29 Treatment of Tobacco Dependency

Stopping Smoking

When stopping smoking, the patient deals on the one hand with physical and on the other hand with psychosocial withdrawal, in other words getting out of smoking behavior. The patient has to learn how to deal with smoking needs and has to change habit patterns and to replace the func- tion of smoking by, for example, learning to relax and deal with stress without cigarettes.

Stages of Change

As in all types of addiction, there is also a process of change in behavior with respect to the recogni- tion of dependency. In order to counsel the patient in becoming aware of his problem, it is important to recognize the stages of change as they are outlined by Prochaska and DiClemente (Figure 29-1).

(See also Figure 26-1.)

Stage 1: Precontemplation

In the precontemplation phase, one does not realize there is a problem – the “happy smoker.”

It is extremely important in this stage to inform the patient in a respectful, non-sermonizing way about the harmful effects of smoking and the pos- sible connection with current complaints, both physical and psychological. One can ask if he or she has ever considered quitting and if so, is this in the near future. If the patient refuses to con- template, then it is important to leave it for the moment and talk about this again at a later time.

Stage 2: Contemplation

Only in the second stage, the contemplation phase, will the patient be open to information about

the short-term and long-term effects of quitting smoking. Short-term advantages are: being in better shape and feeling more energetic, having a better skin, better taste and smell, a better voice, and whiter teeth. Long-term effects are: a better prog- nosis,adding years to life,less chance of,or improve- ment of, lung diseases and heart and vascular diseases, less chance of lung cancer and other forms of cancer. In this stage possible misconceptions must be dispelled. These topics must be discussed to help the patient make a conscious decision.

Stage 3: Decision

In this stage the patient is prepared for stopping with smoking. It is important to prepare him or her for the possible withdrawal symptoms (see Table 29-1) and give advice on the problems that may occur. A date to quit should be set and help with medication must then be discussed.

Stage 4: Action

After the decision, a concrete quitting appointment can be made. From the Prochaska and DiClemente model it can be concluded that the client has a long way to go after his decision. After a successful attempt to quit, the smoker must maintain.

Stage 5: Maintenance

Stopping might be difficult but not starting again is much more difficult. In this stage a series of supporting contacts, for example starting one week after the set quitting date, is extremely important and medication must be considered again to prevent a relapse.

Stage 6: Relapse

In cardiac patients relapse may be present in 30–40% after discharge from the hospital. Relapse

29

Treatment of Tobacco Dependency

Trudi P.G. Tromp-Beelen and Irene Hellemans

239

is an essential part of the pathological process and although everything has to be done to avoid this, it is important to use a possible relapse as an educa- tional tool. This means a positive attitude instead of disappointment when patients admit that they have started again. Both physician or nurse and patient should not give up right away! The smoker must be motivated to stop again as soon as possi- ble. Many smokers have only stopped after various attempts. Relapse does not imply the patient has to start all over again, but has proven he can stop. The relapse can especially be explained on the basis of craving, as discussed in Chapter 28. This must slowly die; it needs time.

Effects of Type of Intervention

Advice given by physicians is effective for smoking cessation.

Interventions involving pro- fessionals from different disciplines have more effect than interventions carried out by profes- sionals from a single discipline.

In their Cochrane review of interventions by nurses in the area of smoking cessation, Rice and Stead indicate that intensive telephone support after discharge from hospital is an essential component of an effective intervention for heart patients.

Brief advice given by nurses to patients with a coronary bypass is also effective. Patients with a myocardial infarct are twice as likely to be successful in stopping than are patients after a bypass operation.

Patients with heart failure who during their stay in hospital had a twice-weekly group session and in addition to this received telephone follow-up on several occasions until 6 months after discharge

had (after 12 months) a biochemically confirmed chance of stopping of 57% compared to 37% in the group of patients who only received advice to stop (numbers needed to treat = 5 (95% CI: 3–6)).

Med- icinal support for patients increases the chance of successfully stopping and is safe.

