Smoking cessation: integration of behavioral and drug therapies -- american family physician

Smoking Cessation: Integration
of Behavioral and Drug Therapies
ROBERT MALLIN, M.D., Medical University of South Carolina, Charleston, South Carolina
Family physicians should take advantage of each contact with smokers to encourage and
support smoking cessation. Once a patient is identified as a smoker, tools are available to

assess readiness for change. Using motivational interviewing techniques, the physician can
tion handout on howto stop smoking, writ- help the patient move from the precontemplation stage through the contemplation stage
to the preparation stage, where plans are made for the initiation of nicotine replacement
and/or bupropion therapy when indicated. Continued motivational techniques and sup-
port are needed in the action stage, when the patient stops smoking. Group or individual
behavioral counseling can facilitate smoking cessation and improve quit rates. Combined
use of behavioral and drug therapies can dramatically improve the patient’s chance of quit-
ting smoking. A plan should be in place for recycling the patient through the appropriate
stages if relapse should occur. (Am Fam Physician 2002;65:1107-14,1117. Copyright 2002
American Academy of Family Physicians.)

Identification of the Smoker and
Assessment of Readiness to Quit

on smoking, heightenedawareness of the conse-quences of smoking, andconsiderable publicity while a patient’s vital signs are being nies, statistics published within the past CAGE questionnaire (Table 1)7 or an (Figure 1)8,9 can provide information group, smoking rates increased by 32 per- about whether a patient is addicted to or patient’s readiness to change. The five- help.3 The advice of a physician alone can for “Practical Therapeu-tics.” This article is one patient does not believe that smoking is a every office or clinic visit. This article cessation. In the contemplation stage, the South Carolina. Guesteditor of the series is age the patient in the precontemplation stage Only 7.9 percent of smokers are able to quit without help. to think about his or her smoking and to con-sider the possibility that smoking is a prob- The combined use of nicotine replacement, social or behav- ioral support, and bupropion can increase the quit rate to Brief interventions can be effective in the precontemplation stage and as the patientmoves from one stage to the next.12 Effectiveinterventions include the following: preparation stage, the patient makes specific 1. Educate the patient about the effects of plans to stop smoking, such as setting a quit date and determining how smoking cessation will be accomplished. In the action stage, the patient stops smoking. Finally, the mainte- nance stage is marked by the patient’s contin- 4. Discuss the patient’s reactions to the physician’s feedback and recommendations.
smoking behavior is common. Patients often cycle through the stages of change several times before reaching stable abstinence.11 This process, known as “motivational inter- viewing,” uses empathy rather than con- Motivational Interviewing
frontation. It acknowledges that the patient, PRECONTEMPLATION STAGE
not the physician, is responsible for changing To select the most appropriate interventions, the family physician needs to know thepatient’s present readiness to change. Offer- CONTEMPLATION STAGE
ing a prescription for nicotine replacement to If further discussion on the return visit stage is unlikely to be successful, because smoking is a problem and would like to con- doing so essentially asks the patient to move sider quitting, the patient has entered the contemplation stage. Interventions to con- sider at this stage include providing further stages. Rather, the physician should encour- education about the effects of smoking andencouraging the patient to consider the pos-itive aspects of not smoking, such asimproved health, a more positive self image, CAGE Questionnaire for Smoking*
1. Have you ever tried to, or felt the need to, Cut down on your smoking?
Once the patient agrees that the benefits of 2. Do you ever get Annoyed when people tell you to quit smoking?
not smoking outweigh the pleasure derived 3. Do you ever feel Guilty about smoking?
from smoking and has decided to quit, he or 4. Do you ever smoke within one-half hour of waking up (Eye-opener)?
she has entered the preparation stage. At thispoint, it is appropriate to discuss various *—Two “yes” responses constitute a positive screening test. nicotine replacement systems, the possibleuse of bupropion, and the need for social and Adapted with permission from Lairson DR, Harrist R, Martin DW, Ramby R, RustinTA, Swint JM, et al. Screening for patients with alcohol problems: severity of family support. The physician should also patients identified by the CAGE. J Drug Educ 1992;22:337-52. help the patient develop a clear plan forsmoking cessation.
