Changing smoking habit patterns and the use of smoking cessation pharmacological agents are effective strategies in helping patients kick the nicotine habit.

Smoke Art.jpg (17138 bytes)Because of the compelling addiction to tobacco and the success of the tobacco industry in recruiting new smokers to the ranks of the habituated, approximately 47 million Americans continue to smoke. Women are rapidly catching up with men. Most adult smokers say that they would like to quit, but because of lack of knowledge, inertia, or perhaps inadequate involvement by health care professionals, they neither try nor succeed in quitting. The purpose of this article is to present a pragmatic approach to smoking cessation.

Smoking is a compelling addiction, as powerful as narcotic or alcohol abuse. Smoking also contains a major social component. Together, addiction as well as smoking with friends and in many social circumstances pose potent challenges for smoking cessation.

Most people quit on their own for socioeconomic or health reasons. The immediate social rewards are better odor of clothing and breath, and saving money. Avoiding premature wrinkles of the face is another payoff, which should be promoted in the young. Protecting the health of children, including aggravation of asthma, and childhood respiratory infections, is a motivating force for parents.

A physician or other health care worker’s advice to a patient to stop smoking, which requires only a few minutes, will often achieve a 3% to 5% quit rate. Patients must decide to completely quit and progress through the sequential stages of decision-making: precontemplation, contemplation, action, and maintenance. The precontemplation stage, of course, is not recognized by the individual. By the time patients plan to stop, they are in the contemplation stage, and can then be directly assisted by a health care professional. The choice of a quit date, along with changing the smoking/social habit pattern, is an important approach. Quitting “cold turkey” is the most successful way of stopping. Maintenance of a smoke-free state through relapse prevention needs to be taught and encouraged.

Preparing to Quit
Behavior modification needs to be offered to all patients whether or not pharmacological agents are prescribed as a part of the stop-smoking strategy. Behavioral modification deals with the changing of habit patterns that results in cues to start smoking. Often, these cues are not even recognized by the individual. These may be as simple as a telephone call, a coffee break, a pleasant meal, or following sexual activity. Sometimes boredom, delays in traffic, or other frustrations are signals to light up once again. The most addicted smokers light up immediately when waking up and find the first cigarette of the day the most necessary and pleasing. Smoking more than one pack a day also identifies the heavily addicted smoker.

The quit date should be coordinated with the use of smoking cessation pharmacological agents. The quit date may be some special occasion such as a holiday or anniversary. Stressful times, such as tax deadlines, just before final examinations, or a job interview, are not preferable. Pharmacological strategies differ and depend on the class of drug used to deal with the nicotine withdrawal symptoms. For example, if nicotine replacement is used, it should be started on the quit date. In contrast, if bupropion is prescribed, this drug should be started approximately 2 weeks before the quit date.

Nicotine withdrawal results in many unpleasant symptoms. These include a craving for tobacco, irritability, anxiety, poor concentration, restlessness, headache, drowsiness, and stomach upset.

Nicotine Replacement Therapies
A number of drugs are useful in nicotine withdrawal. Nicotine replacement products, an antidepressant, and anxiolytics offer different pharmacological strategies in the management and prevention of the symptoms of nicotine withdrawal. Nicotine gum is preferred by many and comes in two sizes (see Table 1). Thus, gum allows patients to titrate their own rate of nicotine absorption through the buccal mucosa by the route of chewing and the frequency of gum use. It is important for the mouth to have a neutral pH for absorption of nicotine. Thus, nicotine gum should not be used immediately after eating food, drinking soda, etc. On average, one piece of gum is chewed per hour while the patient is awake. Side effects include throat irritation, flatulence, and a sore jaw from excess mastication. The most addicted smokers should receive the 4-mg gum.

Method of Administering Unit Dose Dose Interval
A. Nicotine Products
Nicotine polarcrilex (oral) 2-4 mg     Every 1-2 hours
Transdermal nicotine patch, 3 types 21 mg, 14 mg, 7 mg Over 24 hours
15 mg, 10 mg, 5 mg Over 16 hours
22 mg, 11 mg Over 24 hours
Nasal nicotine spray 0.5 mg/inhalation/nostril 8-40 mg/day in hourly or PRN* dose
Nicotine inhaler  10 mg per inhaler 10 puffs over 10 minutes. Delivers approximately 1-mg nicotine
B. Other Agents  
Bupropion sustained- release tablets 150 mg 150 mg for 3 days, then 300 mg (2 tablets) each day
Buspirone tablets 15 mg, 10 mg, 5 mg 7.5-mg b.i.d., starting dose
60 mg/day, maximum dose
*PRN = as occasion requires.
TABLE 1. Pharmacological agents useful as adjuncts to smoking cessation.

