Clinical Guide > Maintenance and Prevention > Smoking Cessation

# Smoking Cessation

*Author:* Jeffery  Kwong, MS, MPH, ANPJanuary 2011

### Chapter Contents

      - Background
      - S: SubjectiveO: ObjectiveA/P: Assessment and PlanPatient Education
Suggested Resources
ReferencesTable 1. The Five A's Model for Treating Tobacco Use and DependenceTable 2. Pharmacologic Options for Smoking CessationHRSA HAB Core Clinical Performance MeasuresBackground
According to the U.S. Centers for Disease Control and Prevention, smoking prevalence among the general adult population in the United States is approximately 20%. Among HIV-infected persons, the prevalence of cigarette smoking appears to be two to three times greater than in the general population, with estimates ranging from 50% to 70%.

The health effects of cigarette smoking are extensive and have been well documented. There are approximately 400,000 smoking-related deaths annually in the United States. HIV-infected smokers appear to be at higher risk of a variety of tobacco-related conditions than HIV-uninfected smokers. These include lung cancer, head and neck cancers, cervical and anal cancers, oral candidiasis, and oral hairy leukoplakia. HIV-infected smokers who smoke are more likely to develop the conditions listed above, as well as bacterial pneumonia, *Pneumocystis jiroveci* pneumonia, other pulmonary conditions, and cardiovascular disease. Additionally, HIV-infected smokers have been shown to have a decreased immunologic and virologic response to antiretroviral therapy.

Thus, for HIV-infected persons, even more so than for HIV-uninfected persons, clinicians should consider smoking cessation a health care priority. Although many care providers may feel that they can do little to affect the smoking behaviors of patients, evidence suggests that brief interventions by physicians are quite effective. Studies indicate that smoking cessation interventions as brief as 3 minutes in duration, when delivered by a physician, have a positive impact on abstinence rates of current smokers. Furthermore, studies have found that more than half of current HIV-infected smokers have expressed interest in, or have thought about, smoking cessation.

Cigarettes are highly addictive; the U.S. Surgeon General has equated the addictive potential of cigarettes to that of heroin and cocaine. This is in part because nicotine stimulates the release of several neurotransmitters in the brain, including dopamine. Over time, chronic exposure to nicotine causes physiologic changes in the brain that contribute to the addictive potential of cigarettes.

Cigarette smoking involves dependence on more than a single chemical compound, however. It is a multidimensional behavior that has both physiologic and psychological components. Therefore, smoking cessation efforts often require a combined approach to be successful.
Behavioral model for smoking cessation
Several behavioral models present a psychological framework for understanding individuals who are attempting to change behaviors. The transtheoretical model of health behavior change is one of the more frequently cited frameworks for understanding the stages of behavior change of smokers. According to this model, there are five phases of behavior change: precontemplation, contemplation, preparation, action, and maintenance. Using this framework, clinicians can devise interventions that are most appropriate for the patient's current stage on the continuum.
- Precontemplation:  The individual does not expect to make any change in behavior within the next 6 months. At this stage, the individual is resistant to hearing or learning about health behavior change.
- Contemplation:  The individual plans to make a behavior change within the next 6 months. This stage is characterized by ambivalence about smoking.
- Preparation:  The individual anticipates making a behavior change within the next month. Individuals in this phase have made plans for taking action and intend to make a change.
- Action:  The individual has made a significant change; in the case of smoking cessation, this means that the individual has quit completely.
- Maintenance:  The individual attempts to prevent relapse.

