Overview - Best Practices in Tobacco Cessation Counseling

(6) Module 3 - Patient Management Concerns

    (6.1) Background

    Nicotine-addicted individuals will seek to utilize multiple "back door" methods to resist tobacco cessation. If the clinician, in helping to treat a patient with nicotine addiction, is to successfully meet not only the psychological and socio-cultural needs of the patient, but also the pharmacotherapeutic needs, then some form of nicotine replacement therapy and possibly some form of adjunct anti-depressant medication will be required. How does the clinician adapt pharmacotherapy for the various differences in patients - differences such as gender, age, and medical condition to name but a few? What are the considerations when prescribing NRT and/ or anti-depressants to a healthy adult male as opposed to a healthy teen female, a young pregnant female, or the patient with one or more medical co-morbidities? What information can the clinician provide in response to patients who indicate that they can quit just as successfully by "cold turkey" method or that they need not quit tobacco use entirely because they are utilizing "safe" tobacco products or that they are better off smoking than they are using NRT products because of the potential dangers, real or imagined, of NRT?

    The material presented in Module 3 covers the gamut of tobacco cessation patient management concerns: safety and efficacy of pharmacological interventions for cessation treatment in healthy adults and special populations such as teens and pregnancy; controversial issues of tobacco cessation treatment such as "safe" cigarettes and NRT safety; pharmacotherapy considerations in the medically complex patient; and relapse prevention and management. It's always better to prevent than it is to treat, but when presented with the latter eventuality, the informed clinician will be better able not only to treat nicotine addiction in a wide range of patients, but also to impact dramatically the health of many patients for whom successful tobacco cessation could literally mean the difference between life and death.

    (6.2) Presentation 1

    Pharmacological Interventions and Special Populations: Young Adults and Pregnancy

      (6.2.1) Presentation Abstracts

        (6.2.1a) Pharmacological Interventions

        When nicotine is taken into the body it alters brain neurochemistry and leads to addiction. The recognition that addiction to nicotine is a "brain disease" has led to important insights regarding potential behavioral and pharmacological interventions.

        Randomized, controlled trials conducted in primary care practices show that a clinician's advice to stop smoking increases smoking cessation rates by about 30% (Fiore, M.C. et al. DHHS 2000). Nicotine Replacement Therapy and the antidepressant, sustained-release bupropion, when used with behavioral interventions in the motivated smoker, produce one-year abstinence rates that are approximately two to three times the rates in control subjects. Absolute quit rates have been measured at from 15% to more than 60% depending upon the unique characteristics of the smoker. Typical smoking cessation rates are 40-60% at the end of drug treatment and 25-30% at one year.

        Overall, state-of-the-art-smoking cessation interventions are among the most cost-effective of all preventive health activities, but they are grossly underutilized. Through education of health professionals, new quality improvement initiatives, and insurance and reimbursement reforms, it is likely that some of the barriers to implementation of state-of-the-art smoking cessation, including pharmacotherapy, will be decreased.

        With more than a billion smokers in the world, most of whom want to quit, pharmaceutical companies are actively researching a variety of new agents that will improve smoking cessation rates, decrease relapse rates, and perhaps even prevent initial experimentation and addiction among adolescents and teens.

        (6.2.1b)Special Populations: Young Adults

        In 2002, the prevalence of smoking (26.7%) among high school seniors in the U.S. was the lowest ever measured in the University of Michigan "Monitoring The Future" study. No decrease, unfortunately, was found in that same study among middle school students. In Indiana, youth smoking rates are higher than the national norms, but recent statewide tobacco control efforts have led to sizable reductions in high school smoking rates (26% decrease) and middle school rates (12% decrease). Adolescent and teen smoking represents an enormous potential source of addicted adult smokers. Recent research indicates that adolescents may become addicted within days to weeks of even occasional use of tobacco. On average, it takes 18 years before the smoker, who was addicted as an adolescent, quits. 90% of adult nicotine-dependent tobacco users become regular addicted users during their teenage years, yet we have little information regarding the optimal management of adolescent or teen smokers and smokeless tobacco users. It is recommended, however, that behavioral interventions and pharmacotherapies that are used for adults be adapted to the developmental age of the adolescent or teen. Data suggests that quit rates among youth treated with traditional cessation strategies are lower than for adult populations. New and innovative smoking cessation strategies are needed for this special population, and all efforts must be made to prevent youth experimentation and initiation of tobacco use; thus recalling the validity of the old adage that an ounce of prevention is worth a pound of cure.