More intensive behavioral counseling increases the chances of successfully stopping by a factor two to three.

One-off and Brief Supportive Interventions

One-off brief interventions during normal care con- tacts are the most relevant for physicians. One-off advice or a brief supportive intervention has an odds ratio of 1.69 (95% CI: 1.45–1.98) equivalent to an absolute difference of 2.5%.

Therefore the advice is that every doctor should always address the topic of smoking and focus on the issue of quitting.

Intensive Interventions

A meta-analysis revealed that the effectiveness of interventions increases if the intervention is more intensive, lasts longer. or contains more points of contact. Adding follow-up consultations was more effective than no follow-up.

This applies to all interventions which in total last for at least 40 minutes and take place in at least four sessions or contacts, including all psychological or psychoso- cial forms of influencing behavior.

Addressing the Patient

Patients who are not motivated to stop smoking should first of all be motivated. Cardiologists and nurses involved should record the smoking behav- ior and motivational level (Figure 29-1)

of their patients with a smoking-related disorder and then support motivated smokers in their attempt to stop.

This should also include attention and support for the period following discharge from hospital, espe- cially in cardiac rehabilitation programs.

Many smokers succeed without aid. Just as various factors may contribute to a some patients

Precontemplation

Contemplation

Decision

Action Maintenance

Relapse

Start

Patient not ready for change:

Exit Goal is

being reached:

Exit

FIGURE29-1. The wheel of change, based on the stages of change by Prochaska and DiClemente.¹

TABLE29-1. Nicotine withdrawal symptoms according to the cri- teria of DSM-IV

• depression • concentration problems

• insomnia • restlessness

• anger • reduced heart frequency

• anxiety • weight gain

getting addicted more quickly to nicotine than others, so some people can stop easily than others.

Some smokers can quit smoking after one single advice to stop; others will need the help of quit- smoking-groups. The best results are gained by the more intensive forms of support, for example a group course.

For those who cannot succeed in quitting this way, medication might increase their chance of success. The treatment with medication is preferably combined with psychosocial support.

The five As (“ask,” “assess,” “advise,” “assist,”

“arrange”) shown in Table 29-2 are a simple guide- line in this aspect. In cardiac patients relapse is an important issue to address during cardiac rehabil- itation. A lot of patients quit smoking during their hospital stay, but find it very hard once they are in their own environment again (Table 29-3).

Pharmacotherapy

Nicotine Replacement Therapy

Before starting the nicotine replacement therapy the user has to quit smoking. Nicotine replace- ment therapy provides an alternative form of nicotine to relieve symptoms of withdrawal in a smoker who is abstaining from tobacco use.

The pharmacokinetic properties of available products differ, but none deliver nicotine as fast as does inhaling nicotine. The patch provides a relatively stable, fixed dose of nicotine over a period of 16 or 24 hours. The other products have a more rapid onset and a shorter duration of action, allowing the user to adjust the dose of nicotine. Blood nico- tine levels peak 5 to 10 minutes after the adminis-

TABLE29-2. The five As: intended for every smoker who wants to stop

Action Implementation strategy

“Ask”: systematically ask (preferably every year) whether he/she is a smoker

Design a department-wide/organization-wide manner in which, for every patient, Implement prompts for health professionals to systematically it is established (preferably yearly) whether he/she smokes and record this. inquire about smoking behavior, for example stickers on the Exception: adults who have not smoked for a considerable period of time, and for status or by placing a reminder in the patient’s electronic

whom the status is clearly established. record.

Smoking status: smoker, has stopped, never smoked.

“Advise”: emphatically advise him or her to stop smoking

Advise the smoker to stop smoking, in a clear, strong, and person-specific manner. Clear: I think that it is important that you stop and I think that I can help you.

Emphatic: You should know that giving up smoking is the best way of keeping your health in the future.

Specific to the person: Look at personal motives for the smoker:

relationship with disease, cost-savings, in the children’s interest, etc.

