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Tobacco Use and Smoking Cessation

Felix B. Chang Cruz, MD, FAAMA, ABIHM and Roberto S. Amado, MD Reviewed 06/2020
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Subject: Tobacco Use and Smoking Cessation

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BASICS

Use of tobacco of any form 

DESCRIPTION

  • The second leading actual cause of death in the United States

  • Smokeless tobacco refers to tobacco products that are vaporized, sniffed, sucked, or chewed.

  • Nicotine sources: cigars, pipes, water pipes, hookahs, cigarettes, and electronic cigarettes

  • Electronic nicotine delivery system (ENDS) use is on the rise.

  • History of using e-cigarette, or vaping, products

EPIDEMIOLOGY

The Centers for Disease Control (CDC) reported that there are 1,080 cases of lung illness reported from 48 states and 1 U.S territory related to vaping and/or e-cigarette use. Eighteen deaths have been confirmed in 15 states. 

Incidence

  • 2.4 million new smokers annually in the United States (2.6% initiation rate)

  • 59% of new smokers are <18 years of age (5.8% initiation rate for teens).

  • 9.7 million people age >18 years smoke 20 or more cigarettes daily.

Prevalence

  • 14% of all adults (34.3 million people): 15.8% of males, 12.2% of females are current cigarette smokers.

  • Age: highest among those ages 45 to 64 years (16.5%)

  • Race: highest among Native Americans (24.0%) and lower among Hispanics (9.9%) and Asians (7.1%)

  • Gender: male > female (15.8% vs. 12.2%)

  • Education: inversely proportional to education level

  • Psychological association: nearly 36% of adults with a serious psychological distress compared to 14% without this distress

  • Cigarette smoking is responsible for >480,000 deaths per year in the United States, including >41,000 deaths from secondhand smoke exposure. This is about 1 in 5 deaths annually or 1,300 deaths every day.

  • Overall, in 2016, 15.3% of adults had ever used an e-cigarette, 3.2% were current users.

  • The prevalence of current e-cigarette use was highest in current cigarette smokers 10.8%, followed by former smokers 4.8%.

  • In 2018, 21% of high school students reported current use of e-cigarettes, up from 12 percent in 2017.

  • 5% of middle school students reported current e-cigarette use.

  • Approximately 80% of patients are under 35 years old. 16% of patients are under 18 years old, 21% of patients are 18 to 20 years old.

ETIOLOGY AND PATHOPHYSIOLOGY

  • Addiction due to nicotine’s rapid stimulation of the brain’s dopamine system (teenage brain especially susceptible)

  • Atherosclerotic risk due to adrenergic stimulation, endothelial damage, carbon monoxide, and adverse effects on lipids

  • Direct airway damage from cigarette tar

  • Carcinogens in all tobacco products

  • E-cigarettes range from nicotine free up to 36 mg/ml.

  • Potential adverse effects of e-cigarettes are related to exposure to nicotine as well as to other vapor components produced by the devices and risk of actual device.

  • If e-cigarette, or vaping product use is suspected as a possible etiology of a patient’s lung injury, obtain detailed history regarding:

    • Substance(s) used: nicotine, cannabinoids (e.g., marijuana, THC, THC concentrates, CBD, CBD oil, synthetic cannabinoids [e.g., K2 or spice], hash oil, Dank vapes), flavors, or other substances

    • Substance source(s): commercially available liquids (i.e., bottles, cartridges, or pods), homemade liquids, and re-use of old cartridges or pods with homemade or commercially bought liquids

    • Device(s) used: manufacturer; brand name; product name; model; serial number of the product, device, or e-liquid; product/device customization or modification by the user (e.g., exposure of the atomizer or heating coil)

RISK FACTORS

  • Presence of a smoker in the household

  • Easy access to cigarettes

  • Comorbid stress and psychiatric disorders

  • Low self-esteem/self-worth

  • Poor academic performance

  • Boys: high levels of aggression and rebelliousness

  • Girls: preoccupation with weight and body image

  • Electronic cigarette use has been associated with several cases of idiopathic acute eosinophilic pneumonia

  • Lipoid pneumonia associated with inhalation of lipids in aerosols generated by e-cigarettes has been reported.

GENERAL PREVENTION

  • Most first-time tobacco use occurs before high school graduation.

