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Last Updated: 9/26/2013  

Smoking Cessation

  • Routinely query all patients about their current smoking status.

  • Ask all smokers about their willingness to quit, as smoking cessation is associated with a reduction in all-cause mortality, atherosclerotic disease, obstructive lung disease, and some malignancies.

  • Encourage smoking cessation strongly in patients with coronary artery disease or obstructive lung disease; patients with established coronary artery disease who quit smoking have a large reduction in risk for death compared with patients who continue.

  • Provide all smokers with a brief counseling intervention to encourage smoking cessation.

  • Recognize that bupropion, nicotine replacement therapy, varenicline, and behavioral counseling all have been shown to be effective aids in smoking cessation and should be offered to all smokers who are interested in quitting.

  • Encourage smoking cessation before and during pregnancy because cessation reduces the incidence of both preterm labor and low-birth-weight infants.

  • Recognize that individuals with established obstructive lung disease who are counseled to quit smoking have a slower deterioration of lung function than patients who continue to smoke.

  • Focus smoking-cessation efforts on individuals with children because environmental tobacco smoke increases the development of respiratory disease in children.

Recognize that all persons who smoke are at increased risk for cardiovascular disease, chronic lung disease, certain cancers, and death, and encourage smoking cessation in all populations. 
Evidence
  • Strong evidence exists for a link between smoking and both illness and death. A cohort study of 34,439 British male physicians found after 40 years of follow-up that smokers had a mortality rate twice that of nonsmokers (40% vs. 20%). Current smokers had 13 times the risk for developing chronic obstructive lung disease, 15 times the risk for lung cancer, and 1.6 times the risk for ischemic heart disease compared with physicians who never smoked (1).

  • A similar cohort study of 6194 female physicians, with 22 years follow-up, found significant associations between cigarette smoking and lung cancer, ischemic heart disease, and obstructive lung disease (2).

  • In a cohort study of 7735 men, the RR for stroke in smokers was 3.7 and among ex-smokers was 1.7, both compared with men who never smoked (3).

  • In a cohort study of 7178 healthy elderly men and women age 65 or older, individuals who continued to smoke had higher rates of mortality as well as cardiovascular and neoplastic disease than former smokers or nonsmokers after 5 years of follow-up. The RR for death was 2.1 for men and 1.8 for women among current smokers vs. nonsmokers, while the RR for death was 1.5 for men and 1.1 for women among former smokers vs. nonsmokers (4).

Institute a routine formal screening system to identify smokers. 
Evidence
  • A meta-analysis of nine studies found that clinicians who had a formal screening system in place to assess smoking status were approximately three times more likely (OR, 3.1 [CI, 2.2 to 4.2]) to introduce a smoking-cessation intervention. A meta-analysis of three studies suggested a two-fold higher abstinence rate when smokers were seen by clinicians using a formal screening system (OR, 2.0 [CI, 0.8 to 4.8]) (5).

Comments
  • One proven system for routinely implementing assessment of tobacco-use status into clinical care is to incorporate smoking-status assessment into the vital signs (6). Chart stickers and computer prompts can also be used (5).

Screen pediatric patients and adolescent patients for tobacco use. 
Evidence
  • Two meta-analyses found promising behavioral interventions for adolescent smokers based on stages of change, social cognitive theory, or motivational interviewing. More studies are needed before recommendations can be made for specific approaches. Drug treatments have not been sufficiently tested in young smokers (5; 7).

Assess smoking status of all hospitalized patients. 
Evidence
  • A 2012 Cochrane review of smoking-cessation interventions for hospitalized patients included 50 randomized and quasi-randomized trials. Intensive counseling interventions with at least 1 month post-discharge follow-up increased post-discharge quit rates (RR, 1.37 [CI, 1.27 to 1.48]). Adding nicotine replacement or varenicline to intensive counseling increased quit rates but adding bupropion did not (8).

  • A 2008 systematic review found that smoking-cessation counseling beginning during hospitalization with ongoing counseling support for at least 1 month after discharge significantly increased the odds of long-term abstinence (OR, 1.65 [CI, 1.44 to 1.90]). Interventions of lower intensity were not beneficial (9).

Comments
  • Hospitalization can provide a unique opportunity to implement smoking-cessation interventions. Smoking-cessation rates are particularly high for smokers hospitalized for cardiovascular disease.

Determine smoking status of all pregnant women and women seeking to become pregnant. 
Evidence
  • Smoking has myriad adverse effects on pregnancy, including an increased risk for stillbirth, spontaneous abortion, premature birth, low birth weight, and placental abruption. Maternal smoking has also been linked to an increased risk for sudden infant death syndrome and cognitive, emotional, and behavioral disturbances in children (10; 11).

  • Effectiveness of smoking-cessation counseling may be particularly good in pregnant women (12; 13).

  • One randomized, controlled trial of a nurse-managed intervention with phone follow-up showed an absolute increase in cessation of 26% at 1 year (14).

  • A 2009 Cochrane review of 65 trials of smoking-cessation interventions implemented during pregnancy found a small but significant reduction in smoking rates in the intervention groups (RR, 0.94 [CI, 0.93 to 0.96]; ARR, 6%) (13).