“Assess”: establish the willingness to stop smoking

Establish whether the smoker is willing to undertake an attempt to stop at this Prepared to stop now; proceed to assistance.

moment (e.g. within the next 30 days)

Needs intensive support; offer this or refer. Not prepared to stop now; intervene at the motivation level.

Special circumstances (child, pregnant, etc.) consider giving additional information.

“Assist”: help him/her in undertaking the attempt to stop

Make a ‘stop plan’ together with the smoker. Agree on a stop date.

Arrange social support from others (tell everybody).

Anticipate difficult moments (withdrawal symptoms).

Remove tobacco products from places (home and work) where the smoker might be.

Give practical support Stop completely; do not even smoke half a cigarette.

Evaluate previous failed attempts.

Establish how the person can recognize a difficult moment.

Suggest avoiding difficult moments (e.g. whilst having an alcoholic drink).

Try to get partners, relatives, and friends to stop at the same time.

TABLE29-2. Continued

Action Implementation strategy

Offer support Where can the smoker always go to in the event of questions

and problems?

Try to arrange support from others Ask partners, parents, and colleagues to support the smoker in the attempt to stop.

Advise pharmacotherapy, except in special situations Consider advising pharmacotherapy if a smoker smokes more than 10 cigarettes per day.

Explain why this increases the chances of stopping.

Obtain additional information

“Arrange”: care for follow-up as a form of preventing relapse

Determine dates for follow-up contact, in person or over the telephone. Timing: follow-up contact must take place soon after the planned stop date, preferably within one week, and a within second one month.

Actions in follow-up: celebrate the success; if the person has still smoked, evaluate why and try to once more obtain a commitment for a complete stop; remind the smoker that failure can be seen as a learning step; discuss difficult moments and anticipate future ones; evaluate pharmacotherapy and consider more intensive treatment.

TABLE29-3. Guidelines for relapse prevention Problem: lack of support

Solution:

• make agreements for follow-up (if need be by telephone)

• try to find sources of support in the neighborhood of the stopped smoker

• refer to a relevant organization which can provide support Problem: negative mood/depression

Solution:

• provide support, see if medication can help and refer to a relevant health professional

Problem: strong withdrawal symptoms Solution:

• see if medication or an adjustment to the medication is needed Problem: weight increase

Solution:

• emphasize the importance of a good diet, discourage strict dieting and try to encourage extra physical activity. State that an increase in weight is normal, but that after a while the weight no longer increases

• consider continuing to use medication which postpones the weight increase, for example bupropion

• refer to a relevant organization which can provide support Problem: decreased motivation and slackness

Solution:

• emphasize that this is a normal reaction

• recommend rewarding activities

• discourage temporary tobacco use and emphasize that smoking (even one cigarette) only makes it more difficult to stop

tration of the nasal spray, 20 minutes after the user begins the chewing gum, sublingual tablet, sucking tablet or uses a inhaler, and 2 to 4 hours after the application of a nicotine patch. The dose depends on the number of cigarettes smoked a day. If more than two packets of cigarettes are smoked each day, two patches are recommended (twice a day) or one patch combined with some other form of nicotine replacement. Different nicotine forms of replacement therapy can be combined safely. The side-effect of these products varies according to the manner in which nicotine is administrated.

Although nicotine increases the myocardial workload, nicotine replacement therapy is safe in patients with cardiovascular disease, including stable angina. The risk of cardiac complications should be lower than with smoking. Unlike smoking, nicotine replacement therapy does not increase the coagulability of blood or expose a patient to carbon monoxide or oxidizing gases that damage endothelium. In women who are pregnant or breastfeeding, the risk of smoking can be more severe than nicotine replacement therapy.

In a meta-analysis of placebo-controlled trials,

nicotine replacement therapy was found to result

in higher rates of smoking cessation, especially

when combined with counseling.

