Tobacco Cessation: A Guide for Clinicians

EUROPEAN UROLOGY FOCUS 1 (2015) 47–49

available at www.sciencedirect.com journal homepage: www.europeanurology.com

Clinical Consultation Guide

Tobacco Cessation: A Guide for Clinicians Laura Brandt a,*, Gabriele Fischer b a

Medical University of Vienna, Center for Public Health, Vienna, Austria; b Medical University of Vienna, Department of Psychiatry and Psychotherapy and

Center for Public Health, Vienna, Austria

1.

Introduction

Substance use disorders (SUDs), including tobacco use disorder (TUD; Diagnostic and Statistical Manual of Mental Disorders, fifth edition [DSM] code 305.1), are defined as chronic relapsing disorders with underlying altered brain regions that control decision making and judgment, influenced by polygenetic, environmental, and cultural factors [1]. About 69% of current smokers reportedly want to quit smoking, and 52% make an unassisted quit attempt, but only 6% successfully quit smoking within a given year [2]. The vast majority of smokers making an attempt to quit relapse to smoking, with up to 76% relapsing within the first week [3]. Most patients with SUDs, however, are able to quit substance use over time [4]. Lifetime dependence remission rates (ie, successful cessation) are estimated at 84% for nicotine compared with 91% for alcohol, 97% for cannabis, and 99% for cocaine [5]. The nicotine-dependence time frame to remission is approximately 26 yr compared with 14 yr for alcohol, 6 yr for cannabis, and 5 yr for cocaine, highlighting the high addiction potential of nicotine and the difficulty entailed in achieving long-term smoking cessation [5]. 2.

Methods of smoking cessation: What works well?

Treatment interventions for smoking cessation available in Europe are separated into those that are clearly beneficial (proven efficacy by randomized controlled trials, documented in systematic reviews, and suitable for most patients) or likely to be beneficial (limited proven efficacy, recommended only with caution or with limitations in guidelines) [6]. 2.1.

Interventions with proven efficacy

Nicotine replacement therapy (NRT) increases smoking quit rates by 50–70%, independent of therapeutic setting, NRT

form (gum, transdermal patch, nasal spray, inhaler, or sublingual tablets or lozenges), or additional provision of support [7]. Varenicline is a partial agonist on the nicotinergic receptor a4b2 that aims to reduce both withdrawal symptoms and perceived rewards associated with smoking. Applying the recommended dose of 1 mg varenicline twice daily produces a two- to threefold increase in abstinence rates (over 6 mo and even longer in some studies) compared with placebo [8]. Treatment success rates range from 14% to 47% compared with 4% to 23% in placebo groups at 52-wk follow-up [8]. Varenicline also has proven efficacy in patients with psychiatric comorbidities [9]. The dopaminergic antidepressant bupropion has shown efficacy in increasing long-term smoking cessation equal to NRT [10]. Its effect on smoking cessation is independent of the antidepressant effect, and the side effects seem acceptable because they rarely lead to treatment dropout. Moreover, the use of bupropion in addition to NRT might increase long-term beneficial effects [10]. A treatment success rate of 16% has been reported at 52-wk follow-up, compared with 22% for varenicline and 8% for placebo [11]. Notably, pharmacologic smoking cessation therapy is not fully reimbursed by health insurance in most European countries despite its proven efficacy and cost-effectiveness [12]. Full reimbursement of smoking cessation therapy could significantly increase its use and, subsequently, the number of successful quitters [13–15]. 2.2.

Interventions with limited efficacy

A psychosocial treatment option known as contingency management (CM) seems promising to promote smoking cessation in high-risk populations such as adolescents or pregnant women and has low drop-out rates [16,17]. It is based on principles of operant conditioning that offer

* Corresponding author. Medical University of Vienna, Center for Public Health, Kinderspitalgasse 15, 1090 Vienna, Austria. Tel. +43 1 4040035000. E-mail address: [email protected] (L. Brandt). http://dx.doi.org/10.1016/j.euf.2014.10.004 2405-4569/# 2015 European Association of Urology. Published by Elsevier B.V. All rights reserved.

48

EUROPEAN UROLOGY FOCUS 1 (2015) 47–49

incentives to encourage a desired behavior such as smoking abstinence. Importantly, an escalating CM design is required to be effective, that is, the incentive value must increase with every demonstration of the desired behavior to avoid habituation. CM for pregnant women increases smoking cessation rates significantly compared with other psychosocial interventions [18]. In addition, CM interventions have a positive impact on fetal growth, birth weight, and breastfeeding duration [19]. CM effects also have demonstrated improved smoking cessation outcomes in the postpartum period: At 12 wk postpartum, 24% of the women using CM were still abstinent compared with 3% of women without the intervention [20]. Motivational interviewing is delivered in person or by phone in one to four sessions of 15–45 min and has shown modest effects for smoking cessation [21]. Efficacy of motivational interviewing can be improved when multiple sessions are provided by primary care physicians or counselors, with a minimum duration of 20 min [21]. Group therapy has shown superior efficiency in increasing the rate of smoking cessation compared with self-help programs but not with individual counseling [22]. 3.

