Treating Tobacco Use: Guidelines for Pharmacists

Multiple factors contribute to making the cessation of tobacco use difficult. First, there are factors associated with the pharmacologic dependence on nicotine.¹ When the use of tobacco is discontinued, nicotine withdrawal symptoms are plentiful. Symptoms including irritability, anger, restlessness, impatience, insomnia, increased appetite, difficulty concentrating, anxiety, and depressed mood all may be present.² These symptoms may last from a few days to months.¹

Second, there are factors associated with social behavior that often are present for an extended period of time in a person's daily rituals. Third, there are factors related to cultural and environmental influences, including advertisements, socioeconomic appeal, and lifestyle.

Most smokers attempting to quit do so on their own, without any assistance from pharmacotherapy and counseling. The knowledge of pharmacotherapy enables pharmacists practicing in all settings to assist patients in treating tobacco use and dependence. Data suggest that offering advice to quit smoking, even just once, helps to increase quit rates.¹ Furthermore, studies indicate that 70% of current smokers want to quit smoking completely, and 46% each year make an attempt at quitting.³

Unfortunately, only a minority of tobacco users achieve lifelong abstinence in a first-time attempt, and the majority typically cycle through periods of relapse.⁴ Approximately 7% of smokers achieve permanent success when attempting to quit on their own and that the use of guideline-recommended treatments may increase this rate to approximately 22%.⁴

In order to counsel patients appropriately about smoking cessation, it is important for pharmacists to understand the chronic nature of tobacco dependence. Tobacco use is now considered a drug dependence similar to dependence caused by amphetamines, cocaine, and opiates. Therefore, chronic tobacco use requires repeated clinical intervention, aggressive counseling, and constant follow- up, as with other addictive disorders.

Nonpharmacologic Therapy

Simple and short advice explaining the dangers of tobacco use has been shown to increase smoking-cessation rates.^1,4-6 The greater the intensity of tobacco dependence counseling, the greater its effectiveness.⁴ There are 3 main approaches to nonpharmacologic therapy, based on the patient's willingness to quit or current status as a quitter.⁴

The first approach is for current smokers willing to make a quit attempt. Table 1 summarizes the 5 important strategies clinicians should adopt with these patients (the "5 As"). These patients should receive both pharmacotherapy and counseling. Counseling should consist of practical counseling (problem solving/ skills training); intratreatment social support, provided as part of a treatment program; and extratreatment social support, received outside of a treatment program?for example, social support from family and friends.⁴ Follow-up visits are important during the first few days of smoking cessation because a majority of relapses occur during that time.

The second approach is for current smokers not willing to make a quit attempt. These patients should be provided with a motivational intervention that educates, reassures, and motivates them to consider making a quit attempt.⁴ Table 2 summarizes the 5 components of a motivational intervention (the "5 Rs").

The last approach is for patients who have recently quit. These patients need relapse-prevention intervention. Clinicians should reinforce the patient's decision to quit, review the advantages of quitting, and assist the patient in solving any problems arising from quitting.⁴

Pharmacotherapy

When smoking is stopped, patients lose the euphoric effects of nicotine and may develop nicotine-withdrawal symptoms. The goal of pharmacologic therapy is to reduce the intensity of nicotinewithdrawal symptoms in order to allow for smoking cessation.^1,5 It also may help to reduce the rate of relapse by decreasing the patient's desire to smoke.¹ Table 3 provides a summary of available pharmacologic agents.

Pharmacotherapy is recommended for all smokers who are willing to quit, unless special consideration is required (for persons smoking fewer than 10 cigarettes/day, pregnant or breast-feeding women, adolescents, and those with medical contraindications).⁴ First-line agents include nicotine replacement therapy (NRT; nicotine gum, patch, inhaler, nasal spray, and lozenge) and sustained-release bupropion hydrochloride.¹ No one of these agents is recommended over the others.^4,6

The choice of therapy may be based on the familiarity of the clinician with the agent, the presence of contraindications to particular therapies, the preference of the patient, the patient's previous experience with the agent (positive or negative), or patient characteristics.⁴ For example, in patients with depression, sustained-release bupropion hydrochloride has been shown to be effective.⁴ For lighter smokers (10-15 cigarettes/day), a reduced initial dose of first-line NRT should be considered; no dose adjustment is necessary for sustained-release bupropion.⁴ It is very important that all patients be advised not to smoke and use NRT concurrently.⁵

NRT has been found to be safe in patients with a history of cardiovascular disease.^1,4-6 Safety has not been established, however, for its use in the immediate post-myocardial infarction period or in patients with unstable or severe angina.⁴ Combining the nicotine patch with other forms of NRT may be more effective than monotherapy with the patch and has been shown to be safe.⁶

During pregnancy and breast-feeding, behavioral and cognitive therapy and support are the optimal treatment recommendations.¹ If these approaches are ineffective, NRT can be used.¹ Sustained-release bupropion hydrochloride should be avoided during pregnancy, and mothers should not breast-feed while taking this drug.¹

In patients with contraindications or inadequate response to first-line agents, second-line agents may be considered. Those found to be efficacious are clonidine hydrochloride and nortriptyline hydrochloride.⁴ Varenicline tartrate (Chantix) is a new drug that was approved by the FDA in May 2006 for smoking cessation. Chantix not only reduces nicotine withdrawal symptoms, but also blunts the pleasurable effects of nicotine if patients do resume smoking while taking this drug.⁷

Conclusion

Pharmacists must keep abreast of the latest guidelines for smoking cessation in order to aggressively counsel patients about the importance of both nonpharmacologic and pharmacologic treatment regimens.

Dr. Shogbon is a pharmacy practice resident at Kingsbrook Jewish Medical Center in Brooklyn, NY. Dr. Pham is an assistant professor of pharmacy practice at Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, Brooklyn, NY.

For a list of references, send a stamped, self-addressed envelope to: References Department, Attn. A. Rybovic, Pharmacy Times, Ascend Media Healthcare, 103 College Road East, Princeton, NJ 08540; or send an e-mail request to: arybovic@ascendmedia.com