Smoking Cessation
Tasks for the patient and physician during the preparation stage may include the following10: Once a patient is in the preparation stage for quitting smok- 1. Setting a definite quit date. Often, a ing, it is appropriate to discuss specific smoking cessation meaningful date, such as a birthday or anni- versary, provides the patient with increasedmotivation.
tion. The patient should let family members meetings, frequent office visits, and/or tele- and other significant persons know that he or she has decided to quit smoking on a certain enhance the effectiveness of the cessation date, and should ask those individuals for should be to support continued smoking ces- patient to take part in a support group or a sation in the recently abstinent smoker. These contacts should be made at least weekly in the 3. Preparing the environment. The patient should be counseled to remove cigarettes, ashtrays, and other smoking-related para- It is important for the patient to report per- ceived benefits from having stopped smok- office. The patient should ask others not to ing, side effects of medications, and current or anticipated difficulty in maintaining absti- 4. Formulating plans to avoid triggers. When prompted, many patients can identify images,rituals, sensory experiences, and emotional Brief Fagerström Test for Nicotine Dependence
rewards that they associate with smoking. Thephysician and patient can begin to discuss Answer the two questions below. Check your total score against the scoring key.
healthy substitution behaviors that might help 1. How soon after waking do you smoke your first cigarette? prevent relapse. Counseling patients to avoid alcohol is a good strategy because drinking chance of successful smoking cessation.
5. Selecting a nicotine replacement system, 2. How many cigarettes do you smoke each day? bupropion is part of the smoking cessation plan, treatment should be initiated one to twoweeks before the quit date.
SCORING KEY: 5 to 6 points = heavy nicotine dependence; 3 to 4 points = mod-erate nicotine dependence; 0 to 2 points = light nicotine dependence. ACTION AND MAINTENANCE STAGES
The action stage begins on the quit date. By FIGURE 1. Abbreviated Fagerström Test for Nicotine Dependence. Fam- this date, bupropion should have been started ily physicians can use this quickly administered tool to evaluate inten- (if used), the nicotine replacement system of sity of nicotine dependence or addiction in their patients.
choice should be on hand (if used), and the Adapted with permission from Rustin TA. Pharmacologic treatment of nicotine dependence. In: The certification review course in addiction medicine for theAmerican Society of Addiction Medicine. Chevy Chase, Md.: American Society of cleared of smoking-related materials.
Addiction Medicine, 1998; based on information in Heatherton TF, Kozlowski LT, During the action stage, behavioral support Frecker RC, Fagerström KO. The Fagerström Test for Nicotine Dependence: a revi- through self-help or professionally run group sion of the Fagerström Tolerance Questionnaire. Br J Addict 1991;86:1119-27. Smoking Cessation
Include “Do you smoke?” with questions routinely asked while taking the patient’s vital signs.
Assess the patient’s nicotine dependence using the modified CAGE questionnaire (see Table 1) and/or the abbreviated Fagerström test (see Figure 1).
Use the five-stage transtheoretical model to assess the patient’s readiness to change.
Precontemplation stage (the patient thinks smoking is not a problem)
Interventions: Educate the patient about the effects of smoking, introduce
ambivalence (inquire about decision to continue smoking), express concern, and recommend quitting.
Physician statement introducing ambivalence: “Today most people agree that smoking is not good for your health. What do you think about that?” Physician statement expressing concern and encouraging contemplation: “I am concerned about your health and believe you should stop smoking. I am wondering how I can help you with that.” Contemplation stage (the patient thinks smoking may be a problem)
Interventions: Assess positive and negative thinking about smoking.
Physician statement resolving ambivalence: “Your cough will improve when
Preparation stage (the patient wants to quit smoking)
Interventions: Set a quit date, select smoking cessation strategies, determine dosage
of nicotine replacement if indicated, identify triggers, gather social support for quitting, and begin bupropion (Zyban) if indicated.
Physician statement encouraging planning and action: “Let’s set a date for you to quit smoking and make plans for how you can do it.” Action stage (the patient quits smoking)
Interventions: Begin nicotine replacement and continue bupropion.
Physician and staff maintain frequent contact with the patient to provide support
and help provide solutions for dealing with specific triggers.
