Tobacco Cessation (Part 1)
Maha Muzaffar, PharmD
PGY1 Pharmacy Resident
Eskenazi Health
3/13/2023
“Tobacco use remains the number one cause of
preventable disease, disability, and death in the
United States. Approximately 34 million
American adults currently smoke cigarettes,
with most of them smoking daily.”
-Robert R. Redfield, M.D.
Director
Centers for Disease Control and Prevention
.
In 2018, 13.7% of U.S.
adults were current
smokers
The majority of cigarette smokers (68%) want to quit smoking completely.
55% tried to quit in the past year.
Reduces the
risk of
premature
death
Reduces the
Increases risk of CVD,
life COPD, and 12
expectancy types of
cancer
Health
Benefits From
Quitting
Reduces the Smoking
financial Benefits people
burden that already
smoking places diagnosed with
on people who CHD or COPD
smoke Benefits the
health of
pregnant
women and
their fetuses
and babies
U.S. Department of Health and Human Services (USDHHS). (2014).
The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General.
Compounds in Tobacco Smoke
An estimated 4,800
compounds in tobacco
smoke, including 16 proven
human carcinogens
Gases Particles
• Carbon monoxide • Nicotine
• Hydrogen cyanide • Nitrosamines
• Ammonia • Lead
• Benzene • Cadmium
• Formaldehyde • Polonium-210
Nicotine is the addictive component of tobacco products, but it does NOT cause the ill health
effects of tobacco use.
Health Consequences of Smoking
Cancers Cardiovascular Diseases
• Bladder/kidney/ureter • Aortic aneurysm
• Blood (acute myeloid leukemia) • Coronary heart disease
• Cervix • Cerebrovascular disease
• Colon/rectum • Peripheral vascular disease
• Esophagus/stomach
• Liver Reproductive effects
• Lung • Reduced fertility in women
• Oropharynx/larynx • Poor pregnancy outcomes (e.g.,
• Pancreatic congenital defects, low birth
weight, preterm delivery)
Pulmonary Diseases • Infant mortality
• Asthma
Other
• COPD
• Cataract, diabetes (type 2), erectile
• Pneumonia/tuberculosis dysfunction, impaired immune function,
• Chronic respiratory symptoms osteoporosis
U.S. Department of Health and Human Services (USDHHS). (2014).
The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General.
Health Problems with
Secondhand Smoke
There is no safe level of exposure to secondhand smoke (SHS); even brief exposure can cause
immediate harm.
Beneficial Effects of Quitting:
Pulmonary Effects
At any age, there are benefits of quitting.
.
Reprinted with permission. Fletcher & Peto. (1977). BMJ 1(6077):1645–1648
Financial Impact of Smoking
* Average national cost, as of January 2019. Campaign for Tobacco-Free Kids, 2018
Patient Case
RC is a 34-year-old male truck driver who is
seeking information about quitting smoking. He
reports that his primary care physician, who is
treating RC’s diabetes, recommended smoking
cessation. He would like to quit smoking by the
end of the month. He currently smokes a pack of
cigarettes a day.
What are some health benefits with RC quitting
smoking?
Nicotine Pharmacology and
Principles of Addiction
Chemistry of Nicotine
H Pyrrolidine ring
N
Pyridine ring
N CH3
Nicotina tabacum
Natural liquid alkaloid
Colorless, volatile base
pKa= 8.0
Nicotine Absorption: Buccal
(Oral) Mucosa
The pH inside the mouth is 7.0
Acidic Media Alkaline media
(limited absorption) (significant absorption)
Cigarettes Pipes, cigars, spit tobacco, oral
nicotine products
Beverages can alter pH, affect absorption
Nicotine Absorption: Lung
• Nicotine is “distilled” from burning
tobacco and carried in tar droplets
• Nicotine is rapidly absorbed across
respiratory epithelium
• Lung pH= 7.4
• Large alveolar surface area
• Extensive capillary system in lung
• Approximately 1 mg of nicotine is
absorbed from each cigarette
Liu C. Infectious Diseases Society of America. January 4, 2011 .
Nicotine Distribution
80
Plasma nicotine (ng/ml)
70
60 Arterial
50
40
30
20
Venous
10
0
0 1 2 3 4 5 6 7 8 9 10
Minutes after light-up of cigarette
Nicotine reaches the brain within 10-20 seconds
Henningfield et al. (1993). Drug Alcohol Depend 33:23–29
Nicotine Pharmacodynamics
Benowitz. (2008). Clin Pharmacol Ther 83:531–541
Nicotine Distribution
Chronic Administration of
Nicotine: Effects on the Brain
Human smokers have increased nicotine
receptors in the prefrontal cortex.
