Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature. Methods of Smoking Cessation With the introduction of the nicotine skin patch, there has been renewed interest in methods of smoking cessation. Given the addictive nature of nicotine and that smoking remains the number one cause of preventable morbidity and mortality in the United States today, a review of the effectiveness of various methods is in order. Self-help methods are the most commonly used and most smokers who quit use these techniques. There are several dozen quit smoking pamphlets, books, and guides offering tips on how to quit and how to remain off cigarettes. They aim at identifying smoking triggers, handling smoking situations, relaxation exercises, and controlling weight. There are videotapes, quit by mail programs, telephone hotlines and even computer programs available to assist the smoker with quitting. Filter systems such as Teledyne Water Pik's "One Step at a Time" aim at reducing the tar and nicotine in cigarettes smoked while smokeless cigarettes provide a simulated flavor without any nicotine. The FDA has ruled that these are medical devices that have not provided data to demonstrate their effectiveness. However, a national survey of adult smokers in the US found that 90-95% of successful quitters used self-help methods rather than an organized program. Several studies of these methods show quit rates of 25-30% at one year and overall long term quit rates of 10-15%. A number of voluntary agencies such as the American Cancer Society, Seventh-day Adventist Church, and the American Lung Association use an educational or a group counseling format to assist the smoker, at reduced or no charge. Commercial programs such as Schick and SmokEnders are available in most major cities. Schick reports a 13 month quit rate of 52% but independent observers estimate only 20-30% short term success rate and an even lower long term success rate despite the extreme methods and very motivated patients as evidence by their willingness to pay for such a program. Both Methodist Hospital and M.D. Anderson have commercial programs available in Houston. One should be aware that most programs self-report their success rates and may have a financial or other interest in inflating them. Most organized commercial programs utilize behavior modification therapy which consists of two types. Aversive therapy, which is some sort of punishment, and positive reinforcement techniques such as stimulus control, relaxation, desensitization. Use of electric shock as a punishing stimulus as is done in the Schick program to eliminate smoking behavior has had limited success. The more promising techniques use a form of smoke aversion such as smoke satiation or rapid smoking. With satiation treatment, subjects are required to increase the number of cigarettes smoked and the rate at which they are smoked. Rapid smoking requires the subject inhale from a cigarette once every six seconds for the duration of the cigarette or until nauseated. Self management techniques are directed by group leaders or a therapist and include self monitoring and forms of nicotine fading. Slowly reducing nicotine intake by changing to brands with a lower nicotine content is called "brand fading" while cutting down the number of cigarettes smoked is termed "tapering". The results with these techniques are not very positive because as cigarettes are reduced, each remaining cigarette can become more reinforcing. Reports regarding the effectiveness of hypnosis are contradictory but this technique is commonly advertised. Quit rates in the literature of between 12 and 88% can be found using various techniques. Acupuncture has become increasingly popular as a method to aid smokers in quitting but again there are no scientifically valid evaluations of it's effectiveness. Mass media programs such as the American Cancer Society's "Great American Smokeout" or the World Health Organization's "No Tobacco Day" are given extensive press and television coverage, but their long-term efficacy is unknown. There are two general categories of pharmaceutical agents that are used to help people quit smoking - agents developed specifically to help smokers break the habit, and drugs prescribed to overcome withdrawal symptoms. Early deterrents consisted of herbs and spices and mouthwashes that produced a disagreeable taste for the smoker. Other products diminish the sensory drive or create dry mouth. In the 1960's lobeline was used as treatment for smoking as it was considered to be a nicotine substitute. It was available in tablets, lozenges, chewing gum, and by injection. Some of these products are still sold over the counter (Bantron, Nikoban, Cigarrest). Lobeline has irritating effects in the mouth and stomach, but its supporters say that it satisfies the craving for nicotine. Clonidine is an alpha-2-agonist often used as an anti-hypertensive. Small randomized placebo-controlled trials have shown it to be effective in controlling some of the short-term nicotine withdrawal symptoms. Nicorette is a drug in the form of chewing gum containing 2 mg of nicotine which is bound by an ion-exchange resin to allow for slow release of nicotine when chewed. Proper chewing for 20-30 minutes can result in the release of 90% of the nicotine which is absorbed through the buccal mucosa. Controlled trials have compared Nicorette gum with a placebo gum containing nicotine in a poorly absorbed form and have found that the gum can relieve the irritability, difficulty in concentrating, and other symptoms that occur after withdrawal from smoking. Quit rates were 47% after one year with Nicorette compared to 21% for those on placebo. Nicorette should be chewed slowly until a tingling sensation is felt, then held until the sensation is gone before resuming chewing. The number of pieces of gum needed daily to maintain abstinence from cigarettes varies from one patient to the next but in general it takes 10-12 pieces per day and the manufacturer recommends that it be used for at least three months. It costs about $14 for a package containing 96 pieces. Some patients complain about burning or soreness of the