by Nervana Elkhadragy, PharmD, and Karen S. Hudmon, DrPH, MS, RPh, Professor of Public Health Pharmacy, Purdue University College of Pharmacy
With the 2016 Great American Smokeout just around the corner (November 17), there is no better time to start planning an attempt to quit smoking! The Smokeout challenges smokers to quit for a full 24 hours, with the hope that this day will be the first of many, many more without tobacco.
Individuals who are interested in quitting often ask, “What’s the best way to quit?” Fortunately, there are countless research studies that collectively inform our knowledge base and provide effective strategies for quitting. However, there is one big problem: Most individuals attempt to quit on their own…without help…and this is the LEAST effective approach to quitting.
Here we describe how to treat tobacco dependence as two parts – specifically, we discuss the importance of: (1) treating the nicotine dependence and (b) receiving professional counseling to address the behavior of smoking. We also suggest different resources for quitters as well as for health care professionals who want to help their patients.
PART 1: Nicotine Dependence
First a few words on nicotine, which is the addictive component in tobacco. Nicotine is not the harmful part of tobacco, but it’s the reason why quitters feel anxious and irritable when they’ve gone too long without a cigarette. Fortunately, there are seven different medications that can make individuals more comfortable by helping to alleviate withdrawal. Three of these are sold without a prescription (nicotine patch, gum, and lozenge), and four require a prescription (nicotine inhaler, nicotine nasal spray, bupropion SR, and varenicline). With so many options, which is best? It depends. All of these options are effective, and several can be used in combination. Below, we list some factors to be considered – with a key factor being the individual’s ability to adhere to the recommended dosing regimen. Cessation medications must be taken according to a fixed schedule to “prevent” withdrawal symptoms, rather than to “treat” them after they occur.
- Nicotine gum and lozenge: The nicotine gum and lozenges are available in 2 mg (if you smoke your first cigarette > 30 minutes after waking) and 4 mg (if you smoke < 30 minutes after waking). These products can serve as an oral substitute for tobacco, and they can be titrated to adjust for withdrawal symptoms throughout the day. The challenge, however, is that gum and the lozenge are short-acting formulations and must be dosed every 1-2 hours while awake, with a minimum of nine 9 doses a day initially for the first 4 to 6 weeks. If an individual is not able to adhere to this rigorous dosing schedule, then the gum and lozenge should be ruled out as an option (unless combined with the nicotine patch – more on this later). The gum is more viscous than normal chewing gum and therefore is not recommended for persons with significant dental work or with jaw disorders. Proper chewing technique, as described on the box, is necessary to ensure appropriate release of the nicotine from the gum.
- Nicotine transdermal patch: The nicotine patch is available in 7 mg, 14 mg, and 21 mg, and the initial strength is based on the number of cigarettes smoked per day. The most important benefit of the patch is its ease of use – it’s a long-acting formulation that is applied only once daily and therefore is ideal for individuals who are unable or unlikely to be able to take the minimum of 9 doses a day initially that is required for the short-acting NRT formulations. The patch can be combined with a short-acting NRT product, such as the gum, lozenge, inhaler, or nasal spray. The patch delivers consistent nicotine levels over 24 hours and the short-acting products are then used as a supplement for situational cravings. The patch is not recommended for persons with dermatologic conditions because nicotine and the patch adhesives can be irritating to the skin.
- Bupropion SR (Zyban) and Varenicline (Chantix): Bupropion SR and varenicline are both tablets that are taken by mouth twice a day (after an initial few days of titrating the dosage upward). Bupropion use requires a discussion with a healthcare provider about potential contraindications and warnings, and both medications require a discussion about monitoring for potential neuropsychiatric symptoms. Bupropion use can lead to increased seizure risk in certain individuals.
- Nicotine inhaler and nasal spray: The nicotine inhaler is designed to release nicotine as a vapor into the mouth (not the lungs) where it is absorbed across the buccal mucosa, and the nasal spray is absorbed across the lining of the nasal passages. These are both are effective when used as prescribed but are short-acting and therefore require frequent dosing throughout the day. Individuals with chronic nasal disorders should avoid use of the nasal spray, and individuals with any type of bronchospastic disease or airways disorder should consider other options.