High
Low
Nonsmoker Smoker
Image courtesy of George Washington University / Dr. David C. Perry
Nicotine Addiction
Factors Contributing to Tobacco
Use
Pharmacology
Individual
• Alleviation of
• Genetic withdrawal
predisposition symptoms
• Weight control
• Coexisting • Pleasure, mood
medical modulation
conditions
Environment
• Tobacco advertising
• Conditioned stimuli
• Social interactions
Tobacco Dependence: A 2-Part
Problem
Tobacco Dependence
Physiological Behavioral
The habit of
The addiction
using
to nicotine
tobacco
Behavior
Medications
change
for cessation
program
Forms of Tobacco
American Cigarettes
• Most common form of tobacco used in U.S.
• Sold in packs (20 cigarettes/pack)
• Avg. 13.5 mg (range, 11.9 to 14.5 mg)
• Machine-measured nicotine yield:
Type of cigarette Yield per cigarette
Full-flavor (regular) 1.1 mg
Light 0.8 mg
Ultra-light 0.4 mg
Average (all brands) 0.9 mg
• Smoker’s nicotine yield, per cigarette:
• Approximately 1 to 2 mg
Marlboro and Marlboro Light are registered trademarks of Philip Morris, Inc
Smokeless Forms of Tobacco
• Estimated 8.8 million users in the U.S. in 2013
• Adult males (6.5%) more likely than adult
females (0.4%) to be current users
• Prevalence highest among
• Young adults aged 18-25 years
• Residents of the Midwest and
Southern U.S.
• Residents of nonmetropolitan areas
• Significant health risks
• Numerous carcinogens
• Nicotine exposure comparable to that of
smokers, leading to
• Physical dependence
• Withdrawal symptoms after
abstinence
The Copenhagen and Skoal logos are registered trademarks of U.S. Smokeless Tobacco Company, and Red Man is a registered trademark of Swedish Match .
Electronic Cigarettes
• Generally similar in appearance
to cigarettes, cigars, pipes, or pen
• Battery operated device that
create a vapor for inhalation
• Stimulates smoking but does
not involve combustion of
tobacco
• Vapor created from heating
nicotine, flavorings, and
other chemicals
• Also known as
• E-cigarette
• E-hookah, Hookah pen
• Vapes, Vape pen, vape pipe
Quick Facts on the Risks of E-cigarettes. CDC Website. 2019
E-cigarettes vs cigarettes
Are e-cigarettes less harmful
than regular cigarettes?
• Yes, but that doesn’t mean
they are safe
• E-cigarette aerosol generally
contains fewer toxic
chemicals than the deadly mix
of 7,000 chemicals in smoke
from regular cigarettes
Can e-cigarettes help adults quit
smoking cigarettes?
• Not currently FDA approved
as a quit smoking aid
• Evidence is insufficient to
recommend e-cigarettes for
smoking cessation in adults,
including pregnant adults
Quick Facts on the Risks of E-cigarettes. CDC Website. 2019
Prevalence of Electronic Cigarettes
Electronic Cigarettes
• 1st: Mimic appearance, 1 time
use
• 2nd: Larger, Rechargeable
batteries
• 3rd: Device customization
(temperature, nicotine dose)
• 4th: Pod mods, nicotine salts
(JUUL)
Why It Matters
What We Know
• Laboratory data show that Vitamin E
acetate, an additive in some THC-
containing e-cigarette, or vaping,
products, is strongly linked to the EVALI
(e-cigarette, or vaping, use-associated
lung injury) outbreak
• Vitamin E acetate should not be added to
any e-cigarette, or vaping, products.
Additionally, people should not add any
other substances not intended by the
manufacturer to products, including
products purchased through retail
establishments.
Severe Lung Disease. CDC Website. 2020
Why It Matters
As of 2/18/2020, a total of 2,807 hospitalized EVALI (e-cigarette, or vaping, use-
associated lung injury) cases or death have been reported from all 50 states
ED visits related to e-cigarettes, or vaping, products continue to decline,
after sharply increasing in August 2019
68 deaths have been confirmed in 29 states and the District of Columbia
(as of 2/18/2020). Including 6 deaths in Indiana.