Assess exposure to secondhand smoke for children and patients with cardiovascular disease. 
Evidence
  • A 1996 meta-analysis found that children exposed to environmental smoke had significantly increased rates of otitis media, tympanostomy, tonsillectomy, adenoidectomy, asthma, cough, lower respiratory-tract illness, fire deaths caused by smoking materials, and the combined endpoint of disease, hospitalizations, and death. The investigators estimated that between 136 to 212 childhood deaths per year in the U.S. were due to environmental tobacco smoke-related illness, and 148 deaths were due to fire caused by smoking materials (15).

Comments
  • A 2006 report from the U.S. Surgeon General estimated that a large portion of the population in the U.S. is exposed to secondhand smoke. Secondhand-smoke exposure causes illness and premature death in people who do not smoke. Adults with environmental tobacco smoke exposure have an increased risk for lung cancer and cardiovascular disease. Most deaths associated with secondhand smoke are due to an increased risk for cardiovascular disease (11).

Advise all smokers to quit. 
Evidence
  • A 2013 Cochrane review of the effect of physician advice on smoking cessation included 42 randomized trials. Brief advice from a physician was associated with increased smoking-cessation rates compared to usual care (OR, 1.66 [CI, 1.42 to 1.94]) (16).

Assess all smokers for willingness to quit. 
Evidence
  • A 2010 Cochrane review of stage-based compared with non-stage-based interventions for smoking cessation found equivalent quit rates with both approaches, but the evidence was limited (17).

  • The U.S. Public Health Service Clinical Practice Guideline recommends this as a preliminary step in identifying smokers who are willing to quit and may be more likely to benefit from smoking-cessation counseling and pharmacotherapy. For smokers unwilling to attempt quitting, the guideline recommends motivational counseling based on the “5 Rs”: relevance, risks, rewards, roadblocks, and repetition (5).

Offer all smokers behavioral counseling, recognizing that intensive counseling is more effective than less intensive counseling. 
Evidence
  • Face-to-face counseling:

    • Meta-analyses conducted for the U.S. Public Health Service Clinical Practice Guideline show that there is a strong dose-response relation between the intensity of tobacco-dependence counseling and its effectiveness. They found an OR of 1.6 (CI, 1.2 to 2.0) for cessation with low-intensity counseling (i.e., 3 to 10 minutes) and an OR of 2.3 (CI, 2.0 to 2.7) with high-intensity counseling (i.e., greater than 10 minutes). It was also identified that eight or more sessions were of greater benefit than programs with three or fewer sessions. Whereas the OR for two to three sessions vs. zero to one session was 1.4 (CI, 1.1 to 1.7), the OR of cessation with eight sessions vs. zero to one session was 2.3 (CI, 2.1 to 3.0) (5).

    • A 2012 Cochrane review of smoking-cessation interventions for hospitalized patients included 50 randomized and quasi-randomized trials. Intensive counseling interventions with at least 1 month post-discharge follow-up increased post-discharge quit rates (RR, 1.37 [CI, 1.27 to 1.48]). Adding nicotine replacement or varenicline to intensive counseling increased quit rates but adding bupropion did not (8).

    • The optimal type of behavioral intervention is unclear. Most counselors incorporate various tools into their counseling approaches, but counseling that provides smokers with practical problem-solving skills appears to be effective. Smokers may also benefit from social support provided within the context of smoking-cessation treatment (5).

  • Group therapy:

    • A 2005 Cochrane review of randomized, controlled trials examining the benefit of group sessions on increased smoking cessation found an OR of cessation of 2.17 (CI, 1.37 to 3.45) in favor of group sessions compared with self-help interventions. However, there was no evidence suggesting it was better than individual therapy (18)

  • Telephone counseling:

    • A 2006 Cochrane review identified 48 randomized, controlled trials of telephone counseling for smoking cessation. Cessation rates were higher for groups randomly assigned to receive multiple sessions of call-back counseling (OR, 1.41 [CI, 1.27 to 1.57]). Phone counseling protocols with a greater number of calls tended to be more effective. Benefits of phone counseling were clearer for trials that recruited smokers who were motivated to quit. Phone counseling was effective as an addition to self-help materials, brief advice, or drug therapy (19).

    • A study of the effectiveness of the California Smokers Helpline randomly assigned smokers to seven telephone-counseling sessions or to telephone counseling on an as-requested basis. In an intention-to-treat analysis, the intervention group had an absolute increase in cessation of 2.2% at 1 year (P<0.001) (20).

    • A randomized, controlled study of 837 smokers at Veterans Affairs medical centers showed that telephone care, combining phone counseling with provision of drug therapy, substantially increased long-term quit rates compared with primary care intervention (13.0% vs. 4.1%, P<0.001) (21).

  • Other:

    • A randomized, controlled trial compared text messaging for smoking-cessation support to unrelated text messaging in 5800 motivated smokers. Abstinence rates at 6 months were higher in the group receiving smoking-related messages (10.7% compared with 4.9%, P<0.001) (22; 23).