mouth or throat and nausea, vomiting, belching and hiccups can occur. About 2% of patients can become dependent on the gum. Three nicotine releasing adhesive patches for the skin have been approved by the FDA. The skin is very permeable to nicotine and the delivery systems in the patches prevent systemic toxicity by maintaining plasma levels throughout the day. So far, there are few clinical trails with these patches and none that are long term, but they have been shown to reduce nicotine craving and withdrawal symptoms such as headache, irritability, and difficulty concentrating. Hurt and associates reported 31 patients using PROSTEP and found that at six weeks 24 (77%) had stopped smoking compared to 39% with placebo. At one year only 9 (29)%) of the 31 were still not smoking. A more recent report by Tonneson et al. in the January 1992 New England Journal of Medicine reported 77 of 145 (53%) patients treated with Nicotrol not smoking after six weeks compared with 17% on placebo, but only 17 (12%) of the 145 were still abstinent two years later. A double-blind placebo-controlled trial in 158 patients found no statistically significant difference in effectiveness between the use of 16 or 24 hour patches. None of these studies used behavior modification. There has been one uncontrolled trial in about 400 patients with behavior modification plus patches achieving a 12 month success rate of about 35%. So far there have been no published trials comparing patches with nicotine chewing gum. These patches are easy to prescribe -- most smokers start with the 21 mg/day patch for 4-8 weeks, and the patient graduates to the next lower dose which should be used for 2-4 weeks. The cost is about $110 wholesale for a months supply which translates to $3.60 a day, which is curiously about the same price as two packs of cigarettes. A few adverse effects have been reported - the patches have caused erythema, itching, or burning in 25-50% of patients. Generalized rash, headache, nausea, vertigo, dyspepsia, myalgias, cough, insomnia, and nightmares have been reported. These patches are obviously not a cure for smoking. All the manufacturers recommend using the patches in conjunction with a behavioral modification program. They are nothing more than the newest delivery system for an alternate source of nicotine. There are even new approaches being worked on including a nicotine vapor and nasal nicotine solution. Case Presentation A 62-year-old white male, with a 40 pack-a-year history of smoking, was diagnosed with T1N0 squamous cell carcinoma of the right true vocal cord in July 1988 and treated with full course radiotherapy. Although he remained without evidence of disease on follow-up exams, he continued to smoke. In January 1992 he indicated his willingness to quit smoking and was referred to the VA smoking cessation clinic. He received counseling and was provided with Nicorette gum. He remained abstinent from cigarettes for two months but complained that the gum caused his mouth to burn and at times made him nauseated. He failed to return for follow-up visits to the smoking cessation clinic and returned to smoking one pack of cigarettes per day by April 1, 1992. Bibliography Abelin T, Buehler A, Muller P, et al. Controlled trial of transdermal nicotine patch in tobacco withdrawal. Lancet 1989;1(8628):7-10. Daughton DM, Heatley SA, Prendergast JJ, et al. Effect of transdermal nicotine delivery as an adjunct to low-intervention smoking cessation therapy. A randomized, placebo-controlled, double-blind study. Arch Intern Med 1991;151:749-52. Feldman J. An assessment of the effectiveness of nicotine chewing gum: unfulfilled expectations. NY State J Med 1985;85:378. Fiore MC, Novotny TE, Pierce JP, et al. Methods used to quit smoking in the United States. JAMA 1990;263:2760-5. Fiore MC, editor. Cigarette smoking: a clinical guide to assessment and treatment. Med Clin N Am 1992:76. Fisher EB Jr, Rost K. Smoking cessation: a practical guide for the physician. Clin Chest Med 1986;7:551-65. Fortmann SP, Killen JD, Telch MJ, et al. Minimal contact treatment for smoking cessation. A placebo controlled trial of nicotine polacrilex and self-directed relapse prevention: initial results of the Stanford Stop Smoking Project. JAMA 1988;260:1575. Gillams J, Lewith GT, Machin D. Acupuncture and group therapy in stopping smoking. Practitioner 1984;228:341-4. Glassman AH, Covey LS. Future trends in the pharmacological treatment of smoking cessation. Drugs 1990;40:1-5. Gourlay SG, McNeil JJ. Antismoking products. Med J Aust 1990;153:699-707. Gritz ER. Cigarette smoking: the need for action by health professionals. CA Cancer J Clin 1988;38:194-212. Hurt RD, Lauger GG, Offord KP, et al. Nicotine-replacement therapy with use of a transdermal nicotine patch - a randomized double-blind placebo-controlled trial. Mayo Clin Proc 1990;65:1529-37. Lando HA, McGovern PG. Nicotine fading as a nonaversive alternative in a broad-spectrum treatment for eliminating smoking. Addict Behav 1985;10:153-154. Rose JE, Levin ED, Behm FM, et al. Transdermal nicotine facilitates smoking cessation. Clin Pharmacol Ther 1990;47:323-30. Russell MAH, Jarvis MJ, Sutherland G, et al. Nicotine replacement in smoking cessation. Absorption of nicotine vapor from smoke-free cigarettes. JAMA 1987;257:3262-5. Schneider NG, Jarvik ME, Forsythe AB, et al. Nicotine gum in smoking cessation: a placebo-controlled double-blind trial. Addict Behav 1983;8:253-61. Tonnesen P, Fryd V, Hansen M, et al. Effect of nicotine chewing gum in combination with group counseling on the cessation of smoking. N Engl J Med 1988;318:15-18. Tonnesen P, Norregaard J, Simonsen K, Sawe U. A double-blind trial of a 16-hour transdermal nicotine patch on smoking cessation. N Engl J Med 1991;325:311-315. Trombatore K. No ifs, ands, or butts. You can help patients quit. Tex Med 1991;87:40-52. Tunstall CD, Ginsberg D, Hall SM. Quitting smoking. Int J Addict 1985 20:1089-112. Grand Rounds Archive | Department Home page BCM Public | BCM Intranet | Privacy Notices | Contact BCM | BCM Site Map | ©2001-2006 Baylor College of Medicine
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