by ANDREW M. GOTTLIEB
In Resource Manual for Guidelines for Exercise Testing and Prescription. Blair, S.N., et. al. (eds.). Philadelphia, PA: Lea and Febiger, 1993. Chapter 71.
HEALTH RISKS OF SMOKING
Cigarette smoking is the leading preventable cause of premature death from heart disease, lung disease, and cancer. Of the 46 million Americans who smoke regularly, approximately 420,000 die of premature illness each year. Worldwide, the negative impact of cigarette smoking on health is staggering. According to a recent survey conducted by the World Health Organization (WHO), 3 million people die each year from smoking related illnesses (1). By the year 2020, the death toll will rise to 10 million per year! Of the people alive today, roughly half a billion will die of tobacco related causes. United State women are disproportionally affected. Though only 5% of women live in the U.S., 50% of women worldwide who die from smoking-related causes live in the U.S.
Although most people are aware of the link between smoking and cancer, far fewer individuals understand the causal relationship between smoking and heart disease. The risk of heart disease is directly related to the number of cigarettes smoked. Smoking one pack per day doubles the risk compared to nonsmoking; smoking more than one pack per day triples the risk. The main mechanisms that affect the development of heart disease are the effects of carbon monoxide. Nicotine in tobacco smoke causes increases in heart rate and blood pressure, which increases the work of the heart. It also may increase platelet adhesiveness, changing blood viscosity. Carbon monoxide interferes with the ability of red blood cells to carry oxygen, thereby reducing oxygen delivered to the heart muscle.
HEALTH BENEFITS OF QUITTING SMOKING
The health benefits of quitting smoking are immediate and substantial. They extend to young and old and to those with and without smoking related disease. Smoking cessation represents the single most important step that smokers can take to enhance the length and quality of life (2).
Although risk from smoking is cumulative, increased risk of cancer and heart disease drops rapidly after stopping smoking, even if the person has smoked for many years (3,4). After 2 1/2 years of nonsmoking, risk of lung cancer is reduced by 50%. Within 3-5 years of nonsmoking, risk of a heart attack is similar to a nonsmoker, and within 5-10 years, risk of major health problems decreases to levels only slightly greater than those who have never smoked. Besides the obvious major health benefits, many other benefits result, including increased energy, improved sense of smell, the ability to exercise more easily, and higher self esteem.
WHY PEOPLE SMOKE
To counsel smokers effectively, it is useful to understand that both physical and psychological components drive smoking behavior (5,6). Physical dependence on nicotine is one major factor. Each cigarette puff delivers a "hit" of nicotine to the brain within 7 seconds, making smoking one of the most effective drug delivery systems known. The average smoker may self-administer 50,000 to 70,000 nicotine doses a year. Nicotine appears to have both stimulating and tranquilizing effects, depending on dosage. Evidence exists that nicotine may increase the production of brain hormones, such as beta-endorphins. This effect may explain why nicotine can reduce the perception of pain and increase feelings of well-being. Smokers can "fine-tune" emotional responses by varying puff rate and depth to control the amount of nicotine delivered to the brain. Thus, a smoker literally has fingertip control of emotional and physical responses, reducing the need for other coping techniques. Once a person becomes dependent on these effects of smoking to function normally, quitting becomes extremely difficult.
The other major component is conditioned psychological dependence. The thousands of nicotine doses received each year are linked to situations and emotional states. Each of these situations and emotional states becomes a cue to the smoker that it is time for a cigarette puff. Situational cues include such things as drinking coffee or an alcoholic beverage, talking on the phone, watching TV, finishing a meal, or driving. Other cues are negative emotions, such as anger, frustration, stress, or boredom. Further, diminishing blood levels of nicotine trigger withdrawal symptoms that also encourage smoking.
CESSATION
The Quitting Process
The experience of quitting varies considerably among smokers. Some smokers quit "easily" and report their surprise at how much easier than expected it was; some report that quitting was the most difficult thing that they ever attempted; while others report some degree of difficulty between these two extremes. Some report the physical factors being the primary difficulty, some the psychological factors, and others report both.