Patients may move back and forth among these stages at various points during the process of smoking cessation.
Cessation interventions in the clinic
As suggested above, brief smoking cessation interventions delivered by clinicians can significantly increase abstinence rates of current smokers. The U.S. Surgeon General has developed guidelines for clinicians to use during clinic visits to help patients who are interested in smoking cessation. These include use of the Five A's model, which provides a brief and structured framework for addressing smoking cessation in clinical settings (see Table 1).
Table 1. The Five A's Model for Treating Tobacco Use and DependenceComponentActionExample
Adapted from Fiore MC, Jaén CR, Baker TB, et al. *Treating Tobacco Use and Dependence: 2008 Update*. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service; May 2008. 
ASK every patient about tobacco useIdentify and document tobacco use at **every visit.**Incorporate questions about tobacco use when obtaining vital signs or when reviewing a patient's history. - "Do you currently use tobacco?"
- "Do you currently smoke cigarettes?"
ADVISE to quitUsing **a clear, strong, and personalized message**, urge every tobacco user to quit.- "It is important for you to quit smoking now."
- "Quitting is the most important thing you can do to protect your health."
- "I can help you quit."
 Also link smoking with something specific to the patient, such as secondhand exposure to children or partners, his/her own lung, cardiovascular, or cancer risk, or the expense of cigarettes. ASSESS readiness to make a quit attemptDetermine whether the tobacco user is **willing and ready** to make a quit attempt within 30 days.- "Are you willing to give quitting cigarettes a try?"
ASSIST in the quit attemptFor the patient willing to quit, **assist in developing a quit plan.** Provide practical counseling, support, and supplementary materials.- Have patient set a quit date and enlist the support of his/her family and friends.
- Offer pharmacotherapy, as appropriate, including nicotine replacement.
- Provide counseling that includes problem solving and skills building.
ARRANGE for follow-upArrange for **follow-up contacts** beginning within the first week after the quit date.- Contact patient via telephone or in person soon after the quit date. This can be done by the primary clinician or other trained staff members.
- During the follow-up encounter, assess and identify any problems, review medication use and side effects, provide reminders about additional resources.
- Congratulate patients on their successes.
- Help those with relapses assess problems with and barriers to quitting, and offer additional or different assistance.
- For patients who report a relapse, help them identify the circumstances that led the relapse and assist them with recommitting to smoking abstinence.

For patients who are not ready to quit, techniques such motivational interviewing (MI) can be used in conjunction with the stages-of-change model to explore the smokers' beliefs, feelings, and barriers to successful cessation efforts. Components of MI include: a) expressing empathy; b) developing discrepancy; c) rolling with resistance; and d) supporting self-efficacy. Effective use of MI involves specialized training. Partnering with clinic staff or outside agencies that are familiar with MI techniques can help improve behavior change outcomes, such as smoking cessation. (For further information, see "References," below.)
Pharmacologic Interventions
In addition to counseling, the use of pharmacologic interventions such as nicotine replacement therapy and other adjuvant therapies should be considered. These therapies were developed for the general population, but current clinical guidelines suggest that they should be efficacious for HIV-infected smokers.

Clinicians should be aware of potential medication adverse effects (see Table 2).
S: Subjective- Ask all patients about their smoking status at every visit. This can be easily incorporated as part the initial intake when vital signs are obtained.
- Document smoking history, including the number of cigarettes smoked per day.
- If the patient is not ready to quit, use MI techniques to identify beliefs and barriers and to create ambivalence about smoking.
- For the smoker interested in quitting:    - Help identify triggers to smoking, and develop a quit plan.
  - Assess for contraindications to pharmacologic smoking cessation treatments such as history of seizure disorders, sleep disturbances, mood disorders, and pregnancy.
- For patients who recently quit, congratulate them on their accomplishments and reinforce the benefits of continued cessation.
- For patients who recently relapsed, help them identify what led to the relapse and how to avoid relapses in the future. Assist them in getting back on track with a cessation program.
O: Objective
During the physical examination, assess for evidence of smoking-related illnesses and the comorbid conditions that may be affected by smoking. At a minimum, measure blood pressure and oxygen saturation measurements and examine for oral lesions, abnormal breath sounds, and decreased peripheral perfusion.
A/P: Assessment and Plan
Determine the smoker's readiness to change (see behavioral model for smoking cessation, above). For those smokers in the preparation or action stage, assist with implementing a quit plan. For those who are in the relapse stage, reinforce self-efficacy and encourage them to recommit to cessation. For those in the maintenance stage, congratulate them and reinforce the benefits of smoking cessation.

For patients willing to quit, offer resources and information that will help them to be successful in their quit attempt. Evidence suggests that the combination of counseling and medication is more effective than either intervention alone. Therefore, every effort should be made to combine counseling sessions with pharmacotherapy for patients who are motivated and ready to quit smoking.

Components of effective counseling include problem solving, skills training, and social support. Problem solving and skills training should focus on how to deal with triggers or urges that may lead to relapse. Examples include recognition of situations or events that may prompt a person to smoke (e.g., drinking alcohol, being around other cigarette smokers, situational stress) and means of reducing or coping with these situations. Social support interventions include providing reassurance that the patient has the ability to succeed with smoking cessation, communicating caring and concern, and encouraging the patient to talk about the quit process.

Offer medications, if there are no contraindications to pharmacologic interventions (see Table 2). All currently available over-the-counter and prescription medications have been shown to be effective. However, studies have shown that combination therapy may be more efficacious than monotherapy. The current tobacco cessation guidelines recommend the following combinations, all of which include nicotine preparations: long-term nicotine patch (>14 weeks) with ad lib use of nicotine gum or spray, nicotine patch with nicotine inhaler, and nicotine patch with sustained-release (SR) bupropion.

