Many of us have committed ourselves to do our part with smoking cessation during our careers, but staying on course with this difficult task can be difficult. The barriers to sustaining our efforts are multiple: tobacco advertisers’ huge marketing budgets, inadequate time and reimbursement for providing treatment, patients’ psychological and physiological barriers and resistance, our own frustration when our best efforts do not have efficacy, etc., etc., etc. This said, persistence and perseverance in efforts to aggressively attack this potentially modifiable risk factor for excessive morbidity and mortality should remain a priority.
California’s prevalence of tobacco use is 10.5 % in teens and 11.7 % in adults1. There is NO level of second hand smoke that is safe. Even those who don’t use tobacco directly are subjected to indirect risks of heart disease, lung cancer, and SIDS. Informing patients of the impact of their behavior on family members may have significant impact in their perception of their smoking habit.
While 52.2% of callers to California Smokers’ helpline identify themselves as having “any mental health condition”2, we recognize that one in three adults with mental illness uses nicotine in coping with their illness. The long term health risks of electronic cigarettes and vaping are unknown, but clearly neither habit is good for health.
First interventional steps in attacking tobacco use:
- Ask patients about their tobacco use—keep at it at every appropriate contact.
- Advise users to quit and employ motivational interviewing techniques to encourage changes in attitude and habits. (“I’d think it would feel great for you to be healthy when you retire”; “… be able to attend your granddaughter’s graduation” ; “… not be at higher risk of getting very sick with Covid-19” ; etc…)
- Refer to California Smokers’ Helpline 1-800-NO-BUTTS, online @ www.nobutts.org
- Persist in suggesting that patients plan for a quit date and find a personalized strategy compatible with their level of motivation and readiness for change.
- Offer encouragement and bolster confidence and persist, even when your own patience with your patient is wearing thin. Persistence pays with some folks and all successes count.
California Smokers’ Free Helpline is funded by tobacco taxes and accommodates many languages. It is available M-Fri 7am-9am and Sat 9am-5pm. The program offers a series of up to 5 calls and in the case of smokers living within homes of children ages 5 yrs or younger often offers free nicotine patches.
Pharmacotherapy for Tobacco Cessation, Fundamentals
- Proven efficacy, superior to quitting efforts without medication.
- Medications can aid in effort to address physiologic effects of the chemical withdrawal.
- Two categories of medication options are
- a) nicotine replacement in various formulations, and
- b) bupropion (Zyban, Wellbutrin) or varenicline (Chantix).
Both help with decreasing cravings, decreasing the pleasurable effect of tobacco, and softening withdrawal symptoms– but both carry black box warnings.
- Nicotine replacement can be used concomitantly with Zyban (bupropion SR) or Chantix (varenicline) but limiting the number of chemicals if feasible is preferred.
Nicotine Replacement Strategies
Patches provide the steadiest release of nicotine over time with nasal sprays offering second most even. Generic patches are least expensive option before gum. Inhalers are the most expensive. MediCal provides FREE pharmacotherapy for eligible members and MediCare provides some Part D benefits as well as reimbursing providers for CPT codes 99406 (3-10 mins) and 99407 (more than ten minutes).
Patch specific instructions:
- Change patch daily and use new hair-free spot next day
- Don’t disturb the delivery system by cutting the patch
- Patches are water safe
- Adhesives can cause irritation and/or allergic reactions
- If nicotine had been started fewer than 30 mins after awakening, 4 mg dose is appropriate. But if first use would typically be later than that, start with 2mg dose.
Lozenge specific instructions:
- Do not eat or drink 15 minutes before or after using lozenges
- If nicotine had been started fewer than 30 mins after awakening, 4 mg dose is appropriate. But if first use would be typically delayed beyond half an hour, start with 2 mg dose.
Bupropion SR (Zyban) Tips
- Starting dose for Bupropion is 150 mg Q AM x 3days, then BID up to 12 weeks.
- Begin bupropion SR about 10 days to 2 weeks BEFORE planned quit date.
- Bupropion SR can be discontinued abruptly when used for smoking cessation alone
- Contraindications include eating disorders, seizure disorders, and cases of suspected withdrawal from alcohol or benzodiazepines
Varenicline (Chantix) Tips
- Days 1-3 Varenicline .5 mg/d, Days 4-7 use 1mg/d, days 8 to end of week 12 use 1mg bid and taken after food AND with 8 oz water
- Longer course is associated with lower relapse
- Depression and agitation are potential adverse effects to monitor and potential nausea or insomnia can resolve without discontinuation.
- CHIS, 2014; CSTS, 2012 CDC Reports collected by American Legacy Foundation
- Zhu et al. 2016, unpublished data