    • A randomized, controlled trial compared a basic Internet-based intervention, an enhanced Internet-based intervention, and an enhanced Internet-based intervention plus telephone counseling in 2005 smokers. Rates of continuous abstinence at 18 months were 3.5% (basic Internet), 4.5% (enhanced Internet), and 7.7% (enhanced Internet plus telephone) (24).

Comments
  • Most clinical practices are poorly equipped to provide intensive smoking-cessation counseling. Consequently, the data on the efficacy of telephone counseling is of critical importance. Every state offers a smoking-cessation quitline that can be reached through a single national number (1-800-QUIT-NOW). Many quitlines will also accept fax or web-based referrals.

  • As a practical strategy, physicians can screen patients for smoking, advise smokers to quit, refer willing smokers to the state tobacco quitline, and offer effective pharmacotherapy.

Offer pharmacotherapy to smokers interested in quitting, including effective first-line agents, such as nicotine replacement therapy, bupropion, and varenicline. 
Evidence
  • Nicotine replacement therapy:

    • A 2012 systematic review compared high-dose nicotine replacement and combination therapy including nicotine replacement with standard-dose nicotine replacement and other therapies for smoking cessation. The study included a total of 146 randomized, controlled trials. Treatment including varenicline led to higher quit rates than other strategies, but there were no other differences among treatments (25).

  • Bupropion:

    • A 2007 Cochrane review of antidepressants for smoking cessation included 31 trials and showed a doubling of smoking cessation for smokers given bupropion (OR, 1.94 [CI, 1.72 to 2.19]). Three trials of extended therapy with bupropion to prevent a relapse failed to show any additional long-term benefit (26).

  • Varenicline (nicotine receptor partial agonist):

    • A meta-analysis of six trials of varenicline (4924 participants) showed a pooled OR for quitting at 12 months of 3.22 (CI, 2.43 to 4.27). Varenicline was also shown to be more effective for smoking cessation than bupropion (OR, 1.66 [CI, 1.28 to 2.16]) (27).

    • One large randomized trial examined the role of varenicline for relapse prevention. Individuals who were abstinent after 12 weeks of treatment with varenicline were randomly assigned to receive an additional 12 weeks (24 weeks total) vs. placebo. Recipients of the additional 12 weeks of varenicline had higher rates of smoking cessation at 1 year (absolute increase, 7%; NNT, 15) (28).

    • Nausea is the most common side effect with varenicline (30%). Symptoms are generally mild and decrease with continued treatment (29; 30).

  • Second-line agents (nortriptyline and clonidine):

    • Nortriptyline has been evaluated for smoking cessation in five trials and was shown to almost double rates of quitting (OR, 1.8 [CI, 1.3 to 2.6]) (5). Dosages of nortriptyline used in these studies ranged from 75 to 100 mg/d. Nortriptyline is currently not approved by the FDA for smoking cessation and the risk for side effects limits its use for smoking cessation.

    • Clonidine has been evaluated for smoking cessation in six trials (three with oral and three with transdermal clonidine). Dosages ranged from 0.1 to 0.75 mg/d. Clonidine was associated with an OR for smoking cessation of 1.89 (CI, 1.30 to 2.74) although the quality of the studies was less than optimal. There was a high incidence of dose-dependent side effects, including dry mouth and sedation. Clonidine is not approved by the FDA for smoking cessation, and a specific dosing regimen for smoking cessation has not been established (31).

    • Selective serotonin-reuptake inhibitors do not improve smoking-cessation rates (26).

Comments
  • There are five types of nicotine replacement therapy on the market in the U.S.: nicotine gum, nicotine lozenge, nicotine patch, nicotine nasal spray, and nicotine inhaler. All currently evaluated forms of nicotine replacement therapy have similar efficacy for increasing cessation rates by about 1.5- to 2-fold at 6 months among motivated persons (32).

  • All of the first-line agents for smoking cessation are effective. Although varenicline appears to be more effective than the other agents, the choice of treatment should be individualized. Patient's preferences, comorbidity, cost, and insurance coverage may be major factors in selecting a treatment.

  • Patients often fail to initiate or adhere to smoking-cessation treatment. Assessment of adherence to dosing and treatment duration may inform the provision of smoking-cessation treatment.

  • Varenicline is excreted by the kidneys and should be used with caution in patients with renal failure. Doses should not exceed 0.5 mg twice daily in patients with substantial renal dysfunction (creatinine clearance <30 mL/min) or 0.5 mg per day in patients on hemodialysis (see manufacturer's label).

  • Even with the most effective pharmacotherapy, most patients will relapse. The availability of varenicline, bupropion, and five different types of nicotine replacement therapy provides alternatives for patients who fail one type of treatment.

  • Second-line agents, such as nortriptyline, should be considered in individuals who fail or cannot afford first-line therapy.

  • Most smoking-cessation studies recruited persons who were highly motivated to quit, which would limit the generalizability of their results.