Withdrawal from nicotine can produce a variety of effects, including craving for tobacco, increased anxiety, increased irritability, increased restlessness, difficulty concentrating, headache, drowsiness, and gastrointestinal disturbances. These symptoms are generally most intense for the first 2-3 days after cessation, then decrease, but increase again around day ten, and finally decrease gradually thereafter. The acute phase of nicotine withdrawal is generally over within 2-4 weeks, although some withdrawal symptoms such as the urge to smoke can continue for months or even years (36). The number and severity of withdrawal symptoms reported varies in number from none to many, and in severity from mild to severe. (Nearly 90% of smokers will experience at least one withdrawal symptom.)
Most smokers quit a number of times before achieving long term abstinence. The majority of smokers who relapse do so within the first 6 months after quitting; some relapse years after cessation, but this is the exception. As the duration of abstinence increases, relapse becomes less likely (2). Many smokers are able to quit for short periods, but maintaining smoking cessation is a major challenge.
Approaches to Smoking Cessation
Most people who have quit smoking report doing so on their own, without the help of a health professional. Formal smoking cessation programs can be helpful to those smokers who cannot quit on their own, often those who smoke more heavily and are more addicted (7,8).
In order to guide a smoker to appropriate assistance for smoking cessation, it is important to know the options available, the effectiveness, as well as potential barriers to participation (cost, location, time, and cultural biases) (7). The appropriateness of a group program vs. individual sessions with a health professional should be considered. When examining effectiveness, it is important to look at the long term quit rate of a strategy or program, since relapse is common. Some programs boast high initial quit rates, but fail to report long term relapse rates. There is not a "magic bullet" available, (at any cost,) that can guarantee long-term quitting. However, there is help in a variety of forms to assist any smoker who would like to quit.
Smoking cessation techniques include the following:
- Pharmacological interventions
- Behavioral interventions
- Other strategies such as acupuncture and hypnosis.
Stop smoking programs are available in a variety of formats:
- Self-help materials (with or without minimal contact)
- Group meetings
- Individual sessions with a health professional
Many studies have been conducted evaluating various behavioral and pharmacological smoking cessation approaches, allowing us to identify with some confidence the approaches that work.
Pharmacological Interventions
Overview of Nicotine Replacement Medications
The most promising pharmacological interventions (currently in widespread use) are nicotine replacement via nicotine polacrilex (Nicorette) and transdermal nicotine patch (Habitrol, Nicoderm, Nicotrol, and Prostep), as well as nicotine nasal spray (Nicotrol NS). The gum and patches are available over-the-counter. They are designed to provide a partial substitute for the nicotine obtained from cigarettes to make the initial phase of tobacco withdrawal less unpleasant, allowing the person to learn new ways of coping with the behavioral aspects of smoking cessation (unlinking smoking-related cues from actual cigarette smoking). Nicotine nasal spray is available by prescription only.
Nicotine replacement treatment should be used for at least 10-12 weeks following quitting; many smokers require 6 months treatment, some will need treatment for 1-2 years before successfully tapering off nicotine medication.
Nicotine Gum
Nicorette (nicotine polacrilex) 2 mg. and 4 mg., available since 1984 by prescription, (and available over-the-counter since 1996) has nicotine bound to a resin base, i.e., nicotine gum. When the medication is chewed, nicotine is released and is absorbed through the oral mucosa. For maximum benefit, the patient needs to chew 12 or more pieces of gum a day. The suggested dosing is as follows:
- Weeks 1 through 6: one piece every hour
- Weeks 7 through 10: tapering
- Week 12: discontinuing use
Patients should be instructed carefully in how to chew the gum, as the optimal use is quite different than regular chewing gum. Current costs of Nicorette over-the-counter are about $50 ($0.46 per piece) for the 2 mg. Starter Kit which includes information on quitting and 108 pieces of gum. The 4 mg. Starter Kit is about $60 ($0.56 per piece). Refills cost about $30 ($0.62 per piece) for 48 pieces of 2 mg. gum and $35 ($0.72 per piece) for 4 mg. Gum. Thus with use of 12 pieces a day, the cost of twelve weeks of treatment would be about $465. (One suggestion to patients is to buy the starter kits rather than the refill kits, as the gum is up to 43 percent cheaper that way.)