Antidepressants and Other Pharmacotherapy

The withdrawal symptoms of smoking cessation can be stress, depression, anxiety, anger, insomnia, and weight gain. For that reason antidepressants can be helpful.

Bupropion is an antidepressant with dopamin-

ergic and norepinephrenic activity. It relieves the withdrawal symptoms and the craving for a cigarette. Because bupropion lowers the thresh-

old for seizures it is contraindicated in patients who are at risk for seizures. The daily dose is 150 mg/day for 6 days, then 150 mg twice a day.

In those predisposed to seizures, in elderly people, or those with decreased kidney or liver func- tion, the maintenance dose should be taken once a day only. Smoking cessation starts about 10 days after the start of medication.

An over- view of drugs used for smoking cessation, contraindications and side-effects is given in Table 29-4.

TABLE29-4. Drugs used for smoking cessation

Duration of Common

Product Daily Dose Maintenance Treatment Side Effects Contraindications

Nicothine – (2) instable angina, serious

replacement cardiac arythmics, recent myocardial

therapy (1) (3) infarction or cerebrovasculair accidents

Trandermal 7-, 14- or 21 mg for idem, after 4–6 weeks 6–12 weeks skin irritation, insomnia (2) serious eczema, allergic to patches patch 7-, 14-, 21- or 24 hours or 15 mg halve the dosage (remove during the

15 mg (1) (3) for 16 hours night)

Chewing 2–4 mg each 2 hour idem, after 4–6 weeks maximum mouthe irritation, (2) jaw problems, esophagitis

gum 2-, 4 mg (maximum halve the dosage 1 year sorc jaw, dyspepsia,

(1) (3) 48 mg/day) hiccups

Sublingual 2–4 mg each idem, after 2–3 months 6 months mouthe irritation, (2)

tablets 2-, 4 mg 1–2 hour phase out dyspepsia, hiccups

(1) (3) (maximum

60 mg/day)

Sucking 1–4 mg each idem, after 2–3 months 6 months mouthe irritation, (2)

tablets 1–2 hour phase out dyspepsia, hiccups

1-, 2-, 4 mg (maximum

(1) (3) 25 mg/day)

Vapor inhalor 6–12 cartridges/day idem, after 2–3 months 6 months mouthe irritation, (2) asthma, rhinitis, nose polyps,

4-, 10 mg phase out dyspepsia, hiccups allergic to menthol

(1) (3)

Nasal spray 1–2 doses each hour idem, after 2–3 month 6 month nasal irritation, (2)

0.5 mg in each nostril phase out sneezing, cough ,teary

(1) (3) (maximum eyes

40 mg/day)

Bupropion 150 mg/day after 6 days 150 mg 7–9 weeks insomnia, dray mouth, allergic to bupropion, epilepsy or

sustained-release (6 days) twice a day 4) when agitation seizures in the past, tumor of the

(3) (6) predisposed to seizures: central nerve system, abrupt

maintain 150 mg/day cessation of benzodiazepines or

alcohol, anorexia nervosa, boulimia, serious livercirrose

Nortiptyline 25 mg/day (3 days) after 7 days 7–12 weeks dry mouth, sedation, see bupropion except the

(3) (5) (6) 50 mg/day 75 mg/day 4) dizziness seizures

(4 days)

(1) Different nicotine-replacement products can be combined safely.

(2) Contraindication for all nicotine-replacement therapy is instable angina, serious cardiac arytmics, recent myocard infarction or cerebrovascular accidents.

(3) Bupropion and nortriptyline can be combined with nicotine-replacement therapy.

(4) Smoking cessation 10 days after start medication.

(5) Nortriptyline has not been approved by the Food and drug Amministration as a smoking-cessation aid. The Public Health Service clinical guidelines recom- mend it as a second-line drug for smoking cessation.

(6) Bupropion and nortriptyline should not be combined with MOA-inhibitors.

thermore, all health professionals should address the topic of quitting smoking from the moment the patient is admitted to the hospital. If there is a combined strategy, the success rate for cardiac patients may be very high, up to 50%. For patients who still smoke, the cardiac rehabilitation program offers a perfect setting for more intensive counseling or addition of medication in those patients that need this support.

