg vs. 2.1kg vs. 1.7kg respectively).62, 122
- Care should be taken when suggesting that patients should focus on quitting now and tackling weight gain later; while some may like this approach, others may perceive a tacit resignation to substantial weight gain. Young women may be especially reluctant to then even attempt stopping smoking because of weight-gain concerns, making it especially important for the physician to express support and an intent to manage this complication.
Motivating the Resistant Patient To Stop Smoking
The physician should motivate patients who are resistant to stopping smoking by:
- Explaining the personal relevance to that patient;
- Advising them of the risks to self and family members (acute, long-term, and environmental);
- Explaining the rewards (improved health, improved senses of taste and smell, money saved, improved self-esteem, improved social acceptance, better-smelling environment, and setting a good example, particularly for children);
- Asking the patient to identify impediments to stopping smoking (withdrawal symptoms, fear of treatment failure, weight gain, lack of support, depression, etc.) and address each one;
- Reassuring the patient that with proper and effective use of medication(s), the patient can stop tobacco use, and avoid the pain and suffering brought about by nicotine withdrawal; and
- Repeating this discussion at each visit, as warranted.
Motivating Smoking Parents
Counsel parents that environmental tobacco smoke in the home has been shown to cause the following health problems in exposed children.
- Higher rates of sudden infant death syndrome (triple the normal risk);
- Other respiratory diseases;
- Middle ear infections;
- Multiple different types of cancer; and
The financial message can be motivating especially when the tobacco user is confronted by the total costs of their addiction.
Daily, Monthly, and Yearly Tobacco Expenditure Smoking Is Expensive
|Amount of Cigarettes Smoked per Day||Cost per Day||Cost per Month*||Cost per Year|
|1 Pack||$5.50 to $8.00||$165 to $240||$2,008 to $2,920|
|2 Packs||$11.00 to $16.00||$330 to $480||$4,015 to $5,840|
*Relate the amount in this column to the cost/month of tobacco-dependence medications. For example, 1-month’s supply of varenicline, 1 mg, q12h, costs $112.99, and may be partially covered by medical insurance.
Remember to be supportive, not judgmental. Tobacco dependence is a medical problem rather than a behavioral or psychological problem or a bad habit. The patient needs you to provide effective treatment and also be a supportive adviser, not be a disciplinarian.
If possible, encourage all family members who use tobacco to stop smoking at the same time. They can help support each other. Furthermore, exposure to tobacco smoke and the ready availability of cigarettes in the household decrease the likelihood of effective, successful tobacco-dependence treatment.
The benefits to society of stopping smoking are obvious. See Coding and Reimbursement. Tobacco-dependence treatment is one of the cheapest forms of medical management in our society.
However, physicians often think the cost to their practice is great, anticipating low reimbursements, extra time per patient and disrupted office flow. Although physicians and other providers want to help their patients stop using tobacco for the same reasons they want to treat other chronic medical conditions, there is a concern that treating tobacco dependence will not be cost-effective for their practices. For information on correct coding and information regarding reimbursement for tobacco-dependence treatment, go to Coding and Reimbursement.
Rationale for Implementation of Tobacco Cessation Strategies in Office Encounters
Meta-analysis of recent research studies has shown that brief physician advice significantly increases the chance of successful termination of tobacco use. As individual providers, physicians already feel the sense of responsibility to address this topic and know they can improve the care given to their own patients. A simple, very-low-intensity intervention (i.e. physician advice to quit) can produce stop-smoking rates two to three times greater than the spontaneous (“cold turkey”) rates. More intensive interventions (i.e., combining behavioral counseling with pharmacologic treatment) can produce stop smoking rates of 50%-65% at the end of 3 to 6 months’ treatment. Research shows that the combination of active engagement on the part of the clinical provider, along with a multimodality approach to treatment, as described above, will achieve the best treatment success rates.
Physicians need to consider assessment of tobacco use to be a mandatory part of every patient encounter.173 In fact, given the public expectation that physicians should provide the best treatments and prevent disease, whenever possible, they have a duty to provide information, counseling, and treatment for tobacco dependence.174 The counseling involved for tobacco dependence is no more difficult than the counseling used for patients with diabetes or hypertension or asthma.
Documentation at each visit should include whether the patient is a current or former tobacco user or has never used tobacco products. This creates a “teachable moment” to discuss reasons for stopping, attempts to motivate the patient to stop, and could lead to additional details on strategies. The physician is encouraged to take an empathic and nonjudgmental tone so as not to alienate the patient, who is already well aware of the need to stop. A non-offensive request to inquire about usage shows your respect for the patient’s autonomy while you are providing the care and concern that patients have come to expect.175 At a minimum, it will document current tobacco use and serve as a marker for increased health risks. Inquiries about tobacco use should become the fifth vital sign-a routine component of every patient encounter.