Most researchers have reported impressive improvements in quit rates, but mostly when combined with some behavioral counseling or follow-up. The 4 mg. gum is more effective than 2 mg. gum for highly nicotine dependent smokers (smokers who smoke > 25 cigarettes a day), yielding two year quit rates of 34% (4mg) vs. 6% (2mg) (11).
Researchers continue to examine ways to increase the effectiveness of nicotine polacrilex. Clear chewing instructions and a behavioral change component should accompany a Nicorette prescription (12,13). When advising a smoker, it is important to steer the individual to either a behavioral program in which nicotine polacrilex use is an integral part or to a physician who will provide good follow-up care along with this medication.
Studies show that the effectiveness of nicotine polacrilex 2mg is influenced by the behavioral intervention component which accompanies it (5,6). If there is no behavioral component, and if a physician simply phones in a prescription to a pharmacy, nicotine polacrilex is no more effective than placebo at the one year follow-up; however, even with minimal behavioral intervention, a significant effect can be expected. By including physician advice with nicotine polacrilex, studies indicate that the one year quit rate increases from approximately 5% to 9%; adding physician advice and follow-up increases quit rates from 15% to 27%; and by adding comprehensive group counseling increases quit rates from 16% to 38%. Studies where behavior modification is combined with nicotine polacrilex are associated with one year quit rates of over 40%. Now that nicotine polacrilex is available without prescription, it is even more important that some type of behavioral support or follow-up be encouraged.
Nicotine Patch
The nicotine patch was approved in the United States in late 1991, and is currently available over-the-counter. Patches provide a much easier route for nicotine delivery than nicotine polacrilex, making both smokers and health professionals happy they are available. Nicotine patches are not the "magic bullet", however.
Patches come in three sizes, 30cm2, 20cm2, and 10cm2, delivering nicotine for 24 hours/day (Habitrol, Nicoderm and Prostep) or 16 hours/day (Nicotrol). The 24 hours/day patches deliver 21, 14 and 7 mg. nicotine/day (30cm2, 20cm2, and 10cm2 respectively), while the 16 hours/day patches deliver 15, 10 and 5 mg. nicotine/day. Nicotine patches are applied once a day. Most smokers who use the 24 hour patches, begin with the 21 mg. Patch, subsequently tapering to 14 and 7 mg. Patches. Most smokers who use the 16 hour patches start with the 15 mg. patch and taper to the 10 and 5 mg patches.
Approximate costs are about $4 per day of treatment. Recommended treatment duration is 8 weeks for light smokers, and 10 weeks for heavy smokers, for a total cost of about $225-280.
Smokers reduce their nicotine intake by using a 21mg patch for six weeks, then tapering down to 14 mg. and 7 mg. over the next four weeks.
Whether to use a 24 hour patch or a 16 hour patch probably depends on how strong the craving for cigarettes is in the morning. Those with intense morning craving may do better on a 24-hour patch, but a 16-hour patch produces less sleep disruption and fewer nightmares. In a study of 935 participants, six-month sustained abstinence rates for those receiving the nicotine patch were significantly higher than for those receiving placebo (26% vs. 12% respectively). Good results have been found with nicotine patch therapy as long as there is regular contact with the patient. Nine group-counseling sessions over 12 weeks of patch therapy resulted in 26% nonsmoking rates at 6 months (14). Seven regular physician visits over 18 weeks of patch therapy produced 34% cessation rates at 6 months (15). Even brief weekly telephone follow-ups during 6 weeks of patch therapy yielded a 21% quit rate at 6 months (16). As with nicotine polacrilex, more needs to be learned about increasing the effectiveness of the nicotine patch.