        (6.2.1c)Special Populations: Pregnancy

        In 2004, more than 580,000 women in Indiana were smokers and more than 20% of them were pregnant, thus making Indiana's rate of maternal tobacco use one of the highest in the nation. Smoking is detrimental to a woman's reproductive health as well as to her fetus. Women who smoke have increased risks for delay in conception and for primary and secondary infertility; they enter natural menopause at a younger average age and some experience heightened adverse menopausal symptoms. Smoking and exposure to secondhand smoke is highly toxic to the embryo, fetus, and newborn, and to the mother as well; the adverse effects increase in proportion to the concentrations and length of exposure. Smoking cessation and elimination of exposure to secondhand smoke greatly diminish the increased rates of disease and death related to tobacco use before, during, and after pregnancy. Research is needed to identify more effective treatment strategies to prevent the high rate of smoking relapse after pregnancy. Cessation programs that incorporate the DHHS Public Health Clinical Practice Guideline: Treating Tobacco Use and Dependence are effective before, during, and after pregnancy and should be used whenever possible to reduce the risk of tobacco-induced injury to the mother and fetus.

      (6.2.2) Learner Objectives

        (6.2.2a) Pharmacological Interventions

        At the conclusion of this presentation participants should be able to:

        • Describe the general neuro-chemical basis for the effectiveness of NRT and bupropion; and
        • Summarize the indications, contraindications, potential adverse effects, and dosing recommendations for tobacco-cessation pharmacotherapy.

        (6.2.2b) Special Populations: Young Adults

        At the conclusion of this presentation participants should be able to:

        • Summarize the prevalence of youth tobacco use in the U.S. and the prevention strategies that have been demonstrated to be effective; and
        • Outline current recommendations for tobacco cessation management in the adolescent/teen/young adult populations (18-24 years).

        (6.2.2c) Special Populations: Pregnancy

        At the conclusion of this presentation participants should be able to:

        • Outline the nature and magnitude of the problems related to smoking before, during and after pregnancy;
        • Review the mechanisms by which tobacco smoke adversely affects human female reproductive health and the human fetus; and
        • Summarize current recommendations for treatment of the tobacco- dependent patient before, during and after pregnancy.

      (6.2.3) References

        (6.2.3a)Pharmacological Interventions

        Benowitz, N .L. (1997). Treating tobacco addiction - nicotine or no nicotine? N Engl J Med, 337, 1230-1231.

        Benowitz, N. L. & Gourlay, S. G. (1997). Cardiovascular toxicity of nicotine: Implications for nicotine replacement therapy. J Am Coll Cardiol, 29(7), 1422-1431.

        Christen, A. G., Jay, S. J., & Christen, J. A. (1996). Treating highly dependent smokers with nicotine gum and patches. Indiana Medicine, 89(2), 169-174.

        Fagerstrom, K. G., Tejding, R., Westin, A., & Lunell. E. (1997). Aiding reduction of smoking with nicotine replacement medications: Hope for the recalcitrant smoker? Tob Control, 6, 311-316.

        Ferry, L. H. & Burchette, R. J. (1994). Efficacy of bupropion for smoking cessation in non-depressed smokers. J Addict Dis, 13, 249.

        Fiore, M. C., Smith, S. S., Jorenby, D. E., & Baker, T. B. (1994). The effectiveness of the nicotine patch for smoking cessation: A meta- analysis. JAMA, 271, 1940-1947.

        Fiore, M. C., Bailey, W. C., Cohen, S. J., et al. (2000, June). Clinical practice guideline: Treating tobacco use and dependence. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. Retrieved from http://www.surgeongeneral.gov/tobacco

        Fiore, M. C., Hatsukami, D., & Baker, T. (2002). Effective tobacco dependence treatment. JAMA, 288(14), 1768.