Maintenance stage
Relapse (the patient starts smoking again)
Interventions: Reassess readiness to change and enter at appropriate stage; identify reasons for relapse and consider how things might be done Physician supports another attempt and, when the patient is ready, works with the patient to develop a more effective smoking cessation plan.
FIGURE 2. A suggested approach to smoking cessation, based on the transtheoretical model forreadiness to change.
Smoking Cessation
nence. Healthy substitution behaviors may ily nicotine-dependent smokers.17 Nicotine replacement is initiated on the quit date.
Nicotine Patch. A number of transdermal tion, based the transtheoretical model, is out- nicotine replacement systems (Habitrol, Nico- derm CQ, Nicotrol) are available over thecounter. The results of the Fagerström Test for Pharmacotherapy
Nicotine Dependence can be used to deter- mine the appropriate starting patch strength drawal include irritability, anxiety, decreased for a patient.9 However, the proper initial heart rate, increased appetite, food cravings, dose can be determined more quickly using restlessness, and difficulty concentrating.15 In the patient’s score on the abbreviated Fager- ström test (Figure 18,9): a score of 5 to 6 war- dependence (Figure 1),8,9 medications that rants use of the 21-mg nicotine patch; a score lessen these signs and symptoms can help to of 3 to 4 means that the 14-mg nicotine patch prevent relapse in the early stages of smoking is appropriate for initial therapy; and a score of zero to 2 indicates initial use of the 7-mgnicotine patch.8 NICOTINE REPLACEMENT
Adverse reactions to transdermal nicotine Nicotine replacement by any delivery sys- replacement systems seldom cause discontinu- ation of therapy. From 30 to 50 percent of cessation rate.16 Currently, four forms of nico- patients experience mild skin irritation under tine delivery are available: patch, gum, inhaler, the patch. In most patients, this problem can and nasal spray. Some data indicate that use of be alleviated by rotating patch application a combination of delivery methods, such as sites. Sleep disruption is usually resolved by the gum and the patch, may be useful in heav- TABLE 2
Effective Pharmacotherapy for Nicotine Withdrawal
*—Estimated cost to the pharmacist for 30 days of treatment, based on average wholesale prices (rounded to the nearest dollar) in Redbook. Montvale, N.J.: Medical Economics Data, 2001. Cost to the patient will be higher, depending on prescription filling fee. It is important to discourage patients from available by prescription. The nicotine is pri- smoking while they are using the nicotine patch. The combination of smoking and nico- (36 percent) and the esophagus and stomach tine patch use results in discomfort from (36 percent), rather than through the lungs higher nicotine levels; more importantly, it (4 percent). Currently, four inhalers a day increases the likelihood of relapse to virtually must be used to achieve adequate nicotine 100 percent.18 Concerns about sudden cardiac levels. Hence, frequent dosing is required, death as a result of concomitant smoking and with each inhaler containing 500 puffs. Side nicotine patch use have been allayed by two effects include mouth and throat irritation.21 clinical trials19,20 that showed no increase in Nicotine Nasal Spray. Nicotine replacement morbidity or mortality associated with nico- can also be accomplished with a nasal spray tine patch use in smokers with heart disease.
(Nicotrol NS), which is available by prescrip- Nicotine patches should be used for about tion. The use of four sprays per hour or a eight to 12 weeks. Tapering to the next lowest dose (e.g., 21 mg to 14 mg) can be done after mended. Nasal and throat irritation, rhinor- four to six weeks. The patient who starts with rhea, and nausea are common side effects.
the 7-mg patch should continue using that Comparison of Delivery Systems. Data are lacking on which nicotine delivery system is Nicotine Gum. Nicotine polacrilex (Nico- most effective. Because all four systems appear rette) is available over the counter in 2-mg and to be efficacious, patient preference usually 4-mg strengths. The gum is most effective in determines the choice of nicotine replacement the 4-mg strength, with initial use of 10 to 15 modality. For example, the patient who needs pieces of gum per day. After two weeks, most to be doing something with his or her hands patients can change to the 2-mg strength.