Consider combination pharmacotherapy for smoking cessation, including combinations of nicotine patch with bupropion, nicotine nasal spray, or nicotine gum. 
Evidence
  • A separate randomized, controlled trial of combination therapy with nicotine patch and nasal spray showed this treatment regimen to be more effective than nicotine patch alone for smoking cessation at 1 year (27% vs. 11%, P = 0.001). There was also a trend toward increased cessation at 6 years (16% vs. 8%, P = 0.08) (33)

  • An a posteriori analysis of clinical trials included in the U.S. Public Health Service Clinical Practice Guideline estimated that nicotine patch combined with ad lib nicotine replacement (gum or spray) is more effective than nicotine patch alone (OR, 1.9 [CI, 1.3 to 2.7]) (5).

  • Combination therapy may provide greater relief of withdrawal symptoms than single agents (34; 35; 36).

Comments
  • Combination therapy may be slightly more effective than use of nicotine patch alone, but more important, it represents another treatment alternative for individuals in whom other treatments have failed. Combination therapy may also be useful for addressing early-morning symptoms in individuals who cannot tolerate the nicotine patch at night.

Recognize that nicotine replacement is safe in most patients, bupropion carries some risk for adverse effects in some patients with comorbid conditions or on other drugs, varenicline was safe and well-tolerated in clinical trials that enrolled primarily healthy participants, and the role of these agents is unclear in pregnancy. 
Evidence
  • Nicotine-replacement therapy:

    • Two randomized trials of nicotine replacement therapy in patients with stable ischemic heart disease found no increase in adverse cardiac events (37; 38).

    • A meta-analysis examining the incidence of adverse effects in individuals using the nicotine patch found no excess of cardiovascular outcomes in participants treated with the patch (39).

    • There have been a few case reports of myocardial infarction and atrial fibrillation in persons who have used nicotine replacement therapy, although causation remains unclear (40; 41).

  • Bupropion:

    • Bupropion is known to reduce seizure thresholds, with a seizure rate of about 1 per 1000 subjects treated. Patients with seizures, bulimia, or anorexia nervosa, and others with lowered seizure thresholds should avoid its use. Anaphylaxis has been reported at a rate of 1 to 3 per 1000 patients enrolled in clinical trials. Drug interactions with antipsychotics and monoamine oxidase inhibitors have been reported. Contraindications are listed in the product monograph (42; 43).

    • Postmarketing cases of serious changes in behavior, depressed mood, hostility, and suicidal thoughts have been reported in patients taking bupropion for smoking cessation.

    • A prospective cohort study including 6442 individuals who were prescribed bupropion for smoking cessation found no association between bupropion use and fatal or nonfatal self-harm (44).

  • Varenicline:

    • Nausea is the most common side effect with varenicline (30%). Symptoms are generally mild and decrease with continued treatment (29; 30).

    • A prospective cohort study including 10,973 individuals prescribed varenicline found no association between varenicline use and fatal or nonfatal self-harm (44).

    • In a randomized, placebo-controlled trial of varenicline among 714 smokers with stable cardiovascular disease, there was a small increased risk for nonfatal myocardial infarction, coronary revascularization, and vascular procedures; these differences were not statistically significant. By contrast, varenicline-arm subjects did not differ significantly in rates of all-cause mortality, cardiovascular death, and noncardiovascular deaths compared with placebo-arm subjects (45).

  • Pregnancy:

    • Guidelines suggest that pregnant women attempt non-drug means of cessation first. If these fail, clinicians can suggest nicotine replacement therapy, recognizing that the benefits and harms of this therapy in pregnant women are not known (5).

Comments
  • Postmarketing cases of serious changes in behavior, depressed mood, hostility, and suicidal thoughts have been reported in patients taking varenicline for smoking cessation.

  • Varenicline is excreted by the kidneys and should be used with caution in patients with renal failure. Doses should not exceed 0.5 mg twice daily in patients with substantial renal dysfunction (creatinine clearance <30 mL/min or 0.5 mg/d) in patients on hemodialysis (see manufacturer's label).

  • At this time, the harms vs. benefits of nicotine replacement therapy in pregnancy are unclear. Further studies examining this issue are required before a definite statement of harm vs. benefit can be made.

  • Bupropion is classified as a Category B drug for pregnancy and should be considered only if behavioral therapy or educational materials are unsuccessful.

  • Although nicotine is the primary addictive ingredient in cigarettes, it is not the primary cause of either the cardiovascular, pulmonary, or cancer-related toxicity of smoking.

  • The “dose” of nicotine smokers receive from nicotine replacement is often much less than they receive from smoking. Smokers absorb approximately 2 mg per cigarette. Absorption of nicotine from gum and lozenges is typically about 50%, i.e., 1 or 2 mg per 2- or 4-mg dose, respectively. A one-pack-per-day smoker using a 21-mg patch typically receives about half of the nicotine from the patch that they receive from cigarettes. Smokers should not be advised to discontinue nicotine replacement when they “slip” and have a cigarette.

  • The FDA recommends that health care professionals who prescribe varenicline and bupropion should monitor patients for any unusual changes in mood or behavior after starting these drugs. Patients should immediately contact their health care professional if they experience such changes. The FDA recommends that providers discontinue treatment and monitor patients until resolution of symptoms.