        Gourlay, S. G. & Benowitz, N. L. (1996). The benefits of stopping smoking and the role of nicotine replacement therapy in older patients. Drugs and Aging, 9(1), 8-23.

        Henningfield, J. (1995). Nicotine medications for smoking cessation. N Engl J Med, 333, 1196-1203.

        Hjalmarson, A., Nilsson, F., Sjostrom, L., et al. (1997). The nicotine inhaler in smoking cessation. Arch Int Med, 157, 1721-1728.

        Hurt, R. D., Sachs, D .P. L., Glover, E. D., et al. (1997). A comparison of sustained-release bupropion and placebo for smoking cessation. N Engl J Med, 337, 1195-1202.

        Jorenby, D. E., Smith, S. S., Fiore, M. C., et al. (1995). Varying nicotine patch dose and type of smoking cessation counseling. JAMA, 274, 1347-1352.

        Kotlyar, M. & Hatsukami, D. (2002). Managing nicotine addiction. J Dental Ed, 66(9), 1061-1073.

        Murray, R. P., Bailey, W. C., Daniels, K., et al. (1996). Safety of nicotine polacrilex gum used by 3094 participants in the Lung Health Study. Chest, 109, 438-445.

        Rigotti, N. A. (2002). Treatment of tobacco use and dependence. N Engl J Med, 346, 506-512.

        Shiffman, S., Dresler, C., Hajek, P., Gilburt, S., Targett, D., & Strabs, K. (2002). Efficacy of a nicotine lozenge for smoking cessation. JAMA and Arch of Intern Med, 162, 1267-1276.

        Silagy, C., Mant, D., Fowler, G., et al. (1994). Meta-analysis of efficacy of nicotine replacement therapies in smoking cessation. Lancet, 343, 139-142.

        Thorndike, A., Rigotti, N., Stafford, R., et al. (1988). National patterns in the treatment of smokers by physicians. JAMA, 279, 604-608.

        U.S. Department of Health and Human Services. (2000). A clinical practice guideline for treating tobacco use and dependence: A U.S. Public Health Service report. JAMA, 283, 3244-3254.

        Working Group for the Study of Transdermal Nicotine in Patients with Coronary Artery Disease. (1994). Nicotine replacement therapy for patients with coronary artery disease. Arch Intern Med, 154, 989-995.

        (6.2.3b) Special Populations: Young People

        Centers for Disease Control. (1998). Selected cigarette smoking initiation and quitting behaviors among high school students. United States, 1998. MMWR, 47, 386-389.

        Centers for Disease Control. (1994). Preventing tobacco use among young people: A report of the Surgeon General. Atlanta, GA: U.S. Dept. of Health and Human Services.

        Centers for Disease Control. (1995). Trends in smoking imitation among adolescents and young adults: United States, 1980-1989. MMWR, 44 (28), 521-525.

        Centers for Disease Control. (1998). Tobacco use among high school students - U.S., 1997. MMWR, 47(12), 229-233.

        Centers for Disease Control. (2003). Secondhand smoke exposure among middle and high school students-Texas, 2001. MMWR, 52(8), 152.

        DiFranza, J. R., Rigotti, N. A., et al. (2000). Initial symptoms of nicotine dependence in adolescents. Tob Control, 9, 313-319.

        Ellickson, P. L., Orlando, M., et al. (2004). From adolescence to young adulthood: Racial/ethnic disparities in smoking. Am J Pub Health, 94, 293-299.

        Feighery, F., Borzekowski, D. L. G., Schooler, C., & Flora, J. (1998). Sex, wanting, owning: The relationship between receptivity to tobacco and smoking susceptibility in young people. Tob Control, 7, 123-128.

        Fiore, M. C., Bailey, W. C., Cohen, S., et al. (2000, June). Clinical practice guideline: Treating tobacco use and dependence. Children and Adolescents (pp. 101-103). Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. Retrieved from http:// www.surgeongeneral.gov/tobacco

        Flay, B. R. (1993). Youth tobacco use: Risk, patterns, and control. In C. T. Orleans & J. Slade (Eds.), Nicotine addiction principles and management (pp. 365-384). New York: Oxford Univ. Press.