may prefer the nicotine inhaler over the nico- The most important adverse events associ- ated with nicotine gum appear to be gastroin- about gaining weight may prefer to use nico- testinal side effects from swallowing large tine gum, which has been shown to delay (but improperly. Nicotine gum is intended to be parked in the buccal area and chewed once ortwice every few minutes. If the gum is chewed BUPROPION
too quickly, nicotine is swallowed with saliva, been shown to have similar positive effects on Nicotine Inhaler. A nicotine inhalation sys- tem (Nicotrol Inhaler) has recently become appears to be the most effective treatment fornicotine dependence.
nephrine, serotonin, and dopamine. Themechanism by which bupropion enhances the ability of patients to abstain from smok- ROBERT MALLIN, M.D., is assistant professor in the Department of Family Medicine at ing is unknown; however, the drug is believed the Medical University of South Carolina, Charleston. He received his medical degreefrom the University of South Carolina School of Medicine, Columbia, where he also to reduce the urge to smoke through its effect completed a family practice residency at Richland Memorial Hospital. Dr. Mallin is on the norepinephrine and dopamine neuro- board certified in family practice and is also certified by the American Society of Addic- One controlled trial5 found that bupropion Address correspondence to Robert Mallin, M.D., Department of Family Medicine, therapy resulted in a 12-month abstinence Medical University of South Carolina, 295 Calhoun St., P.O. Box 250192, Charleston,SC 29425 (e-mail: Reprints are not available from the author. rate of 30 percent, compared with 16 percent Smoking Cessation
for nicotine replacement therapy alone. Com-bination therapy using bupropion plus nico- If bupropion is to be used in smoking cessation, the drug tine replacement resulted in an even higher should be started one to two weeks before the planned Bupropion therapy is initiated in a dosage of 150 mg per day for three days. The dosage is then increased to 150 mg twice daily. Thequit date should be set for one to two weeks to review the treatment plan to determine after bupropion therapy is initiated. Bupro- pion therapy is usually continued for eight to A patient may not return immediately after 12 weeks after the patient has quit smoking.
a relapse and may smoke for months before Contraindications to the use of bupropion another visit. At that point, the patient’s readi- include a history of seizure disorder and the ness to change needs to be reevaluated, and the presence of eating disorders or uncontrolled smoking cessation process must be repeated.
hypertension. The most common side effects Nicotine dependence is a tenacious and dif- of the drug are dry mouth and sleep distur- ficult addiction to treat successfully. Clearly, perseverance on the part of the patient and the physician is most effective for achieving permanent abstinence. The use of nicotinereplacement and bupropion can improve OTHER DRUGS
results, and the application of readiness-to- Silver acetate, which causes cigarettes to have change strategies and motivational interview- a bad taste, has been used as a smoking ces- ing techniques are essential for success.
sation aid for many years. The literature con- Behavioral therapy and support in a group tains no support for this agent as an effective rates. Individual counseling can also be effec- tive. A supportive telephone call during the azepines have been used to reduce the anxiety first few days of abstinence may help the associated with nicotine withdrawal. However, patient who is trying to quit smoking.26,27 treatment with benzodiazepines has not beenshown to improve smoking cessation rates.
The author indicates that he does not have any con- Clonidine (Catapres) initially appeared to flicts of interest. Sources of funding: none reported. be useful in the treatment of nicotine with-drawal,24 but long-term quit rates did not im- 1. State-specific prevalence of cigarette smoking The addition of mecamylamine (Inversine), among adults, and children’s and adolescents’exposure to environmental tobacco smoke—United a ganglionic blocker classified as an antihyper- States, 1996. MMWR Morb Mortal Wkly Rep 1997; tensive agent, to transdermal nicotine replace- ment has been shown to improve the absti- 2. Rigotti NA, Lee JE, Wechsler H. US college students’ use of tobacco products: results of a national sur- nence rate in smokers, compared with use of 3. Cigarette smoking among adults—United States, Dealing with Relapse
4. Jorenby DE, Fiore MC. The Agency for Health Care Most patients relapse within the first six to Policy and Research smoking cessation clinical 12 months of a smoking cessation attempt. If practice guideline: basics and beyond. Prim Care1999;26:513-28.
a patient relapses, the physician needs to 5. Jorenby DE, Leischow SJ, Nides MA, Rennard SI, encourage the patient to try again. It is useful Johnston JA, Hughes AR, et al. A controlled trial of Smoking Cessation
sustained-release bupropion, a nicotine patch, or 17. Kornitzer M, Boutsen M, Dramaix M, Thijs J, Gus- both for smoking cessation. N Engl J Med 1999; tavsson G. Combined use of nicotine patch and gum in smoking cessation: a placebo-controlled 6. Fiore MC. Smoking cessation. Rockville, Md.: U.S.
clinical trial. Prev Med 1995;24:41-7.