Although Vitamin E acetate has been removed from e-cigarettes, it’s important
to note that data assessing the other components and their impact on patient
health is still ongoing
Severe Lung Disease. CDC Website. 2020.
Assisting Patients with Quitting
Clinical Practice Guideline for
Treating Tobacco Use and
Dependence
• Update release May 2008
• Sponsored by the U.S. Department of
Health and Human Services, Public Health
Service with:
• Agency for Healthcare Research and
Quality
• National Heart, Lung, & Blood Institute
• National Institute on Drug Abuse
• Centers for Disease Control and
Prevention
• National Cancer Institute
Expert Consensus Statement
for Tobacco Cessation
Treatment
Why Should Clinicians Address
Tobacco?
• People who use tobacco are expected to be encouraged to quit
by health professionals
• Screening for tobacco use and providing tobacco cessation
counseling are positively associated with patient satisfaction
• Compared to patients who receive no assistance from a clinician,
patients who receive assistance are 1.7-2.2 times as likely to quit
successfully for 5 or more months
• Compared to smokers who receive assistance from no clinicians,
smokers who receive assistance from two or more clinician types
are 2.4-2.5 times as likely to quit successfully for 5 or more
months
Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update.
Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008
Tobacco Dependence: A 2-Part
Problem
Tobacco Dependence
Physiological Behavioral
The habit of
The addiction
using
to nicotine
tobacco
Behavior
Medications
change
for cessation
program
The 5 A’s
Ask Advise Assess Assist Arrange
Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update.
Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008
The 5 A’s
Ask about tobacco use
• “Do you ever smoke or use other types of tobacco
or nicotine, such as e-cigarettes?”
• “I take time to ask all of my patients about tobacco use-
because it’s important”
• “How long have you smoked cigarettes?”
• “On average, how many cigarettes do you smoke in
a day?”
The 5 A’s
Advise people who use tobacco to quit (clear, strong,
personalized)
• “It’s important that you quit as soon as possible,
and I can help you.”
• “Cutting down while you are ill is not enough”
• “Occasional or light smoking is still harmful”
• “I realize that quitting is difficult. It is the most
important thing you can do to protect your health
now and in the future. I have training to help my
patients quit, and when you are ready, I will work
with you to design a specialized treatment plan.”
The 5 A’s
Assess readiness to make a quit attempt
• Would you like to establish a quit date?
• How ready are you to quit smoking within the next
month?
Assist with the quit attempt
• Not ready to quit: enhance motivation (the 5 R’s)
• Ready to quit: design a treatment plan
• Recently quit: relapse prevention
The 5 A’s
Arrange follow-up care
Number of sessions Estimated tobacco quit rate
0 to 1 12.4%
2 to 3 16.3%
4 to 8 20.9%
More than 8 24.7%
Provide assistance throughout the quit attempt
The 5 A’s: Review
Assess
Advise
readiness Assist with Arrange
Ask about people who
to make a the quit follow-up
tobacco use use tobacco
quit attempt care
to quit
attempt
Assessing Readiness to Quit
Patients differ in their readiness to quit
Stage 1: Not ready to quit in the next month
Stage 2: Ready to quit in the next month
Stage 3: Recent quitter, quit within past 6
months
Stage 4: Former tobacco user, quit > 6 months
ago
Assessing Readiness to Quit
For most patients, quitting is a cyclical process, and
their readiness to quit (or stay quit) will change over
time
Not ready
Former Not thinking to quit
Relapse tobacco user about it
Thinking
Recent
about it,
quitter
not ready
Ready to
quit
Patient Case
RC is a 34-year-old male truck driver who is
seeking information about quitting smoking. He
reports that his primary care physician, who is
treating RC’s diabetes, recommended smoking
cessation. He would like to quit smoking by the
end of the month. He currently smokes a pack of
cigarettes a day.
What stage of readiness to quit is RC in currently?
Assessing Readiness to Quit
Stage 1: Not ready to quit in the next month
Not thinking about quitting in the next month
• Some patients are aware of the need to quit
• Patients struggle with ambivalence about change
• Patients are not ready to change, yet
• In the patient's mind: pros of continued tobacco
use outweigh the cons
GOAL: Start thinking about quitting
Stage 1: Not Ready to Quit
DO DON’T
• Strongly advise to quit • Persuade
• Provide information • “Cheerlead”
• Ask noninvasive questions; • Tell patient how bad tobacco
identify reasons for tobacco is, in a judgmental manner
use • Provide a treatment plan
• Raise awareness of health
consequences/concerns
• Demonstrate empathy, foster
communication
• Leave decision up to patient
Stage 1: Not Ready to Quit
Stage 1: Not Ready to Quit
The 5 R’s: Methods for
enhancing motivation
• Relevance
• Risk Tailored,
• Rewards motivational
messages
• Roadblocks
• Repetition
Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update.
Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008
Assessing Readiness to Quit
Stage 2: Ready to quit in the next month
• Patients are aware of the need to, and the benefits
of, making the behavioral change
• Patients are getting ready to take action
GOAL: Achieve Cessation
Stage 2: Ready to Quit
• Assess tobacco use history
• Current use: type(s) of tobacco, amount
• Past use: duration, recent changes
• Past quit attempts:
• Number, date, length
• Methods/medications used, adherence, duration
• Reasons for relapse
• Discuss key issues
• Facilitate quitting process
• Practical counseling (problem solving/skills training)
• Social support delivered as part of treatment
Stage 2: Ready to Quit
Discuss Key Issues
• Reasons/motivation to quit
• Confidence in ability to quit
• Triggers for tobacco use
• What situations lead to temptations to use tobacco?
• What led to relapse in the past?
• Routines/situations associated with tobacco use
• When drinking coffee
• While driving in the car
• When bored or stressed
• While watching television
Stage 2: Ready to Quit
Discuss Key Issues
Stress-Related Tobacco Use
The Myths The Facts
• “Smoking gets rid of all • There will always be
my stress” stress in one’s life
• “I can’t relax without a • There are many ways to
cigarette” relax without a cigarette
People who smoke confuse the relief of withdrawal
with the feeling of relaxation
Stress management suggestions:
Deep breathing, shifting focus, taking a break
On average, quitters gain 9 to 11 pounds,
but there is a wide range.
Stage 2: Ready to Quit
Discuss Key Issues
Concerns about Weight Gain
Discourage strict dieting while quitting
• Encourage healthful diet and meal planning
• Suggest increasing water intake or chewing sugarless gum
• Recommend selection of nonfood rewards
When fear of weight gain is a barrier to quitting
• Consider pharmacotherapy with evidence of delaying
weight gain (bupriopion SR of 4-mg nicotine gum or
lozenge)
• Assist patient with weight maintenance or refer patient to
specialist or program
Stage 2: Ready to Quit
Discuss Key Issues
Concerns about Withdrawal Symptoms
• Most pass within 2-4 weeks after
quitting
Most symptoms
• Cravings can last longer, up to several manifest within the
months or years
first 1-2 days, peak
• Often can be ameliorated with cognitive
or behavioral coping strategies within the first week,
and subside within 2-
• Refer to withdrawal symptoms
information sheet 4 weeks.
• Symptom, cause, duration, relief
Nicotine Withdrawal Symptoms:
Time Course and Management
Irritability / Frustration / Anger Most symptoms
Anxiety manifest within the
Difficulty concentrating
Restlessness / Impatience first 1-2 days, peak
Depressed mood / Depression within the first week,
Insomnia
Impaired task performance and subside within 2-
Increased appetite 4 weeks.
Weight gain
Cravings
1 week 4 weeks 12 weeks
Former
Recent quitter
tobacco user
• Cognitive & behavioral coping strategies
• Medications for cessation
Data from Hughes. (2007). Nicotine Tob Res 9:315–327
Stage 2: Ready to Quit
Facilitate the Process
• Discuss methods for quitting
• Discuss pros and cons of available methods
• Pharmacotherapy: a treatment, not a crutch!
• Importance of behavioral counseling
• Set a quit date
• Recommend Tobacco Use Log
• Helps patients to understand when and why they use
tobacco
• Identify activities or situations that trigger tobacco use
• Can be used to develop coping strategies to overcome the
temptation to use tobacco
Stage 2: Ready to Quit
Facilitate Quitting Process
Cognitive coping strategies
• Review commitment to quit
• Distractive thinking
• Positive self-talk
• Relaxation through imagery
• Mental rehearsal and visualization
• “Retraining the way a patient thinks”
• Remind yourself that urges are brief
Stage 2: Ready to Quit
Facilitate Quitting Process
Behavioral coping strategies
• Control your environment
• Tobacco-free home and workplace
• Remove cues to tobacco use; actively avoid trigger
situations
• Modify behaviors that you associate with tobacco:
when, what, where, how, with whom
• Substitutes for smoking
• Water, sugar-free chewing gum or hard candies (oral
substitutes)
• Minimize stress where possible, obtain social support, take a
break, and alleviate withdrawal symptoms
Patient Case
RC is a 34-year-old male truck driver who is
seeking information about quitting smoking. He
reports that his primary care physician, who is
treating RC’s diabetes, recommended smoking
cessation. He would like to quit smoking by the
end of the month. He currently smokes a pack of
cigarettes a day.
