A clinician’s guide to successful intervention timing
Editor’s note: This is an abridged version of an article originally published in the Cleveland Clinic Journal of Medicine. The article in its entirety, including a complete list of references, can be found here.
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By Humberto K. Choi, MD, Jorge Ataucuri-Vargas, MD, Charlie Lin, MD, and Amanda Singrey, PharmD
Tobacco use continues to be a major public health problem and a major risk factor for deaths from heart disease and several types of cancer such as lung, head and neck, and colorectal cancers. The prevalence of smoking has declined over the last six decades, to an all-time low of 13.7% in adults in 2018. However, nicotine dependence is still considered a common and significant clinical problem.
A number of effective therapies exist, yet treating patients for tobacco cessation remains a challenge, not only for patients, but also for clinicians, who may not be aware of effective therapies available and may fail to offer treatment. Therefore, it is important for clinicians to familiarize themselves with treatment options they can offer to every smoker.
In this article, we review opportunities to encourage tobacco cessation. Previous articles addressed behavioral and pharmacological interventions.
Female patients of childbearing age and pregnant patients represent an opportunity for clinicians to encourage smoking cessation. All pregnant patients should be counseled to quit. Patients should be counseled about the adverse effects of tobacco use and about effects such as subfertility and miscarriage risks.
The American College of Obstetricians and Gynecologists recommends that NRT be considered for pregnant women with a strong resolution to quit. Bupropion is also a reasonable first-line therapy. However, there is limited evidence supporting the subsequent addition of bupropion in patients as a first-line treatment in female patients unable to tolerate NRT or as an addition to counseling and NRT. Varenicline is typically not used in this setting due to the limited data supporting its safety.
Hospital admission requires temporary tobacco abstinence, providing an opportunity to initiate treatment. The primary reason for hospitalization may serve as an opportunity to provide personalized advice and motivation to quit, especially if surgery is undertaken during the same admission.
Smokers are far more likely to quit if they are provided close follow-up after inpatient discharge (e.g., during follow-up appointments) vs. traditional provision of postdischarge pharmacotherapy and recommendations alone.
The increased risk of cardiovascular disease from tobacco use is well known. In patients with known atherosclerotic cardiovascular disease, the approach to tobacco cessation is the same as for patients without cardiovascular disease. Data show that NRT, bupropion, and varenicline do not significantly increase the risk of adverse cardiovascular events.
The lack of evidence regarding the efficacy and safety of NRT in acute coronary syndrome and the theoretical concern for nicotine’s vasoconstrictive properties may explain why clinicians tend to avoid recommending it. However, NRT is a first-line therapy for the relief of withdrawal symptoms in inpatients with acute coronary syndrome, according to expert consensus. NRT or varenicline can be prescribed at hospital discharge.
Because cigarette smoking increases the risk for poor postoperative outcomes, formal preoperative counseling and use of NRT are recommended because they result in greater rates of preoperative cessation and lower rates of postoperative complications than no treatment.
Concerns that quitting shortly before surgery could increase the risk of pulmonary complications have been found to be unsubstantiated. Patients should be advised to quit at any time before surgery. Although the optimal duration of abstinence is not known, a greater reduction in risk of complications is associated with longer periods of abstinence. As with hospitalized patients undergoing surgical procedures, postdischarge cessation rates were found to be highest in those who received formal perioperative counseling and pharmacotherapy.
Psychiatric and mental health considerations
Nicotine dependence is known to exacerbate concurrent mental illnesses and psychiatric disorders. However, patients with psychiatric needs are less likely to be provided with tobacco cessation counseling or pharmacotherapy. Recent studies have shown that the safety of NRT, varenicline and bupropion are comparable between patients with and without psychiatric disorders. It is reasonable to offer varenicline and NRT alongside formal tobacco cessation counseling, followed by use of bupropion as a second-line agent in the absence of a documented seizure history.
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