If pharmacotherapy is planned, begin treatment 2 to 4 weeks before target quit date. 
Evidence
  • Nicotine replacement therapy:

    • A 2008 meta-analysis of four studies comparing nicotine patch 2 to 4 weeks before the target quit date vs. patch on the quit date showed that patch before the target quit date doubled the odds of smoking cessation (OR, 1.96 [CI, 1.31 to 2.93]) at 6 weeks and at 6 months (OR, 2.17 [CI, 1.46 to 3.22]) (46).

  • Varenicline:

    • A study randomly assigned 101 smokers to receive 3 weeks of placebo, then 1 week of varenicline (standard varenicline dosing) or four weeks of varenicline (varenicline “preloading”), followed by 3 months of varenicline treatment in both arms. Varenicline preloading reduced pre-quit smoking enjoyment and increased 12-week abstinence rates, 47.2% vs. 20.8% (P=0.05) (47).

Consider extended duration of pharmacotherapy for up to 24 weeks to prevent relapse. 
Evidence
  • Nicotine replacement therapy:

    • In a randomized, double-blind trial of 568 smokers, participants were randomly assigned to receive nicotine patch for 24 weeks or nicotine patch for 8 weeks followed by placebo patch for 16 weeks. Participants receiving 24 weeks of active patch had significantly higher cessation rates, decreased risk for lapse, and increased time to relapse (48).

  • Varenicline:

    • One large randomized trial examined the role of varenicline for relapse prevention. Individuals who were abstinent after 12 weeks of treatment with varenicline were randomly assigned to receive an additional 12 weeks (24 weeks total) vs. placebo. Recipients of the additional 12 weeks of varenicline had higher rates of smoking cessation at 1 year (absolute increase 7%; NNT, 15) (28).

For smokers unwilling to quit, consider using nicotine replacement therapy while asking them to reduce their daily smoking. 
Evidence
  • A 2009 meta-analysis of seven randomized, controlled trials including 2767 smokers unwilling to quit showed significantly higher rates of tobacco abstinence at 6 months among smokers randomly assigned to receive nicotine replacement therapy while trying to reduce their smoking compared with controls (9.3 % vs. 5.4%). There were no significant differences in serious adverse events among smokers receiving nicotine replacement therapy compared with controls, although nausea was slightly, and significantly, more common in the nicotine replacement therapy group. Most studies included behavioral interventions as well (49).

  • A later trial randomly assigned 1154 smokers not willing to quit to receive counseling and 4 weeks of nicotine replacement therapy or brief smoking-cessation advice. Six-month tobacco abstinence was significantly higher among those who received counseling plus nicotine replacement therapy compared with those who received brief advice (17 vs. 10.2; P=0.01) (50).

Comments
  • Since these studies included behavioral interventions as well as nicotine therapy, the effect of nicotine therapy alone is unclear.

Recognize that smoking cessation dramatically reduces morbidity and mortality. 
Evidence
  • Evidence for the benefits of smoking cessation in the elderly comes from a cohort study of 7178 healthy men and women age 65 or older. Individuals who continued to smoke had higher rates of mortality as well as cardiovascular and neoplastic disease than former smokers or nonsmokers after 5 years follow-up. The RR of death was 2.1 for men and 1.8 for women among current smokers vs. nonsmokers, while the RR of death was 1.5 for men and 1.1 for women among former smokers vs. nonsmokers (4).

  • In 1990, the U.S. Surgeon General reviewed the literature on the risk of malignancy in former and current smokers and observed that after 10 years of smoking cessation the risk for lung cancer in former smokers was 30% to 50% less than that of current smokers. Individuals who quit smoking for 5 years had half the risk for cancers of the oral cavity and esophagus compared with smokers who continued. Smoking cessation also resulted in a 50% reduction in bladder cancer. Former smokers had a reduced risk for cervical cancer within a few years of smoking cessation and a reduced risk for pancreatic cancer after 10 years of smoking cessation (51).

  • A meta-analysis of 12 cohort studies of the effect of smoking cessation after myocardial infarction found the combined OR for death in patients who quit was 0.54 compared with patients who continued, equivalent to an NNT of 13 (52). Similar mortality-rate benefits have been observed in individuals who quit smoking after coronary artery bypass surgery, after coronary angioplasty, and among patients with angiographically documented coronary stenosis (53; 54; 55; 56)

  • A cohort study of patients post-myocardial infarction found that mortality among patients who quit smoking post-infarct approached that of nonsmokers within 3 years (57).

  • A randomized trial showed that an intensive smoking-cessation intervention targeting smokers hospitalized with acute cardiovascular disease increased abstinence rates (33% intervention vs. 9% usual care), and over a 2-year follow-up period reduced hospitalizations and all-cause mortality (2.8% intervention vs. 12.0% usual care; ARR, 9.2%; NNT = 11) (58).

  • A randomized clinical trial of a smoking-cessation program was conducted among 5887 smokers with mild chronic obstructive lung disease. The cessation rate was 35% in the active-intervention group and 20% in the usual-care group. Sustained quitters had a 5-year decline in FEV1 of 72 mL compared with a decline of 301 mL among participants who continued to smoke. During the first 3 years of follow-up, sustained quitters had an improvement in their FEV1 from baseline (59)

  • In a cohort study of 7735 men, the RR for stroke in smokers was 3.7 and among ex-smokers was 1.7, both compared with men who never smoked. The reduced risk for stroke in ex-smokers compared with continuing smokers was seen within 5 years of smoking cessation (3).