Combining the use of nicotine gum with nicotine patch provides better relief of nicotine withdrawal symptoms than either drug alone (17,32, 33), and may increase the odds of 12 month cessation by a factor of 1.8 (31). Used this way, the nicotine patch provides baseline levels of nicotine, while the gum adds nicotine in high-risk situations, and may provide a higher level of nicotine replacement. But the overall dosage of nicotine would still be less than that attained by smoking.
Nicotine Nasal Spray
Nicotine nasal spray is simply aqueous nicotine delivered into the nasal pathways using a device similar to that used to deliver intranasal steroids. Nicotine nasal spray may be helpful for heavy smokers who do not get adequate relief using nicotine gum or patches. Available by prescription as Nicotrol NS, nicotine nasal spray delivers nicotine in a quickly absorbed form, resulting in blood nicotine levels that peak within 4-15 minutes at a level of between 2 to 12 ng/ml. Some twenty percent of users achieve a blood nicotine level similar to that derived from smoking one cigarette. Dosing is 1mg of nicotine per two sprays (one in each nostril). Maximum daily dose is 5 per hour, or 40 per day, with a treatment time of 3 months. However, according to the package insert, 32% of spray users reported feeling dependent, therefore the potential for addiction may be higher than with patch or gum (18).
Cost is approximately $46 per 10mg, or about one hundred doses. At the recommended dosing of one to two doses per hour, cost for ten weeks of treatment is between $515 and $1030. A recent study found that combining nicotine nasal spray with nicotine patch produced more than doubled abstinence rates at 6 months (31% vs. 16%), one year (27% vs. 11%), and six years (16% vs. 9%) when compared to the patch alone (31).
All of these nicotine medications seem to be safe. The commonest side effects are local, such as skin irritation from patches or heartburn from nicotine gum, and nasal irritation from nicotine spray. Contrary to press reports from July 1992, nicotine patch does not cause heart attacks (19).
Cigarettes deliver nicotine more rapidly than any of the medications. Next is nicotine nasal spray, followed by nicotine policrex, and slowest (but steadiest) , a nicotine patch. Thus it may be that nicotine nasal spray best simulates the nicotine bolus effect of smoking cigarettes, but whether this will make it difficult to give up the spray remains to be seen (19).
Other Pharmacologic Approaches: Buspirone and Bupropion
Buspirone (Buspar) is a non-benzodiazepine anti-anxiety medication. One randomized, double blind, placebo-controlled trial demonstrated that participants using buspirone had 4-week abstinence rates of 47% compared to 16% for placebo (20). Buspirone may be useful, either alone, or in combination with nicotine gum or patches, especially with smokers who use cigarettes to cope with anxiety.
A series of interesting findings relate cigarette smoking and depression. Although the lifetime prevalence of major depression is 3.7-6.7%, in the general smoking population it is 27%, and it is 46-61% in smokers who present for treatment. Of those with major depression, 74% smoke, in contrast to only 26% of the general population. Further, the quit rate of those with major depression is about half that for smokers with no psychiatric diagnosis (21,22).
Thus it appears that some smokers may use smoking to control depression. For those smokers concomitant treatment with an antidepressant may be helpful. The best published studies on antidepressants and smoking are on sustained release bupropion (Wellbutrin, or Zyban). One found 55% of patients treated with bupropion abstinent at 6 months as compared to 0% treated with placebo (23). Another study of 190 people showed 40% of bupropion-treated patient abstinent at 4 weeks compared with 24% of placebo treated subjects (24). A large scale study using 244 subjects compared four treatment conditions: bupropion, nicotine patch, bupropion combined with patch, and placebo. Cessation rates at 12 months were respectively 30.3%, 16.4%, 35.5%, and 15.6%, which suggests that the combination of bupropion and nicotine patch is an effective treatment (30). Evaluating smokers for depression using the Beck Depression Inventory (Center for Cognitive Therapy, Philadelphia) or other similar instruments, and concomitant treatment for depression may significantly improve smoking cessation results.