        Gold, M. S. (1995). Tobacco. Drugs of abuse. A comprehensive series for clinicians. Vol 4. New York: Plenum Medical Book Co.

        Hum, K. A., Dino, G. A, et al. (2004). Appalachian teen smokers: Not on tobacco 15 months later. Am J Pub Health, 94, 181-184.

        Jay, S. J., Lubitz, R. M., Christen, A. G., & Anderson, J. O. (1996). Smoking Cessation: Strategies and expected outcomes in practice. J Clin Outcomes Man, 3(2), 9-19.

        Lynch, H. S. & Bonnie, R. J. (Eds.) (1994). Institute of Medicine Committee on Preventing Nicotine Addiction in Children & Youth. Growing up tobacco free: Preventing nicotine addiction in children and youths. Washington, D.C.: National Acad. Press.

        Mowery, P. D. & Farrelly, M. C. (2004). Progression to established smoking among U.S. youths. Am J Pub Health, 94, 331-337.

        National Institutes of Health. (1998). Cigars. Health effects and trends. (Monograph 9.) Washington, D.C.: U.S. Department of Health and Human Services. Public Health Service.

        Nichter, M., Nichter, M., Vuckovic, N., et al. (1997). Smoking experimentation & initiation among adolescent girls: Qualitative and quantitative findings. Tob Control, 6, 285-295.

        Rigotti, N. A., Lee, J. E., & Wechsler, H. (2000). U.S. college students' use of tobacco products: Results of a national survey. JAMA, 284, 699-705.

        Sargent, J. D. & DiFranza, J. R. (2003, April/ May). Tobacco control for clinicians who treat adolescents. CA-A Cancer Journal for Clinicians, 53(2), 102-125.

        Sepe, E. & Glantz, S. A. (2002). Bar and club tobacco promotions in the alternative press: Targeting young adults. Am J Pub Health, 92, 75-78.

        U.S. Department of Health and Human Services. (1994). Preventing tobacco use among young people: A report of the Surgeon General. Atlanta, GA: Public Health Service. Centers for Disease Control & Prevention.

        U.S. Department of Health and Human Services. (1998). Tobacco use among U.S. racial/ethnic minority groups - African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics: A report of the Surgeon General. Atlanta, GA: Public Health Service. Centers for Disease Control & Prevention.

        Wee, C. C., Rigotti, N. A., Davis, R. B., et al.(2001). Relationship between smoking and weight control efforts among adults in the U.S. Arch Intern Med, 161, 546-550.

        (6.2.3c) Special Populations: Pregnancy

        Benowitz, N. (1991). Nicotine replacement therapy during pregnancy. N Engl J Med, 266, 3174-3177.

        Campaign for Tobacco Free Kids. Harm caused by pregnant women smoking or being exposed to second hand smoke. Retrieved from www.tobaccofreekids.org

        Colman, G. J. & Joyce, T. (2000). Trends in smoking before, during, and after pregnancy in ten states. Am J Prev Med, 24, 29-35.

        Ershoff, D. H., Quinn, V. P., Boyd, N. R., et al. (1999). The Kaiser Permanente prenatal smoking-cessation trial. Am J Prev Med, 17, 161-168.

        Fiore, M. C., Bailey, W. C., Cohen, S. J., et al. (2000, June). Clinical practice guideline: Treating tobacco use dependence. Pregnancy. (pp. 92-96). Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. Retrieved from http://www.surgeongeneral.gov/tobacco

        Floyd, R. L., Rimer, B. K., Giovino, G. A., et al. (1993). A review of smoking in pregnancy: Effects on pregnancy outcomes and cessation efforts. Ann Rev Pub Health, 14, 379-411.

        DiFranza, J. R. & Lew, R. A. (1995). Effect of maternal cigarette smoking on pregnancy complications and SIDS. J Fam Pract, 40, 385.

        Ilet, K. & Hale, T. W., et al. (2003). Use of nicotine patches in breast feeding mothers: Transfer of nicotine and cotinine into human milk. Clin Pharm & Ther, 74, 516-524.