  • Observational studies suggest that there is an immediate 50% reduction in cardiac events in the first year following smoking cessation and that between 2 to 3 years after smoking cessation the level of risk approaches that of persons who have never smoked (60; 61).

Recognize that smoking cessation may lead to weight gain or produce depressive symptoms. 
Evidence
  • Weight gain:

    • In a study of 5247 patients age 35 and older, it was found that persons who had quit smoking were significantly heavier than patients who smoked. Men who were former smokers were on average 4.4 kg heavier than men who continued smoking. Women who were former smokers were on average 5.0 kg heavier than women who continued smoking (62).

  • Depression:

    • A study enrolled 100 smokers with a history of major depression not currently requiring treatment in a 2-month smoking-cessation program. Thirteen abstainers and two smokers had an episode of major depression at follow-up; the OR for an episode of major depression in patients who successfully quit compared with patients who did not was 7.17 (CI, 1.5 to 34.5) (63).

Comments
  • Neither weight gain nor the risk for depression should discourage the initiation of smoking-cessation interventions, although physicians should monitor for both.

Recognize that smoking cessation interventions appear to play a direct role in reducing mortality.  
Evidence
  • The 1990 report of the U.S. Surgeon General examining the health benefits of smoking cessation identified five smoking-cessation studies that examined the effect of different interventions on risk for death (51).

  • The Lung Health Study was a randomized clinical trial of smoking-cessation intervention and inhaled ipratropium in smokers aged 35 to 60 years with asymptomatic mild to moderate airway obstruction. After 5 years, it showed that smoking cessation produced a reduced decline in FEV1, and subgroup analysis showed reductions in fatal and nonfatal cardiovascular disease and coronary heart disease (59; 64). In a subsequent follow-up study at 14.5 years, all-cause mortality in the intervention group was 8.83 per 1000 person-years and 10.38 per 1000 person-years in the usual-care group with a hazard ratio in the usual-care group of 1.18 (CI, 1.02 to 1.37). The benefit was greatest for patients who quit smoking entirely (65).

  • A randomized trial showed that an intensive smoking-cessation intervention targeting smokers hospitalized with acute cardiovascular disease increased abstinence rates (33% intervention vs. 9% usual care) and over a 2-year follow-up period reduced hospitalizations and all-cause mortality (2.8% intervention vs. 12.0% usual care; ARR, 9.2%; NNT = 11) (58).

Appreciate the direct evidence showing that smoking-cessation programs reduce adverse outcomes in pregnancy (low-birth-weight children and preterm birth). 
Evidence
  • A systematic review examined the effectiveness of smoking-cessation programs during pregnancy. The RR for smoking cessation was 0.94 (CI, 0.93 to 0.96) in favor of cessation efforts. The women who received the intervention had a reduction in both low-birth-weight children (OR, 0.83 [CI, 0.73 to 0.95]) and preterm birth (OR, 0.86 [CI, 0.74 to 0.98]), as well as an increase in mean birth weight of 54 g (CI, 10 to 95). No effect on perinatal death or very low birth weight was observed (13).

Know that smoking-cessation programs have been shown to reduce surrogate outcomes, such as decline in FEV1. 
Evidence
  • A randomized clinical trial of a smoking-cessation program was conducted among 5887 smokers with mild chronic obstructive lung disease. The cessation rate was 35% in the active intervention group and 20% in the usual-care group. Sustained quitters had a 5-year decline in FEV1 of 72 mL compared with a decline of 301 mL among participants who continued to smoke. During the first 3 years of follow-up, sustained quitters had an improvement in their FEV1 from baseline (59).

Assess the smoking status in all patients routinely, and encourage all smokers, from adolescents to patients over age 65, to quit smoking. 
Evidence
  • A meta-analysis of nine studies found that clinicians who inquired about smoking status were approximately three times more likely (OR, 3.1 [CI, 2.2 to 4.2]) to introduce a smoking-cessation intervention (5).

  • The 2012 U.S. Surgeon General report“Preventing Tobacco Use among Youth and Young Adults” stated that over 80% of adult daily smokers began before the age of 18, with nearly 100% of adults having begun before the age of 26.

  • In a cohort study of 7178 healthy elderly men and women age 65 years or more, persons who continued to smoke had higher rates of mortality as well as cardiovascular and neoplastic disease than former smokers or nonsmokers after 5 years of follow-up. The RR for death was 2.1 for men and 1.8 for women among current smokers vs. nonsmokers, whereas the RR for death was 1.5 for men and 1.1 for women among former smokers vs. nonsmokers (4).

Arrange follow-up visits after cessation attempts to increase cessation rates and maintain smoking cessation. 
Evidence
  • A meta-analysis of 45 studies examining person-to-person smoking-cessation interventions found that persons who received four to eight treatment sessions had approximately twice the likelihood of cessation compared with individuals who received zero to one session (OR, 1.9 [CI, 1.6 to 2.2]) (5).