Dept. of Health and Human Services, Public Health 18. Gourlay SG, Forbes A, Marriner T, Pethica D, Service, Agency for Health Care Policy and McNeil JJ. Prospective study of factors predicting Research, Centers for Disease Control and Preven- outcome of transdermal nicotine treatment in tion, 1996. Clinical practice guideline no. 18; smoking cessation. BMJ 1994;304:842-6.
19. Joseph AM, Norman SM, Ferry LH, Prochazka AV, 7. Lairson DR, Harrist R, Martin DW, Ramby R, Rustin Westman EC, Steele BG, et al. The safety of trans- TA, Swint JM, et al. Screening for patients with dermal nicotine as an aid to smoking cessation in alcohol problems: severity of patients identified by patients with cardiac disease. N Engl J Med 1996; the CAGE. J Drug Educ 1992;22:337-52.
8. Rustin TA. Pharmacologic treatment of nicotine 20. Nicotine replacement therapy for patients with dependence. In: The certification review course in coronary artery disease. Working Group for the addiction medicine for the American Society of Study of Transdermal Nicotine in Patients with Coro- Addiction Medicine. Chevy Chase, Md.: American nary Artery Disease. Arch Intern Med 1994;154: Society of Addiction Medicine, 1998.
9. Heatherton TF, Kozlowski LT, Frecker RC, Fager- 21. Fant RV, Owen LL, Henningfield JE. Nicotine ström KO. The Fagerström Test for Nicotine Depen- replacement therapy. Prim Care 1999;26:633-52.
dence: a revision of the Fagerström Tolerance 22. A clinical practice guideline for treating tobacco Questionnaire. Br J Addict 1991;86:1119-27.
use and dependence: a US Public Health Service 10. Rustin TA. Assessing nicotine dependence. Am report. The Tobacco Use and Dependence Clinical Practice Guideline Panel, Staff, and Consortium 11. Prochaska JO, DiClemente CC, Norcross JC. In Representatives. JAMA 2000;283:3244-54.
search of how people change. Applications to 23. Lancaster T, Stead LF. Silver acetate for smoking addictive behaviors. Am Psychol 1992;47:1102-14.
cessation. Cochrane Database Syst Rev 2000;(2): 12. Barnes HN, Samet JH. Brief interventions with sub- stance-abusing patients. Med Clin North Am 24. Glassman AH, Jackson WK, Walsh BT, Roose SP, Rosenfeld B. Cigarette craving, smoking with- 13. Miller WR, Rollnick S. Motivational interviewing: drawal, and clonidine. Science 1984;226:864-6.
preparing people to change addictive behavior.
25. Rose JE, Behm FM, Westman EC, Levin ED, Stein 14. Fiore MC, Novotny TE, Pierce JP, Giovino GA, nicotine skin patch facilitates smoking cessation Hatziandreu EJ, Newcomb PA, et al. Methods used beyond nicotine patch treatment alone. Clin Phar- to quit smoking in the United States. Do cessation programs help? JAMA 1990;263:2760-5.
26. Lancaster T, Stead LF. Individual behavioural coun- 15. Rustin TA. Management of nicotine withdrawal. In: selling for smoking cessation. Cochrane Database Graham AW, Schultz TK, Wilford BB, eds. Principles of addiction medicine. 2d ed. Chevy Chase, Md.: 27. Carlson LE, Taenzer P, Koopmans J, Bultz BD. Eight- American Society of Addiction Medicine, 1998: year follow-up of a community-based large group behavioral smoking cessation intervention. Addict 16. Prochazka AV. New developments in smoking ces- sation. Chest 2000;117(4 suppl):169S-75S.


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