        Jaakkola, J. J. & Gissler, M. (2004). Maternal smoking in pregnancy, fetal development, and childhood asthma. Am J Pub Health, 94, 136-140.

        Lumley, J., Oliver, S., & Waters, E. (2003). Interventions for promoting smoking cessation during pregnancy (Cochrane Review). In The Cochrane Library, (1). Oxford: Update Software. Retrieved from http://www.update-software.com/cccweb/cochrane/revabstr/ab001055.htm

        Ness, R. B. et al. (1999). Cocaine and tobacco use and the risk of spontaneous abortion. N Engl J Med, 340, 333-339.

        Oncken, C.A., Hatsukami, D.K., Lupo, V.R., et al. (1996). Effects of short-term use of nicotine gum in pregnant smokers. Clin Pharm & Ther, 59, 654-661.

        U.S. Department of Health and Human Services. Women and Smoking. Report of the Surgeon General. Rockvil!e, MD: Public Health Service. Retrieved from http://surgeongeneral.gov/library

    (6.3) Presentation 2

    Controversial Issues of Tobacco Treatment

      (6.3.1) Presentation Abstract

      Enormous progress has been made in the past 15 years in the development of Smoking cessation strategies. However, it was only in 1996 that the first evidence-based review of the smoking cessation literature was accomplished and published in April 1996 as the Clinical Practice Guideline # 18: Smoking Cessation, U.S. Public Health Service, Agency for Health Care Policy and Research. A review of the literature published from 1996 to 2000 (about three thousand new research reports) was published as a sequel in 2000 as the Clinical Practice Guideline, Treating Tobacco Use and Dependence, 2000. While the recent advances in knowledge and practice have been substantial, approximately 80% of persons who receive today's recommended treatment for tobacco dependence fail to achieve long-term abstinence. Many aspects of cessation practice and tobacco control remain speculative and controversial. Several controversial issues will be reviewed and include: gender differences in smoking cessation; "harm reduction;" abuse potential of NRT; "alternative/ complementary" treatment; effectiveness of NRT and counseling vs. the effectiveness and/or efficacy of non-drug "cold turkey" methods; cost-effectiveness of hospital-based smoking cessation programs; and, finally, "safe-cigarettes." Front-line smoking cessation professionals will be asked by patients, clinicians, and administrators about some of these issues. Participants armed with knowledge gained from this presentation will have the information necessary to educate patients and effectively clarify and debunk myths regarding these topics.

      (6.3.2) Learner Objectives

      At the end of this learning activity, participants should be able to:

      • List some key controversies in the management of nicotine- dependent patients; and

        (6.3.3) References

        Breland, A. B., Evans, S. E., Buchhalter, A. R., et al. (2002). Acute effects of advanced TM: A potential reduced exposure product for smokers. Tob Control, 11, 376-378.

        Farone, W. A. (2002). Harm reduction: 25 years later. Tob Control, 11, 287-288.

        Henningfield, J. E. et al. (2002). Brave new world of tobacco disease prevention: Promoting dual tobacco-product use? Am J Prev Med, 23, 226-228.

        National Center on Addiction and Substance Abuse (CASA) Columbia University. Big differences in why girls vs. boys use cigarettes, alcohol and drugs. Retrieved from http://www.casacolumbia.org

        Hughes, J. R., Shiffman, S., Callas, P., et al. (2003). A meta- analysis of the efficacy of over-the-counter nicotine replacement. Tob Control, 12, 21-27.

        Jay, S. J. (2001). Origins of "denicotinized" tobacco. Tob Control, 10, 295.

        Rigotti, N. A., Munafo, M. R., et al. (2003). Interventions for smoking cessation in hospitalized patients. Cochrane Database of Systematic Reviews, (1):CD001837.

        Tomar, S. L. (2002). Snuff use and smoking in U.S. men: Implications for harm reduction. Am J Prev Med, 23, 143-149.

        Sutherland, G. (2003). Evidence for counseling effectiveness for smoking cessation. J Clin Psych Monograph 1, 18, 22-34.

