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Smoking cessation for pulmonary patients

This is an excerpt from Practical Pharmacology in Rehabilitation With Web Resource by Lynette Carl,Joseph Gallo & Peter Johnson.

Smoking Cessation

Smoking cessation continues to be the most important therapeutic intervention in the pulmonary patient. Many patients with COPD have a history of smoking, and many currently smoke. A smoking-cessation plan is an essential part of a comprehensive management strategy. Success rates associated with smoking cessation are low. Any smoking-cessation program must involve multiple interventions. According to the U.S. Preventative Services Task Force guidelines, clinicians should ask all adults about use of tobacco products and should provide interventions to encourage smoking cessation to smokers.

The guideline uses a “five A” approach to counseling:

• Ask about tobacco use.
• Advise to quit through personalized messages.
• Assess willingness to quit.
• Assist smoking cessation.
• Arrange for follow-up.

The transition from smoking to abstention from smoking consists of five stages: pre-contemplation, contemplation, preparation, action, and maintenance. Depression and anxiety can negatively affect the COPD patient's motivation to quit smoking. It is therefore important for health care providers to be aware of the signs of psychological problems when smoking cessation is advised (Fischer et al., 2007).

Physicians and other health care providers should help the patient set the target quit date and should follow up with respect to progress in following the plan for smoking cessation. Brief (

Supervised use of pharmacologic agents is an important adjunct to self-help and group smoking-cessation programs. Medications used to help patients stop smoking include nicotine-replacement products such as nicotine patches and oral medications such as Chantix or Zyban. Table 22.3 summarizes medications used to assist with smoking cessation.

Nicotine is the ingredient in cigarettes that is primarily responsible for addiction. Withdrawal from nicotine may cause adverse effects including anxiety, irritability, difficulty concentrating, anger, fatigue, drowsiness, depression, and sleep disruption. These effects usually occur during the first several weeks of any attempt at smoking cessation. Nicotine-replacement therapies help reduce withdrawal symptoms. A smoker who requires a cigarette within 30 min of waking is likely to be highly addicted and could benefit from nicotine-replacement therapy.

Several nicotine-replacement therapies exist. Nicotine polacrilex is a chewing gum that leads to better quit rates than counseling alone. Nicotine-replacement chewing pieces are marketed in two strengths: 2 mg and 4 mg. An individual who smokes 1 pack/day should use the 4 mg pieces, and an individual who smokes less than 1 pack/day should use the 2 mg pieces. For the first 2 wk, patients should chew a piece hourly as well as at the time of cravings. Patients should gradually reduce frequency of chewing over the next 3 mo. Transdermal nicotine patches are also readily available. Long-term success rates of patches range from 22% to 42% whereas those of a placebo range from 2% to 25%. These agents are well tolerated and the adverse effects are limited to localized skin reaction. Nicotine patches are sold under the trade names NicoDerm CQ, Nicotrol, and Habitrol. The usual dosing schedule is the same for all three brands. Individuals who smoke more than 1 pack/day should initially place the 21 mg patch on the skin each day for 30 days, then apply the 14 mg patch for 30 days, and then apply the 7 mg patch for 30 days. Those that smoke less than 1 pack/day should start with the 14 mg patch for 30 days and then apply the 7 mg patch for 30 days. There is no benefit to using nicotine replacement patches for more than 2 months.

Bupropion (Zyban) is an antidepressant that is effective in smoking cessation. Twenty-three percent of smokers using bupropion maintained cessation 1 yr after quitting whereas only 12% of smokers using a placebo maintained cessation. Bupropion was shown to be effective when used in patients who failed to quit smoking while using nicotine-replacement therapy.

Varenicline (Chantix) binds to nicotinic acetylcholine receptors and prevents nicotine from binding to these receptors. This product also provides 44% successful quit rates compared to 12% attained with counseling alone. The dose should be titrated up to 1 mg by mouth twice/day after meals at least 1 wk before the quit date. The dose should be decreased to 0.5 mg twice/day in patients with severe renal impairment or to 0.5 mg/day in patients with end-stage renal disease. Serious neuropsychiatric symptoms, reported during post-marketing surveillance, may include changes in behavior, agitation, depressed mood, suicidal ideation, and attempted and completed suicide (Sharma & Arneja, 2010; U.S. Preventative Services Task Force, 2009).

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