What are some techniques you would use to help
motivate RC to quit smoking?
Assessing Readiness to Quit
Stage 3: Recent quitter, quit within past 6 months
Actively trying to quit for good
• Patients have quit using tobacco sometime in the
past 6 months and are taking steps to increase their
success
• Withdrawal symptoms occur
• Patients are at risk for relapse
Goal: Remain tobacco free for at least 6 months
Recent Quitters: Evaluate the
Quit Attempt
• Tailor intervention for to match each patient’s needs
• Status of attempt
• Ask about social support
• Identify ongoing temptations and triggers for relapse (negative
effect, smokers, eating, alcohol, cravings, stress)
• Encourage healthy behaviors to replace tobacco use
• Slips and relapse
• Has the patient used tobacco/inhaled nicotine at all-even a puff?
• Medication adherence, plans for termination
• Is the regimen being followed?
• Are withdrawal symptoms being alleviated?
• How and when should pharmacotherapy be terminated?
Stage 3: Recent Quitters
Facilitate Quitting Process
Relapse Prevention
• Congratulate success!
• Encourage continued abstinence
• Discuss benefits of quitting, problems encountered, successes
achieved, and potential barriers to continued abstinence
• Ask about strong or prolonged withdrawal symptoms (change
dose, combine or extend use of medications)
• Promote smoke-free environments
• Schedule additional follow-up as needed
Assessing Readiness to Quit
Stage 4: Former tobacco user
Tobacco-free for 6 months
• Patients remain vulnerable to relapse
• Ongoing relapse prevention is needed
Goal: Remain tobacco free for life.
Stage 4: Former Tobacco Users
• Assess status of quit attempt
• Congratulate continued success
• Inquire about and address slips and relapse
• Plans for termination of pharmacotherapy
• Review tips for relapse prevention
Continue to assist throughout the quit attempt
Helpful Resources
• English tobacco cessation quit line: 1-800-QUIT-NOW
• Spanish tobacco cessation quit line: 1-877-44U-QUIT
• https://www.cdc.gov/tobacco/patient-
care/index.html?s_cid=OSH_hcp_GL0007
• https://rxforchange.ucsf.edu/
• https://smokefree.gov/
• https://www.takingtexastobaccofree.com/videos
Indiana Standing Order for
Tobacco Cessation Products
Indiana Code 16-19-4-11
Medications:
• Nicotine gum
Dr. Kristina Box issued a • Nicotine lozenge
statewide standing order for
pharmacists to dispense
• Nicotine patch
FDA approved medications • Nicotine inhaler
with an indication for • Nicotine nasal spray
smoking cessation • Bupropion SR tablets
• Varenicline
Qualifications for the Standing
Order
• Active Indiana pharmacist license
• Education and training in tobacco use disorder
• Complete continuing education on tobacco
cessation each biennium
• Act in good faith and exercising reasonable
care
Assessment for Standing Order
• Must assess readiness to quit (5 A’s)
• Screening
• Medical, Social, Family, Medication History
• Allergies and comorbidities
• Refer high-risk patients
• Pregnant or planning to become pregnant
• Heart attack in past 2 weeks, history of arrhythmias or
irregular heartbeat
• Unstable angina or chest pain with strenuous activity
• History mental health disorder and currently not stable
Follow Up
• Pharmacists shall follow up with patients
• Within 2 weeks of initiating therapy
• After completion of a course of therapy
• Pharmacists should also document record of the
screening and prescription and keep on record for
7 years
• Must provide patient with record and notify the
PCP of the prescription within 3 business days
Patient Case
RC is a 34-year-old male truck driver who is
seeking information about quitting smoking. He
reports that his primary care physician, who is
treating RC’s diabetes, recommended smoking
cessation. He would like to quit smoking by the
end of the month. He currently smokes a pack of
cigarettes a day.
What are some helpful resources you could provide
RC to help him quit smoking?
Questions?
Please fill out this quick feedback
survey!
https://butler.qualtrics.com/jfe/form/SV_4PzZjdaqVZ
wFrTM