Both bupropion SR and varenicline may cause sleep disturbance, and varenicline may cause exacerbation of neuropsychiatric symptoms. For HIV-infected patients who take efavirenz as part of their antiretroviral therapy, concomitant use of either bupropion SR or varenicline may increase the possibility of these side effects. Additional research in this area is needed.
Table 2. Pharmacologic Options for Smoking CessationDrug RecommendedDosingCommon Side EffectsComments
* Use with caution for patients with cardiovascular disease (particularly those within 2 weeks of myocardial infarction), those with serious arrhythmias, and those with unstable angina pectoris (however, note that, for many patients, continued smoking may be more dangerous than nicotine replacement).

The adverse effects of cigarette smoking during pregnancy are well established, and smoking generally is more harmful than the use of nicotine replacements. Smoking cessation aids may help motivated patients quit during pregnancy.
**Nicotine Formulations***
**Nicotine Patch (available OTC)**

*Dosage varies by brand:*

**Nicoderm or Habitrol:**
- 21 mg/24 hours
- 14 mg/24 hours
- 7 mg/24 hours

**Nicotrol:**
- 15 mg/24 hours
- 10 mg/24 hours
- 5 mg/24 hours
Dosing recommendations vary based on the number of cigarettes smoked. Individualize treatment. Sample treatment recommendation for smokers who smoke ≥10 cigarettes per day: - High-dose patch for 4-6 weeks, then
- Medium-dose patch for 2 weeks, then
- Low-dose patch for 2 weeks
 For smokers who smoke <10 cigarettes per day: - Medium-dose patch for 6-8 weeks, then
- Low-dose patch for 2 weeks
Local skin reaction, insomnia or vivid dreams- Apply upon awakening.
- Place patch on a relatively hairless location, rotating sites to avoid irritation.
- If experiencing sleep disturbance, remove patch prior to bedtime or use the 16-hour patch.

**Nicotine Lozenge (available OTC)**
- 2 mg and 4 mg
- For patients who smoke their first cigarette >30 minutes after waking, start with 2 mg dose. For patients who smoke their first cigarette within the first 30 minutes after waking, start with 4 mg.
- Most patients should use 1 lozenge Q1-2H during the first 6 weeks.
- Allow lozenges to dissolve, do not chew or swallow. Most individuals use 9 lozenges per day; maximum is 20 per day.
- Lozenges should be used for up to 12 weeks, decreasing dosing from 1 lozenge Q1-2H for the first 6 weeks, to 1 lozenge Q2-4H during weeks 7-9, and 1 lozenge Q4-8H during weeks 9-12.
Nausea, hiccups, heartburn, headache, cough- Do not eat or drink anything except water for 15 minutes before using a lozenge.

**Nicotine Inhaler (prescription only)**
- 4 mg per inhalation,
- 10 mg cartridge
Recommended dosage: 6-16 cartridges per day. Duration of therapy: up to 6 months, taper dosage in last 3 months.Local irritation in the mouth and throat, cough, rhinitis; may cause bronchospasm (<1%)- Use caution in persons with severe reactive airway disease.