No one pharmacologic intervention seems to be significantly more effective when used alone. One randomized study of nicotine gum, nicotine patch, nicotine nasal spray, and nasal inhaler found 12 week quit rates of 20%, 21%, 24%, and 24%, respectively, with high compliance with use of patch, lower compliance for gum, and very low compliance for nicotine spray or inhaler (35).
Behavioral Interventions
Behavioral interventions including components such as self-monitoring, contracts, and assertiveness skills training are often included in stop smoking programs. As previously stated, these components may increase long-term effectiveness. One of the most effective techniques is rapid smoking; when properly administered, this approach has had long-term abstinence rates of 64-70%. Rapid smoking is a multicomponent treatment that involves several different elements, including relapse prevention training (see subsequent discussion) and rapid smoking, in which the patient inhales smoke from his own cigarette every 6 seconds until he no longer wants to take another puff. The procedure creates an aversion to smoking that, when combined with skills training, leads to good cessation outcomes. This technique must not be attempted without support and guidance from a health professional. It is used more rarely now because it requires good medical support. In addition, other, non-aversive methods have become more widely available.
Relapse prevention is a useful behavioral approach to maintaining smoking cessation. Relapse prevention teaches anticipation of those situations where temptation to smoke may be present and development of new coping methods for avoiding relapse in these situations (25,37). Simple questionnaires can be used to measure confidence in ability to resist smoking during exposure to high-risk situations (26). These questionnaires may be helpful in determining the types of coping skills on which to focus attention.
The relapse prevention approach is particularly valuable in smoking cessation. As Mark Twain said, "Quitting smoking is easy; I have done it many times." Staying quit is difficult.
Other Techniques
Smokers are often attracted to acupuncture or hypnosis as "the magic bullet" or as an easy way to achieve long term smoking cessation. Controlled studies fail to show any positive correlation between acupuncture and smoking cessation (27). Hypnosis can be provided individually or in groups, for one or multiple sessions and is often combined with other behavioral techniques. However, there are no controlled studies of hypnosis for smoking cessation that demonstrate a significant long term treatment effect.
Stop Smoking Programs
Programs are available in a variety of formats. In a self-help or minimal intervention format, a smoker works on his or her own to quit smoking without the continued assistance of health professionals, trained leaders, or organizations; reliance on self is the primary method with a self-help book or guide to assist in devising ways to quit and stay off cigarettes. A study using the American Lung Association's Freedom From Smoking in 20 Days, (one of the many manuals available), reports a 1-year quit rate of 5% (vs. 2% for controls). Generally, self-help programs report substantially lower quit rates than more formal programs, but are low cost and generally widely available. Efforts are underway to maximize effectiveness of self-help programs (28).
Programs in a group format provide a support group which some smokers find very helpful. The content, cost, and providers of these programs vary, but generally health organizations, as well as commercial groups, offer these programs. Few well designed studies have been completed to evaluate this type of program. When specific programs advertise high success rates, it is important to inquire about long term (ideally one year, but minimally six months) rates, and the method for determining those rates.
Some smokers prefer working with a health professional on an individual basis. Under this format, it is important to inquire about approaches used and qualifications of the health professional. Typically the health professional is a physician, a nurse, or counselor of some type. Research projects (at medical schools, universities or other medical facilities) can often provide another resource for smokers.
HOW TO HELP SOMEONE STOP SMOKING
Exercise professionals are often asked to help with smoking cessation in individual cases. The following guidelines may be useful as aids to promote successful quitting.