  • The Tar Wars program of the American Academy of Family Physicians has successfully targeted tobacco use prevention in 4th and 5th graders.

  • Smoking bans in public areas and workplaces

  • Restriction of minors’ access to tobacco

  • Restrictions on tobacco advertisements

  • Raising prices through taxation

  • Media literacy education

  • Tobacco-free sports initiatives

COMMONLY ASSOCIATED CONDITIONS

  • Coronary artery disease

  • Cerebrovascular disease

  • Peripheral vascular disease

  • Abdominal aortic aneurysm (AAA)

  • Chronic obstructive coronary disease (COPD)

  • Cancer of the lip, oral cavity, pharynx, larynx, lung, esophagus, stomach, pancreas, kidney, urinary bladder, cervix, and blood

  • Pneumonia, osteoporosis

  • Periodontitis

  • Alcohol use

  • Depression and anxiety

  • Reduced fertility

  • Vaping/e-cigarette use has been associated with cough, shortness of breath, fatigue, fever, chest pain, weight loss, nausea, and diarrhea.

Pregnancy Considerations

Women who smoke or are exposed to secondhand smoke during pregnancy have increased risks of miscarriage, placenta previa, placental abruption, premature rupture of membranes, preterm delivery, low-birth-weight infants, and stillbirth.

 
Pediatric Considerations
  • Secondhand smoke increases the risk for:

    • Sudden infant death syndrome

    • Acute upper and lower respiratory tract infections

    • More severe exacerbations of asthma

    • Otitis media and need for tympanostomies

  • Nicotine passes through breast milk. Effects on growth and development of nursing infants are unknown.

 

DIAGNOSIS

HISTORY

  • Ask about tobacco use and secondhand smoke exposure at every physician encounter.

  • Type and quantity of tobacco used:

    • “Heavy smoking” is 20 or more cigarettes per day or 20 or more pack-years.

    • Pack-years = packs/day × years. Twenty pack-years is equivalent to a pack a day for 20 years or 2 packs a day for 10 years. Other common cut points for heavy smoking include 15 and 25 cigarettes per day.

  • Assess for awareness of health risks.

  • Assess interest in quitting.

  • Identify triggers for smoking: stress, habit, pleasure.

  • Prior attempts to quit: method, duration of success, reason for relapse

PHYSICAL EXAM

  • General: tobacco smoke odor, staining of facial hair

  • Skin: premature wrinkling, especially the face

  • Mouth: nicotine-stained teeth; inspect for mucosal changes, hypertrophy, fungating lesions.

  • Lungs: crackles, wheezing, increased or decreased volume, chronic cough

  • Vessels: carotid or abdominal bruits, abdominal aortic enlargement or aneurysm, weak peripheral pulses, stigmata of peripheral vascular disease

DIAGNOSTIC TESTS & INTERPRETATION

  • Chest x-ray for patients with pulmonary symptoms or signs of cancer but not for screening

  • The U.S. Preventive Services Task Force (USPSTF) recommends one-time screening abdominal ultrasound (US) for AAA in men ≥65 years of age who ever smoked (number needed to screen to prevent one AAA = 500).

  • Low-dose computed tomography is more sensitive than chest radiograph for identifying small, asymptomatic lung cancers.

  • USPSTF recommends yearly screening for lung cancer with low-dose CT for individuals 55 to 80 years with a 30 pack-years history of smoking; current smokers or those who have quit within past 15 years

Diagnostic Procedures/Other

Pulmonary function tests for smokers with chronic pulmonary symptoms, such as wheezing, cough, or dyspnea. This includes spirometry, diffusion studies, and body plethysmography. 

TREATMENT

Both behavioral counseling and pharmacotherapy benefit patients who are trying to quit smoking especially when used in combination. 
ALERT

Report cases of lung injury of unclear etiology and a history of e-cigarette or vaping product use within the past 90 days to state or local health department. Ask all patients who report e-cigarette or vaping product use within the last 90 days about signs and symptoms of respiratory illness.

 

GENERAL MEASURES

  • Behavioral counseling includes the 5 As:

    • Ask about tobacco use at every office visit.

    • Advise all smokers to quit.

    • Assess the patient’s willingness to quit.

    • Assist the patient in his or her attempt to quit and provide quit line number (1-800-QUIT-NOW in the United States).