Comments
  • Although follow-up is critically important to successful cessation, follow-up in many clinical practices has been hampered by lack of formal systems for counseling and follow-up and concerns about reimbursement. An alternative is to refer patients to state-supported smoking-cessation quitlines (1-800-QUIT-NOW).

Recognize the cost-effectiveness of nicotine replacement therapy and behavioral counseling for smoking cessation and the benefit they provide for a reduction in illness and death associated with smoking. 
Evidence
  • A meta-analysis of all smoking-cessation interventions determined that the average cost per life saved was $1500 for one episode of advice (12). By comparison, the cost-effectiveness of dialysis is $46,322 (1994 dollars) per year of life saved (66).

  • A cost-effectiveness analysis of nicotine patch, based on two meta-analyses, determined that the cost per quality-adjusted life-year was between $4390 and $10,943 for men and between $4995 and $6983 for women. These values were sensitive to baseline cessation rates, physician counseling, and discounted rates. The baseline 1-year cessation rates used in this analysis were 2.5% for no intervention, 4% for physician counseling, and 7.9% for physician counseling plus nicotine patch (67).

Comments
  • A simulation model based on Swedish population data suggests that including bupropion SR as part of smoking-cessation programs is cost-effective, and potentially cost-saving from the societal perspective, compared with the use of nicotine patch or gum (68).

Appreciate the particular cost-effectiveness of smoking-cessation interventions in patients with coronary artery disease because of the probable large reduction in risk for death. 
Evidence
  • In an economic analysis of a nurse-managed intervention for smoking cessation following myocardial infarction, the cost-effectiveness ratio was $220 per life-year gained. The cost-effectiveness was attributed to the success of the intervention itself (ARR, 26%) and the beneficial reduction in risk for death associated with smoking cessation after myocardial infarction (69).

Know that smoking cessation during the first trimester of pregnancy can substantially reduce health costs by contributing to a decrease in preterm births and that smoking cessation throughout pregnancy can reduce costs due to maternal illness. 
Evidence
  • A U.S. study of the direct medical costs of low birth weight due to maternal smoking estimated the cost per live birth for each maternal smoker to be $511, a total cost of $263 million. The study estimated that a reduction of maternal smoking by 1% would save $572 million over 7 years (70).

  • An economic analysis determined that smoking costs per year (1993) due to the effect on maternal health were $135 million to $167 million (71).

Recognize the value that all clinicians, including physicians, have in providing cessation interventions to smokers. 
Evidence
  • In a meta-analysis included in the 2008 U.S. Public Health Service Clinical Practice Guideline, interventions delivered by both physicians and nonphysicians were found to be effective in improving smoking cessation (5).

  • A 2008 Cochrane review of 31 studies found that nursing-based interventions increased smoking cessation when compared with control/usual-care groups (OR, 1.28 [CI, 1.18 to 1.38]) (72).

Consider use of Internet- and computer-based interventions to assist smokers in their cessation efforts. 
Evidence
  • Although results have been mixed, a 2009 meta-analysis of 22 studies showed positive findings for Internet- or computer-based interventions compared with control conditions (OR, 1.44 [CI, 1.27 to 1.64]) (73).

Comments
  • The optimal features of Internet resources have not been identified and more research is needed, but the low cost and broad potential reach of these interventions makes this an appealing adjunct to smoking-cessation efforts.

Consider use of text message-based interventions to help smokers quit. 
Evidence
  • A single-blind, randomized trial of 5,800 smokers willing to make a quit attempt compared a text-messaging intervention, including motivational messages and behavior change support, with a control intervention, including text messages unrelated to quitting. Abstinence at 6 months was significantly higher in the text-messaging intervention arm (10.7% vs. 4.9%; RR = 2.2 [CI, 1.8 to 2.68]) (22).

Note that a special referral is not required to initiate smoking-cessation therapy, and it is important for all physicians to address issues of smoking cessation in all smokers they treat. 
Evidence
  • In a systematic review examining smoking-cessation therapies with at least 6 months of follow-up, 17 randomized clinical trials included one episode of advice and encouragement from a physician. The summary absolute reduction in the rate of smoking was 2% (CI, 1 to 3) (12).

  • A 2008 Cochrane review evaluated the impact of physician advice on smoking cessation and included 41 randomized, controlled trials. Brief advice from a physician was associated with increased smoking-cessation rates (OR, 1.66 [CI, 1.42 to 1.94]). If unassisted quit rates are assumed to be 2% to 3%, brief advice can increase quitting by another 1% to 3% (74).

Consider referring smokers to telephone quitlines for follow-up counseling for smokers attempting to quit, noting that this should not replace the role of the provider in initial counseling and selection of appropriate pharmacotherapy. 
Evidence
  • Face-to-face counseling:

    • The U.S. Public Health Service Clinical Practice Guideline states that there is a strong dose-response relation between the intensity of tobacco dependence counseling and its effectiveness. In a review of the evidence they found an OR of 1.6 (CI, 1.2 to 2.0) for cessation with low-intensity counseling (i.e., 3 to 10 minutes) and an OR of 2.3 (CI, 2.0 to 2.7) with high-intensity counseling (i.e., greater than 10 minutes). It was also identified that eight or more sessions were of greater benefit than programs with three or fewer sessions. The OR of cessation with eight sessions vs. zero to one session was 2.3 (CI, 2.1 to 3.0), whereas for two to three sessions vs. zero to one session was 1.4 (CI, 1.1 to 1.7) (5).