**Nicotine Nasal Spray (prescription only)**
- 0.5 mg per spray
- Patient should use 1-2 sprays each nostril per hour (total 1-2 mg per hour), increasing as needed for symptom relief.
- Minimum recommended treatment is 16 sprays (8 mg) per day, with a maximum limit of 80 sprays per day (10 sprays per hour).
- Recommended duration of therapy: 3-6 months.
- Do not sniff, swallow, or inhale through the nose while administering doses. Tilt head slightly back when dosing.
Nasal irritation, transient changes in sense of smell and taste; may cause bronchospasm (<1%)- Use caution in persons with severe reactive airway disease.
- Nicotine nasal spray has highest dependence potential of the nicotine replacement therapies.
**Non-Nicotine Medications, First Line****Bupropion SR**- 150 mg
Begin 1-2 weeks before quit date. - Start at 150 mg daily for 3 days, then increase to 150 mg BID for 7-12 weeks.
- May consider longer term therapy.
Insomnia, dry mouth- May lower seizure threshold in certain patients.
- Levels increased in patients on P450 3A4 inhibitors.
- Use with caution in patients with history of seizures, eating disorders, or who have used a monoamine oxidase (MAO) inhibitor in the past 14 days.
**Varenicline**- 0.5 mg and 1 mg
Begin 1 week before quit date. - Start with 0.5 mg daily for 3 days, increase to 0.5 mg BID for 4 days, then 1 mg BID for duration of therapy.
- Typical duration: 12 weeks.
- Varenicline is approved for maintenance therapy for up to 6 months.
Nausea; flatulence; headache; sleep disturbance; abnormal, vivid, or strange dreams; depression; agitation; suicidal ideation; and suicide FDA Black Box warning regarding neuropsychiatric adverse effects - Use with caution in patients with history of psychiatric illness. Monitor closely for mood and behavior changes.
- Dosage reduction recommended for patients who have creatinine clearance (CrCl) of <30 mL/min or are on dialysis.
- To reduce nausea, should be taken with food. To reduce insomnia, second pill can be taken at dinner rather than at bedtime.
- Dosage may be reduced for patients with adverse effects.
**Non-Nicotine Medications, Second Line****Clonidine**- 0.1 mg tablet
- 0.1 mg transdermal patch
- 0.1 mg tablet PO BID
**OR**- 0.1 mg transdermal patch per day. Can increase by 0.1 mg/day per week if needed.
- Duration of treatment: 3-10 weeks.
- Do not discontinue therapy abruptly.
Dry mouth, drowsiness, dizziness, sedation, and constipation Rebound hypertension if discontinued abruptly - Monitor blood pressure when using this medication. If discontinuing, taper medication to avoid rebound hypertension.
- If using patch, place on relatively hairless location between the neck and waist.
**Nortriptyline**- Begin 10-28 days before quit date.
- Start at 25 mg once daily and increase to target dosage of 75-100 mg once daily if tolerated.
- Treatment duration: approximately 12 weeks; some may consider extending treatment up to 6 months.
Sedation, dry mouth, blurred vision, urinary retention, lightheadedness, tremor, cardiac conduction abnormalities- Use with caution in patients with cardiac conduction abnormalities disease.
- Do not coadminister with MAO inhibitors.
- Overdose may produce life-threatening cardiovascular toxicity, as well as seizures and coma.

All patients who are actively quitting should have close follow-up, and they should be offered support. Research has shown that ongoing support during the quit phase results in higher abstinence rates.

Follow-up can include telephone calls or in-person evaluation.

For patients who recently quit or relapsed, continue to provide support and encouragement. Assist individuals who relapsed with the opportunity to continue with cessation plans.

Refer patients to smoking cessation groups, classes, and other resources.
Patient Education- For patients who have decided on pharmacologic interventions and for whom there are no contraindications, provide education regarding medication side effects, anticipated withdrawal symptoms, and strategies for managing withdrawal.
- Review and reinforce strategies in the event of relapse.
- For those who are not ready to quit, inform them of the consequences of continued smoking and remind them about the available resources.
Suggested Resources- National Telephone Counseling and Quit Line (800-QUIT-NOW) (800-784-8669)
- American Cancer Society
- American Lung Association  (maintains profiles of state tobacco control activities)
- National Cancer Institute
- Office on Smoking and Health at the Centers for Disease Control and Prevention
References- Cook PF, Bradley-Springer L, Corwin M.  Motivational Interviewing and HIV: Reducing Risk, Inspiring Change . Mountain Plains AIDS Education Training Center; August 2009.
- Crothers K, Goulet JL, Rodriguez-Barradas MC, et al.  Impact of cigarette smoking on mortality in HIV-positive and HIV-negative veterans.  AIDS Educ Prev. 2009 Jun;21(3 Suppl):40-53.
- Fiore MC, Jaen CR, Baker TB, et al.  Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline.  Rockville, MD: U.S. Department of Health and Human Services, Public Health Service; 2008.
- Prochaska JO.  Decision making in the transtheoretical model of behavior change . Med Decis Making. 2008 Nov-Dec;28(6):845-9.
- Prochaska JO, Velicer WF.  The transtheoretical model of health behavior change . Am J Health Promot. 1997 Sep-Oct;12(1):38-48.
- Reynolds NR.  Cigarette smoking and HIV: more evidence for action . AIDS Educ Prev. 2009 Jun;21(3 Suppl):106-21.
- Vidrine DJ.  Cigarette smoking and HIV/AIDS: health implications, smoker characteristics and cessation strategies . AIDS Educ Prev. 2009 Jun;21(3 Suppl):3-13.
- Walters ST, Wright JA, Shegog R.  A review of computer and internet-based interventions for smoking behavior . Addict Behav. 2006 Feb;31(2):264-77.
**HRSA HAB Core Clinical Performance MeasuresPercentage of clients with HIV infection who received **tobacco cessation counseling** within the measurement year. (Group 3)**