References

1. Prochaska JO, DiClemente CC. Toward a compre- hensive model of change. In: Miller WR, Heather N, eds. Treating Addictive Behaviors: Processes of Change. New York: Plenum Press; 1992:3–27.

2. Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence. Clinical Practice Guideline. Rockville, MD: US Department of Health and Human Services. Public Health Service;

2000.

3. Rice VH, Stead LF. Nursing interventions for smoking cessation [Cochrane review]. The Cochrane Library.

Issue 3. Oxford: Update Software, 2002.

4. Hajek P, Taylor TZ, Mills P. Brief intervention during hospital admission to help patients to give up smoking after myocardial infarction and bypass surgery: randomised controlled trial. BMJ 2002;

324:641–645.

5. Quist-Paulsen P, Gallefoss F. Randomised controlled trial of smoking cessation intervention after admis- sion for coronary heart disease. BMJ 2003;327:

1254–1257.

6. Tonstad S, Farsang C, Klaene G, et al. Bupropion SR for smoking cessation in smokers with cardiovas- cular disease: a multicentre, randomised study. Eur Heart J 2003;24:946–955.

7. Silagy C, Stead LF. Physician advice for smoking cessation [Cochrane review]. The Cochrane Library. Issue 3. Oxford. Cochrane Database Syst Rev. 2004;(3):CD000146.

8. Silagy C, Lancaster T, Stead L, Mant D, Fowler G.

Nicotine replacement therapy for smoking cessa- tion. Cochrane Database Syst Rev 2004;(3):

CD000146.

9. Rigotti NA. Treatment of tobacco use and depen- dence. N Engl J Med 2002;346(7):506–512.

10. Jørenby DE, Leischow SJ, Nides MA, et al. A con- trolled trial of sustained-release bupropion, a nico- tine patch or both for smoking cessation. N Engl J Med 1999;340:685–691.

11. Gonzales D, Rennard SI, Nides M, et al. Varenicline, an α4β2 nicotinic acetylcholine receptor partial agonist, vs sustained-relaese bupropion and placebo for smoking cessation. JAMA 2006;296:47–55.

Nortriptyline is an antidepressant with seroton-

ergic and norepinephrenic activity. This antide- pressant is not approved as a smoking cessation aid but is recommended in many public health services guidelines for smoking cessation. The daily dose is 25 mg/day for 3 days, then 50 mg/day 4 days, then 75–100 mg/day. Smoking cessation starts from the tenth day after the start of med- ication. Duration of treatment is 7–12 weeks.

Both bupropion and nortriptyline can be com- bined with all kinds of nicotine replacement therapy. In randomized, controlled trials they double smoking cessation rates as compared with placebo treatment especially when combined with counseling.

No other antidepressant has had demonstrated efficacy for use in smoking cessation.

There is research on the efficacy of other med- ications, for example rimoabant and varenicline,

as well as a vaccination against nicotine.

Acupuncture, Hypnosis, Laser Therapy

There are no good randomized, controlled trials to support the efficacy of these options.

Relapse Control

When one wants to check if the patient has quit smoking one can measure the CO level in expired air. About 6 hours after the last cigarette this level should be <10ppm.

In urine, blood, or saliva one can measure the cotinine level. These determinations should be normalized within 24 hours. The topic should be addressed in all patients during the first years of follow-up.

Summary and Conclusion

Smoking is not just a bad habit. Because of nicotine, smoking is quickly and strongly addictive. This will result in a chronic change in the brain, causing a strong craving and a high chance of relapse after quitting. Greater understanding of the neurophysi- ological background of addiction, that is, the dis- ruption of the neuroreceptors, has increased the possibilities of treatment with medication.

Cardiac rehabilitation plays an important role

in supporting the patient to quit smoking. Fur-