    • The optimal type of behavioral intervention is unclear. Most counselors incorporate various tools into their counseling approaches, but the counseling that provides smokers with practical problem-solving skills appears to be effective. Smokers may also benefit from social support provided within the context of smoking-cessation treatment (5).

  • Group therapy:

    • A 2005 Cochrane review of randomized, controlled trials examining the benefit of group sessions on increased smoking cessation found an OR of cessation of 2.17 (CI, 1.37 to 3.45) in favor of group sessions. However, there was no evidence suggesting it was better than individual therapy (18).

  • Telephone counseling:

    • A 2006 Cochrane review identified 48 randomized, controlled trials of telephone counseling for smoking cessation. Cessation rates were higher for groups randomly assigned to receive multiple sessions of call-back counseling (OR, 1.41 [CI, 1.27 to 1.57]). Phone counseling protocols with a greater number of calls tended to be more effective. Benefits of phone counseling were clearer for trials that recruited smokers who were motivated to quit. Phone counseling was effective as an addition to self-help materials, brief advice, or drug therapy (19).

    • A study of the effectiveness of the California Smokers Helpline randomly assigned smokers to seven telephone-counseling sessions or to telephone counseling on an as-requested basis. In an intention-to-treat analysis, the intervention group had an absolute increase in cessation of 2.2% at 1 year (P<0.001) (20).

    • A randomized, controlled study of 837 smokers at Veterans Affairs medical centers showed that telephone care, combining phone counseling with provision of drug therapy, substantially increased long-term quit rates compared with primary care intervention (13.0% vs. 4.1%, P<0.001) (21).

Table Grahic Jump Location
 5-Step Brief Interventions to Promote Smoking Cessation

Swipe to view table

The Public Health Service's Clinical Practice Guideline on treating tobacco dependence describes the following 5-step (5 A's) brief intervention for smoking cessation in the patient willing to quit:
Ask about tobacco use
Advise to quit
Assess willingness to make a quit attempt
Assist in quit attempt
Arrange follow-up
For the patient unwilling to quit, the guideline recommends the following interventions (5 R's) to enhance motivation to quit:
Encourage patient to think of relevance of quitting smoking to their lives
Assist patient in identifying the risks of smoking
Assist patient in identifying rewards of smoking cessation
Discuss with patient roadblock or barriers to attempting cessation
Repeat the motivational intervention in all visits
See the 2008 guideline for more details of these interventions. The brief clinical interventions are described in Chapter 3.
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ARR

adjusted relative risk

CI

confidence interval

FEV1

forced expiratory volume in 1 second

NNT

number needed to treated

OR

odds ratio

RR

relative risk


Guidelines

Counseling and interventions to prevent tobacco use and tobacco-caused disease in adults and pregnant women: U.S. Preventive Services Task Force reaffirmation recommendation statement

Clinical practice guideline: treating tobacco use and dependence: 2008 update

Counseling: tobacco use

Clinical practice guideline: treating tobacco use and dependence: 2008 update

Counseling and interventions to prevent tobacco use and tobacco-caused disease in adults and pregnant women: U.S. Preventive Services Task Force reaffirmation recommendation statement

Systematic Reviews

Influence of smoking cessation after diagnosis of early stage lung cancer on prognosis: systematic review of observational studies with meta-analysis.

Systematic review: smoking cessation intervention strategies for adults and adults in special populations

Prevention of relapse after quitting smoking: a systematic review of trials

Risk of tuberculosis from exposure to tobacco smoke: a systematic review and meta-analysis

Smoking cessation interventions for hospitalized smokers: a systematic review

Effects of Web- and computer-based smoking cessation programs: meta-analysis of randomized controlled trials

Effect of smoke-free workplaces on smoking behaviour: systematic review

Systematic review of the effectiveness of stage based interventions to promote smoking cessation

Effectiveness and safety of nicotine replacement therapy assisted reduction to stop smoking: systematic review and meta-analysis

Physician advice for smoking cessation (Cochrane review)

Workplace interventions for smoking cessation (Cochrane review)

Mortality risk reduction associated with smoking cessation in patients with coronary heart disease: a systematic review

Active smoking and the risk of type 2 diabetes: a systematic review and meta-analysis

History of depression and smoking cessation outcome: a meta-analysis

DOI: 10.7326/prev374
The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.
Authors and Disclosures:
Kumanan Wilson, MD has nothing to disclose. Shadi Nahvi, MD, MS has nothing to disclose.

The following editors of ACP Smart Medicine have nothing to disclose: Deborah Korenstein, MD, FACP, Editor in Chief; Richard B. Lynn, MD, FACP, Editor; and Davoren Chick, MD, FACP, Editor.

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