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Tobacco Use and Smoking Cessation

BASICS

DESCRIPTION

Use of tobacco in any form.
Nicotine sources include cigars, pipes, water pipes, hookahs, cigarettes, e-cigarettes, and smokeless tobacco (dip, snuff).
Electronic Nicotine Delivery Systems (ENDS) use is on the rise.
E-cigarettes include e-cigs, vapes, e-hookahs, and vape pens.

EPIDEMIOLOGY

  • >2 million new smokers annually in the US
  • >50% of new smokers are <18 years (6% teen initiation rate)
  • >480,000 deaths/year in the US, including >41,000 from secondhand smoke
  • Smoking responsible for 1 in 5 deaths annually (1,300 deaths/day)
  • 2018: 21% of high school students used e-cigarettes
  • 2020: ~31 million US adult smokers
  • 2019: 14% of adults were current smokers (15.3% men, 12.7% women)

ETIOLOGY AND PATHOPHYSIOLOGY

  • Addiction due to nicotine-induced dopamine stimulation
  • Atherosclerosis from adrenergic stimulation, CO, endothelial injury
  • Direct airway damage from tar; carcinogens in all tobacco
  • EVALI (e-cigarette or vaping-associated lung injury): linked to THC and Vitamin E acetate

RISK FACTORS

  • Smoker in household
  • Easy access to tobacco
  • Psychiatric disorders, low self-esteem, poor academics
  • Boys: aggression, rebelliousness
  • Girls: body image concerns

GENERAL PREVENTION

  • Anti-tobacco ads, smoke-free policies, sports initiatives
  • Peer education, motivational interviewing, media campaigns

COMMONLY ASSOCIATED CONDITIONS

  • Cardiovascular: CAD, stroke, PVD, AAA
  • Respiratory: COPD, pneumonia
  • Cancer: lip, oral, lung, stomach, pancreas, cervix, bladder, etc.
  • E-cigarettes: idiopathic acute eosinophilic pneumonia
  • Mental health: depression, anxiety, alcohol use disorder

PREGNANCY CONSIDERATIONS

  • Risks: miscarriage, congenital anomalies, IUGR, preterm birth, placental abruption
  • Evidence lacking for pharmacotherapy safety in pregnancy

PEDIATRIC CONSIDERATIONS

  • Secondhand smoke increases risk of SIDS, asthma, otitis media
  • Nicotine suppresses prolactin, reduces milk production

DIAGNOSIS

HISTORY

  • Ask and document tobacco use and secondhand exposure
  • Quantify use: “Heavy” smoking ≥20 cigarettes/day or ≥20 pack-years
  • Identify triggers, previous quit attempts, relapse reasons

PHYSICAL EXAM

  • Odor, staining, premature wrinkles, oral lesions
  • Lung sounds, vascular bruits, PVD signs

DIAGNOSTIC TESTS & INTERPRETATION

  • USPSTF: screen all adults, offer behavioral + pharmacologic cessation
  • Screening:
  • AAA: one-time US in men ≥65 yrs who smoked
  • Lung CA: annual low-dose CT for 55–80 yrs, 30 pack-year history, current or recent quitters
  • Cotinine levels (blood/urine)
  • PFTs if respiratory symptoms present

TREATMENT

⚠️ ALERT

Report lung injury with recent e-cigarette/vaping use to public health authorities.

GENERAL MEASURES: The 5 A’s

  1. Ask about tobacco use
  2. Advise to quit
  3. Assess readiness
  4. Assist with resources
  5. Arrange follow-up

Set a quit date within 2 weeks.
Brief advice significantly improves cessation success.

MEDICATION

First Line

  • Varenicline (Chantix)
  • 0.5 mg/day → 0.5 mg BID → 1 mg BID for 11 weeks
  • Start 1–4 weeks prior to quit date
  • Superior to bupropion/placebo (NNT = 6)

  • Caution in psychiatric/cardiovascular disease

  • Bupropion SR (Zyban)

  • 150 mg daily × 3 days → 150 mg BID for 7–12 weeks
  • Good for comorbid depression, schizophrenia

  • Contraindicated in seizures, eating disorders

  • Nicotine Replacement Therapy (NRT)

  • Patch: 21/14/7 mg Q24H × 6/2/2 weeks
  • Gum: 2/4 mg based on smoking level
  • Lozenge, inhaler, nasal spray also options
  • Use combo with bupropion or varenicline
  • Pregnancy Category D

Second Line

  • Nortriptyline: 25–75 mg/day PO, start 10–14 days before quit date
  • Clonidine: 0.1 mg PO BID or patch weekly

ADDITIONAL THERAPIES

  • Pharmacotherapy + counseling = best outcomes
  • Naltrexone: reduces cravings, especially in drinkers
  • Hypnotherapy, acupuncture may help

ADMISSION & INPATIENT CONSIDERATIONS

  • Intensive inpatient counseling + follow-up >1 month = ↑ cessation at 6 months

ONGOING CARE & MONITORING

  • Relapse: 35–40% in 1–5 yrs; 2/3 want to quit again within 30 days
  • Follow-up: 3–7 days after quit date, then monthly × 3 months
  • Watch for withdrawal symptoms: irritability, anxiety, insomnia, ↑ appetite

PROGNOSIS

  • Quitting = ↓ CHD, stroke, cancer risk
  • Lung CA mortality ↓ 50% after 10 years
  • ↓ COPD progression, ↓ AML, ↓ diabetes risk
  • Life expectancy ↑ by 10 years
  • Relapse: >60% initially → 2–4% after 2 years

COMPLICATIONS

  • Heart attack, stroke, COPD, cancers
  • Cancers: lung, esophagus, pancreas, bladder, cervix, etc.

CODES

  • ICD-10:
  • F17.210 — Nicotine dependence, cigarettes, uncomplicated
  • F17.213 — ...with withdrawal
  • F17.211 — ...in remission

CLINICAL PEARLS

  • Most smokers want to quit
  • NRT improves cessation success
  • Set a quit date and use support resources like 1-800-QUIT-NOW

PATIENT EDUCATION

REFERENCES

Howes S et al. Cochrane Database Syst Rev. 2020; Lindson N et al. 2019; Green R et al. 2019