Combination Therapy: There is abundant evidence to suggest that combination therapy (using two or more cessation medications) outperforms monotherapy (use of one medication alone), and it should be recommended with confidence for most patients who are quitting smoking. This approach, which is likely new to many tobacco users, typically involves the nicotine patch plus one of the short-acting NRT medications. Another option is to combine the nicotine patch with bupropion SR. Combination therapy should be a regimen of choice for anyone who: (a) has a high level of dependence, e.g., smoking a pack or more of cigarettes a day, or (b) has tried to quit before using one medication but suffered significant withdrawal symptoms (despite appropriate dosing of their medication) that led to relapse.
In general, all of these medications work well – when taken as directed – but the tips provided above will help patients decide which approach is best for them. Whether you are a patient talking with a healthcare professional, or a clinician trying to help a patient, be sure to discuss how many cigarettes are smoked daily, how soon after waking the first cigarette of the day is smoked, and whether it will be possible to stick to a frequent dosing schedule (e.g., 9 or more times a day).
PART 2: Changing Behavior
Equally important, if not more important than using cessation medication(s), is the need to focus on changing smoking-related behaviors. Several strategies have been shown to enhance the rate of quitting and prolong abstinence. A strategy that can help is to consider the “5 R’s”:
Relevance: Think about reasons why quitting is important for you or might be important for your family – it could be that you have children and do not want to expose them to second hand smoke, that you want to be a good role model, or that you want to live to see your grandchildren.
Risk: Identify the potential negative consequences of smoking on your health – these could include difficulty with breathing, increased risk of cancers, reduced ability to conceive, or reduced heart function.
Rewards: Identify the potential benefits of quitting – examples range from improved health, ability to exercise or be more active, or reduced skin wrinkles.
Roadblocks: Write down what’s keeping you from quitting and what coping strategies you can use to overcome those barriers. Be honest and explicit when thinking about those roadblocks, it could be fear of failure, or concern about weight gain.
Repetition: Continue to reassess and revisit your 5 R’s, determine new coping methods, and repeat interventions.
In addition to thinking about the 5 R’s, consider accessing one or more of the variety of available services, such as individualized tobacco cessation counseling sessions via the Tobacco Quitline (call 1-800-QUIT NOW), local group programs, or web-based programs such as www.quitnet.com. In general, the more help you get, the better the odds are of quitting for good. But that’s not enough – remember, when you sign up for those sessions, make sure you do the “homework” assigned to you during the program. Moreover, when enrolled in a program, be sure to learn effective coping strategies for withdrawal symptoms; those who have effective coping methods have better results.
Whether you have no previous experience with quitting tobacco, or you’ve had numerous quit attempts, having the right tools, knowledge, and support is important for long-term success! There has never been a time when resources that provide individualized support and reliable information was so widespread and accessible. Why not make the most of it?
And for the history buffs, a little background on the Great American Smokeout… it was started by Fred Mayer, a pharmacist in Marin County California, back in 1977.Fred is widely regarded as the “Father of Public Health Pharmacy,” not only for his initiation of the Great American Smokeout, but also for his work in promoting safety caps on prescription vials, working with the Drug Enforcement Agency for Medication Take Back Day programs, and reducing unplanned pregnancies and sexually transmitted diseases and infections by promoting condom awareness campaigns, advocating for sex education in schools, and working in tandem with Planned Parenthood and PTAs in school districts.
For healthcare providers:
- Clinical Practice Guideline for Treating Tobacco Use and Dependence, 2008
- Tobacco Cessation Continuing Education Programs
- Rx for Change: Clinician-Assisted Tobacco Cessation program (teaching materials for speakers and professors)
For individuals who want to quit:
- 1-800-QUIT NOW – tobacco cessation quitline for individualized counseling