    • Arrange follow-up and support.

  • Patients ready to quit smoking should set a quit date within the next 2 weeks; no difference in success rates between patients who taper prior to their quit date and those who stop abruptly

  • Success increased with a quitting partner, such as a spouse, friend, or coworker, to provide mutual encouragement.

MEDICATION

First Line

  • Varenicline (Chantix): 0.5 mg/day PO for 3 days, then 0.5 mg BID for 4 days, and then 1 mg BID for 11 weeks (1)[A]:

    • Start 1 to 4 weeks prior to smoking cessation and continue for 12 to 24 weeks.

    • Superior versus placebo and bupropion; number needed to treat = 6 and 15, respectively

    • May be combined with nicotine replacement therapy (NRT) for those with cravings

    • Side effects: nausea, insomnia, headache, depression, suicidal ideation; safety not established in adolescents or patients with psychiatric or cardiovascular disease; pregnancy Category C

  • Bupropion SR (Zyban): 150 mg PO for 3 days and then 150 mg BID:

    • Start 1 week prior to smoking cessation and continue for 7 to 12 weeks.

    • Twice as effective as placebo

    • Drug of choice for patients with depression or schizophrenia; additional benefit of weight loss

    • May be combined with varenicline and NRT in men who smoke >1 PPD

    • Side effects: tachycardia, headache, nausea, insomnia, dry mouth; contraindicated in patients who have seizure disorders or anorexia/bulimia; pregnancy Category C (1)[A]

  • NRT (e.g., patch, gum, lozenge, inhaler, nasal spray) (1)[A]:

    • Improves quit rates by 50–70% versus placebo

    • Available over the counter

    • Patch (NicoDerm CQ 21, 14, and 7 mg):

      • 1 patch q24h

      • Start with 21 mg if smoking ≥10 cigarettes per day; otherwise, start with 14 mg.

      • 6 weeks on initial dose and then taper

      • 2 weeks each on subsequent doses

      • No proven benefit beyond 8 weeks

    • ENDS—electronic nicotine delivery systems

      • Contain less nicotine than cigarette

      • Controversial if less “dangerous” than tobacco; not well studied as NRT

      • Conflicting data on whether teen use increases or decreases risk to cigarette progression

      • Not an effective adjunct for cessation

    • Gum (Nicorette, 2 and 4 mg):

      • Use 4 mg if smoking ≥25 cigarettes per day.

      • Chew 1 piece q1–2h for 6 weeks, then 1 piece q2–4h for 3 weeks, and then 1 piece q4–8h for 3 weeks.

    • May use in combination with bupropion; monitor for hypertension.

    • Side effects: headache, pharyngitis, cough, rhinitis, dyspepsia; all mainly with inhaler and spray forms

    • Pregnancy Category D

    • NRT is reasonable in hospitalized smokers because NRT products immediately treat nicotine withdrawal symptoms, whereas varenicline and bupropion take time to reach steady state.

Second Line

  • Nortriptyline: 25 to 75 mg/day PO or in divided doses (1)[A]:

    • Start 10 to 14 days prior to smoking cessation and continue for at least 12 weeks.

    • Efficacy similar to bupropion, but side effects are more common; pregnancy Category D

    • The antidepressants bupropion and nortriptyline aid long-term smoking cessation (2)[A].

  • Clonidine: 0.1 mg PO BID or 0.1 mg/day transdermal patch weekly (1):

    • Side effects: hypotension, bradycardia, depression, fatigue; pregnancy Category C

ADDITIONAL THERAPIES

  • Electronic cigarettes: low grade of evidence

  • Pharmacotherapy and behavior support increase success compared with minimal intervention or usual care (2)[A].

  • Naltrexone: no evidence

  • Individual behavioral counseling for smoking cessation increases effectiveness for both those with pharmacotherapy and without pharmacotherapy.

COMPLEMENTARY & ALTERNATIVE MEDICINE

Acupuncture, aversive therapy, and hypnosis have not been proven to enhance long-term smoking cessation. 

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

Intense counseling interventions in hospitalized patients combined with hospital follow-up for more than 1 month after discharge showed significant improvement in smoking cessation rates at 6 months or more post discharge. 

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

  • Follow up 3 to 7 days after scheduled quit date and at least monthly for 3 months thereafter.