      (6.4) Presentation 3

      Medically Complex Patient Issues

        (6.4.1) Presentation Abstract

        A variety of factors and co-morbidities may complicate the choice, delivery, and efficacy of tobacco dependence treatment. While smoking cessation therapy in healthy adults may be provided successfully by primary care health professionals, medically complicated cases often require the input of various specialists and sub-specialists. It is important that "front-line" caregivers recognize complex management problems in their patients and seek assistance of specialists who can assist in caring for these individuals. An ideal model for patient management involves a coordinated team effort where the patient's primary care physician and a front-line non-physician caregiver work closely with the patient's specialist or sub-specialist (perhaps a cardiologist, a pulmonologist, or an addictions expert) to formulate and implement a plan to meet specific needs of the patient. Delineation of roles and responsibilities of the team for acute management and follow-up is critical. Communicating updates and changes in treatment plans over time to team members and the patient and family is vital to achieve optimum clinical outcomes.

        (6.4.2) Learner Objectives

        At the end of this learning activity the participant should be able to:

        • Outline examples of complex management issues that require specialist involvement in care; and
        • Summarize key issues in coordinating a team effort to address medically complex patient problems.

        (6.4.3) References

        Benowitz, N. L. (1988). Pharmacologic aspects of cigarette smoking and nicotine addiction. N Engl J Med, 319, 1318-1330.

        Benowitz, N. L. (1998). Nicotine safety and toxicity. New York: Oxford University Press.

        Fiore, M. C., Bailey, W. C., Cohen, S. J., et al. (2000, June). Clinical practice guideline: Treating tobacco use and dependence. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. Retrieved from http://www.surgeongeneral.gov/tobacco

        Gritz, E. R., Kristeller, J. L., & Burns, D. M. (1993). Treating nicotine addiction in high-risk groups and patients with medical co- morbidity. (pp. 279-309). In C. T. Orleans & J. Slade (Eds.), Nicotine addiction principles and management. New York: Oxford University Press.

        Orleans, C. T. and Slade, J. (Eds.) (1993). Nicotine addiction principles and management. New York: Oxford University Press.

        Rigotti, N. A., Munafo, M. R., et al. (2003). Interventions for smoking cessation in hospitalized patients. (Update of Cochrane Database of Systemic Reviews, 2001) Cochrane Database of Systematic Reviews. (1):CD001837.

        Rigotti, N. A. (2002). Treatment of tobacco use and dependence. New Engl J Med, 346, 506-512.

        Sessa, A., Conte, F., Meroni, M., & Battini, G. (2000). Cigarette smoking and the kidney. Contributions to nephrology. Basel (Switzerland): Karger.

      (6.5) Presentation 4

      Relapse Prevention Case Study

        (6.5.1) Presentation Abstract

        Multiple quit attempts are common for those people who are trying to quit smoking. Relapse is a common experience. It can be very frustrating and result in feelings of inadequacy and failure on both the patient's and the clinician's part. Instead, relapse should be seen as a "wrong turn" on the road to cessation. The successful traveler will use a good map (treatment plan), learn from each mistake (progressive treatment plan development), and eventually arrive safely at their intended destination (tobacco cessation and freedom from nicotine addiction). The clinician's role is to support the patient in their quit process: good directions, patience, and a supportive attitude are the keys to a successful journey.

        (6.5.2) Learner Objectives

        At the conclusion of this presentation participants should be able to:

        • Outline common causes of relapse;
        • Define relapse and slips;
        • Describe strategies for preventing relapse; and
        • Describe strategies for managing relapse.

        (6.5.3) References

        Fiore, M. C., Bailey, W. C., Cohen, S. J., et al. (2000, June). Clinical practice guideline: Treating tobacco use and dependence. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. Retrieved from http://www.surgeongeneral.gov/tobacco

        Marlatt, G. A. & Gordon, J. R., (Eds.) (1985). Relapse prevention. Maintenance strategies in the treatment of addictive behaviors. New York: Guilford Press.

        Seidman, D. F. & Covey, L. S., (Eds.) (1999). Helping the hard-core smoker: A clinician's guide. New Jersey: Lawrence Erlbaum Associates.