The Patch
The transdermal patch is more convenient. Different patch dosage strategies are available. These are listed in Table 1. The patch is often used for 6 weeks. There have been no comparisons between the effectiveness of the various strengths of patches.

Nasal Spray
A new nasal spray is available by prescription. It can be used instead of gum or patch, or used in conjunction with other nicotine-containing products. A nicotine inhaler, which looks very much like a cigarette holder, has nicotine impregnated in menthol. It will give immediate relief from nicotine withdrawal symptoms in many patients.

Non-Nicotine Replacement
Non-nicotine replacement products include bupropion, which is a neurotransmitter modifier.1 Bupropion has dopaminergic features. It should not be used in patients with a seizure history or hypertension that is difficult to control with medications. Bupropion can also be used with nicotine replacement. Up to a 50% quit rate has been claimed when bupropion and nicotine replacement are used together.

Buspirone, a non-benzodiazepine tranquilizer, is also useful in dealing with nicotine withdrawal. In one controlled trial, its success was equal to nicotine-containing gum.2

Other Methods
Other methods of dealing with the most addicted smoker include acupuncture and hypnosis. These are successful in selected patients. Demonstrating the presence of exhaled carbon monoxide, which is available through many hospitals’ respiratory departments, may also convince smokers that poisonous levels of carbon monoxide are associated with daily smoking of tobacco.

Strategies in Smoking Cessation
The first step in smoking cessation is for the patient to decide to quit. Seeking advice from a health care practitioner can be very helpful. Using the comprehensive booklet, “You Can Quit Smoking,” produced for the Agency for Health Care Policy and Research, is an excellent educational aid. It is available by calling (800) 358-9295.

Many hospital libraries offer patient information services through their computer networks. Additionally, many homes now have personal computers and are able to search the Internet for clues in stopping smoking. Key words are “tobacco cessation,” “smoking cessation,” and “quitting smoking.”

Many addicted patients fail on the first or subsequent attempts to stop smoking. Failure should not be regarded as an indication of futility. In fact, the more often the patient tries to quit, the more the chances for success. On average, five to seven failures occur before the patient succeeds in stopping.

Concerns of smokers about stopping include the problems of weight gain and depression. Weight gain is a concern, particularly in women. Many women use nicotine as a weight control measure. Nicotine replacement helps mitigate weight gain, which, on average, is 10 pounds over the first 6 months. This weight gain can be controlled through exercise, however. Exercise itself may reduce the craving for tobacco.

Some women also use nicotine to combat depression. Thus, depressed patients who are candidates for smoking cessation must be closely counseled by their health care professionals. If the possibility of worsening depression is a realistic consideration, bupropion is also used as an antidepressant. This drug may be particularly useful in women who are on the verge of depression while stopping smoking.

The money saved over a lifetime by not purchasing tobacco products may be $15,000 to $20,000. Reducing the risk of heart attack, lung cancer, stroke, and chronic obstructive pulmonary disease (COPD) is also a major payoff.

Today, we need a grassroots effort in smoking cessation. Such an effort may be the result of the new National Lung Health Education Program, which aims to identify smokers at risk of developing symptomatic COPD and associated diseases of lung cancer, heart attack, and stroke. All of these disease states have a much greater prevalence when airflow obstruction is present than when it is normal. Thus, the spirometer becomes a tool in early identification of the four most common killers in the United States.3 Knowledge of spirometric abnormalities can also help encourage smoking cessation.

petty.jpg (11748 bytes)  Thomas L. Petty, MD, is chairman of the National Lung Health Education Program and professor of medicine, University of Colorado Health Sciences Center, Denver.

1. Hurt RD, Sachs DP, Glover ED, et al. A comparison of sustained-release bupropion and placebo for smoking cessation. N Engl J Med. 1997;337:195-202.
2. Hilleman DE, Mohiaddin SM, Delcore MG. Comparison of fixed-dose transdermal nicotine, tapered-dose transdermal nicotine, and buspirone in smoking cessation. J Clin Pharmacol. 1994;34:222-224.
3. Petty TL. Spirometry for all. RT Magazine. 1997;10(2):18, 20.