Advise The Smoker To Quit
Advice to quit from a health professional with good rapport may have substantial impact. For example, studies show that 60 seconds of definitive advice from a physician has substantial impact on long term (1 year) quit rate, increasing it 17-fold in one study (29). Advice should be clear, succinct and unequivocal regarding the dangers of smoking and the benefit of quitting. Timing the discussion to occur when a patient is experiencing symptoms caused by, attributed to, or exacerbated by smoking such as coughing, shortness of breath, or angina, may be especially effective. Avoidance of moralism or punitive action is important. Emphasize the benefits experienced after quitting and advise the patient to completely eliminate tobacco products. There are NO healthy tobacco products, and virtually no smokers can smoke in a limited way.
Help Develop a Specific Plan for Cessation
Help the smoker choose a specific quit date. A specific quit date helps prepare for nonsmoking. Review prior quit attempts to evaluate what was helpful and identify problems. Reframe past relapses in a positive light by emphasizing that past attempts can teach something useful. Say that most successful long term quitters have made more that one attempt to quit.
Inform the smoker about resources in the community such as self-help or minimal contact programs, group programs, and individual health professionals who work in smoking cessation. A list of the programs with names and phone numbers for additional information is helpful, as well as information about the components, format, cost, and effectiveness of the intervention. Good sources of information concerning local programs include:
- Local universities
- Medical groups, hospitals
- Agencies such as American Cancer Society, American Lung Association and the American Heart Association
- Commercially available over-the-counter nicotine replacement options such as nicotine gum or patches
Encourage Quitting Efforts and Provide Support During Difficult Times
Help motivate by asking about positive health benefits or other positive occurrences resulting from quitting, such as increased stamina, better breathing, less coughing, and improved sense of smell. Reassure that withdrawal symptoms are temporary and are signs that dependence on nicotine is diminishing. Since relapse is common after quitting, ask about difficult times and help identify ways to cope.
Some smokers may not be ready to quit immediately, but will express readiness at a later date. Those not ready to quit are sometimes concerned about the negative impact of quitting or their ability to succeed; these factors should be addressed if they are clearly expressed. Gentle, but firm, reminders about the importance of quitting can influence motivation to make the attempt.
Respond To Concern About Weight Gain
Smokers may express concern about weight gain, either as a reason not to quit or after cessation. Approximately 80% of those who quit gain weight after cessation. The average weight gain is approximately five pounds. Increased food intake and/or decreased energy expenditure may be partially responsible for post-cessation weight gain. The health benefits of smoking cessation far exceed any risks from the average weight gain (2). It is useful to tell the patient that 100 pounds would have to be gained before the health impact of gaining weight would equal that of continued smoking. Suggestions such as increasing physical activity, eating low-fat sweets in response to an increased desire for sweet foods, having low calorie snacks available, etc. may be helpful. The best way to avoid excessive weight gain is to increase levels of physical activity and exercise. Also, using bupropion (Zyban) during cessation can reduce weight gain (30).
SUMMARY
Cigarette smoking is the leading preventable cause of death. Smoking cessation has major and immediate health benefits. Advice to quit smoking from a health professional with good rapport may have substantial impact. Millions of smokers have quit successfully; however, for some quitting is difficult. Both physical and psychological factors contribute to maintaining cigarette smoking behavior. There is no "magic bullet" but help is available. Most smokers quit without assistance and most successful long term quitters have made many short term quit attempts before achieving long term abstinence.
A variety of techniques provided in a variety of formats are available to help smokers who want to quit but are unable to do without assistance. Programs that include nicotine replacement in combination with behavioral interventions seem to provide the best results. There are a number of options for nicotine replacement, and both nicotine gum and nicotine patches are now available without a prescription. Bupropion (Zyban) is a useful adjunct treatment especially when combined with nicotine replacement.
It is important to encourage smokers to quit, and to provide clear information and support to help increase chances of success. The good news is that even small interventions seem to have large effects, especially compared to no intervention. Thus with a little knowledge and persistence, a professional can have a powerful positive effect on the health of patients.
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