  • Refraining from tobacco products for first 2 weeks is critical to long-term abstinence.

  • Encourage patients who relapse to try again.

  • E-cigarettes and vaping increasingly related to significant lung disease. This is an area of rapid health policy change.

Patient Monitoring

  • Short-term withdrawal symptoms include dysphoria, depressed mood, irritability, anxiety, insomnia, increased appetite, and poor concentration.

  • Longer term risks of smoking cessation include weight gain (4 to 5 kg on average) and depression.

  • Quitting is also associated with exacerbations of ulcerative colitis and worsening of cognitive function in patients with schizophrenia.

  • Nicotine withdrawal syndrome: dysphoric or depressed mood, insomnia, irritability, frustration, or anger; anxiety, difficulty concentrating, restlessness, and increased appetite or weight gain

  • Lung cancer risk by smoking status: heavy smokers 1.00, light smokers 9.44 (0.35 to 0.56), ex-smokers 0.17 (0.13 to 0.23), never smoker 0.09 (0.06 to 0.13); adjusted hazard ratio (95% CI)

PATIENT EDUCATION

PROGNOSIS

  • Measurable cardiovascular benefits of smoking cessation begin as early as 24 hours after quitting and continue to mount until the risk is reduced to that of nonsmokers by 5 to 15 years.

  • People who quit smoking after a heart attack or cardiac surgery reduce their risk of death by 1/3.

  • Relapse rates initially >60% but decrease to 2–4% per year after completing 2 years of abstinence

  • >16 million Americans are living with a disease caused by smoking or exposure to tobacco smoke.

  • For every smoking-related death, at least another 30 people live with a serious smoking-related illness.

  • Smokers die of 10 years earlier than nonsmokers.

  • Pharmacotherapy for preoperative smokers increases cessation rates and decreases postoperative complications.

COMPLICATIONS

  • Disability and premature death due to heart attack, stroke, cancer, COPD

  • Smoking more than doubles the risk of coronary artery disease and doubles the risk of stroke.

  • Worldwide, tobacco use causes nearly 6 million deaths per year, and current trends show that tobacco use will cause >8 million deaths annually by 2030.

  • Screening by low-dose CT include complications associated with needle biopsy, bronchoscopy, and thoracotomy from false positives.

REFERENCES

1
Cahill K, Stevens S, Perera R, et al. Pharmacological interventions for smoking cessation: an overview and network meta-analysis. Cochrane Database Syst Rev.  2013;(5):CD009329.
2
Stead LF, Koilpillai P, Fanshawe TR, et al. Combined pharmacotherapy and behavioural interventions for smoking cessation. Cochrane Database Syst Rev.  2016;(3):CD008286.

ADDITIONAL READING

SEE ALSO

Nicotine Addiction; Substance Use Disorders 

CODES

ICD10

  • F17.210 Nicotine dependence, cigarettes, uncomplicated

  • F17.213 Nicotine dependence, cigarettes, with withdrawal

  • F17.211 Nicotine dependence, cigarettes, in remission

  • Z71.6 Tobacco abuse counseling

  • F17.219 Nicotine dependence, cigarettes, w unsp disorders

  • F17.218 Nicotine dependence, cigarettes, w oth disorders

ICD9

  • 305.1 Tobacco use disorder

  • V15.82 Personal history of tobacco use

  • V65.42 Counseling on substance use and abuse

SNOMED

  • 89765005 Tobacco dependence syndrome (disorder)

  • 56294008 Nicotine dependence (disorder)

  • 191887008 Tobacco dependence, continuous

  • 191889006 Tobacco dependence in remission

  • 191888003 Tobacco dependence, episodic (disorder)

CLINICAL PEARLS

  • Every patient who uses tobacco should be offered cessation advice.

  • Depression with suicidal ideations is no longer a contraindication to varenicline use; FDA

  • Refrain from using e-cigarettes and vaping products.

  • Nicotine replacement (delivered by nicotine polacrilex gum, nicotine lozenges, nicotine nasal spray, and transdermal nicotine) has an effect comparable to cigarette smoking in terms of increasing myocardial work and endothelial damage. The risks associated with NRT in patients with cardiac disease, however, are lower than the risks of ongoing smoking.

  • Electronic nicotine delivery systems (ENDS) are not an effective adjunct for tobacco cessation.

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