Implementation of smoking cessation

Among those smokers who do not quit on their own, successful cessation is dependent on interventions that consider the whole spectrum of factors influencing smoking behavior and nicotine dependence. Any pharmacologic intervention has to be delivered within an addiction therapy setting because medication alone most likely will not lead to successful long-term cessation. Many persons with SUDs are addicted to more than one substance, and this complicates recovery. In addition, successful smoking cessation often leads to other ‘‘rewarding behaviors,’’ most prominently, increased food consumption [23]. In fact, a significant portion of smokers who quit smoking gain weight or even develop an eating disorder. This phenomenon merits treatment intervention because it puts former smokers at increased risk for obesity [24]. Intensive lifestyle interventions have shown efficacy in reducing obesity and other cardiovascular and diabetes risk factors and should be considered from a sociopolitical perspective for smoking cessation [25,26]. Another important aspect to consider is that many persons with psychiatric disorders smoke more heavily, are more prone to TUD, and show lower quit rates than those without such disorders [5,27–29]. Lifetime smoking rates of up to 83% are reported for those with a lifetime DSM axis I disorder compared with 39% for those without such disorders [29]. Nicotine consumption might represent a form of self-medication for persons with psychiatric comorbidities [30]. Furthermore, the type of medication administered influences the extent of self-medication with nicotine; for example, atypical antipsychotics are associated with reduced severity of nicotine dependence and craving for cigarettes compared with typical antipsychotics [31].

A comprehensive, structured diagnostic process and treatment for TUD and for any comorbid disorder is crucial as early as possible because poor prognosis is expected if treatment fails to address both. How to troubleshoot problems in the cessation 4. process TUD and nicotine dependence are acknowledged as psychiatric disorders in the DSM and the International Classification of Diseases, respectively, and thus should be included as integral parts of the diagnostic process and in medical reports, including the number of cigarettes smoked per day and treatment suggestions. This approach has the potential to call patients’ attention to the severity of the disorder, especially among those who are not willing to make a quit attempt, and to raise awareness among general practitioners. Intrinsic motivation is a key variable in the smoking cessation process. This is highlighted by smoking cessation during pregnancy. Increased intrinsic motivation to deliver a healthy baby is seen as an important window of opportunity for quitting smoking [32]. Up to 45% of smoking women quit without assistance between learning of their pregnancy and their first prenatal visit [18]; however, up to 80% relapse after the postpartum period [33]. If intrinsic motivation decreases (eg, after delivery or after the breastfeeding period), prompt professional support with effective interventions such as CM is crucial to avoid relapse. Smoking cessation typically follows a cyclical pattern: The average smoker makes at least four quit attempts until achieving successful long-term smoking cessation [34]. Consequently, support has to be offered repeatedly because every quit attempt increases the chances of ultimate successful cessation [35]. 5.

Conclusions

Smoking behavior is a complex phenomenon that entails innumerable variables. Key factors such as psychiatric comorbidity play significant roles in smoking prevalence and in failed cessation and relapse. Successful treatment interventions must be based on a comprehensive diagnosis and must consider the whole spectrum of factors influencing smoking behavior and nicotine dependence. From a public health perspective, broader availability and accessibility of treatment options—especially increased quality of smoking cessation interventions—has the potential to increase patients’ health and quality of life and to significantly lower the considerable societal and economic burden caused by smoking [15,36]. Author contributions: Laura Brandt had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Fischer, Brandt. Acquisition of data: None. Analysis and interpretation of data: None. Drafting of the manuscript: Brandt.

EUROPEAN UROLOGY FOCUS 1 (2015) 47–49

Critical revision of the manuscript for important intellectual content:

49

[17] Krishnan-Sarin S, Duhig AM, McKee SA, et al. Contingency man-

Fischer, Brandt.

agement for smoking cessation in adolescent smokers. Exp Clin

Statistical analysis: None.

Psychopharmacol 2006;14:306–10.

Obtaining funding: None. Administrative, technical, or material support: None. Supervision: Fischer. Other (specify): None.

[18] Lumley J, Chamberlain C, Dowswell T, Oliver S, Oakley L, Watson L. Interventions for promoting smoking cessation during pregnancy. Cochrane Database Syst Rev 2009:CD001055. [19] Higgins ST, Washio Y, Heil SH, et al. Financial incentives for smoking cessation among pregnant and newly postpartum women. Prev

Financial disclosures: Laura Brandt certifies that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, employment/affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: None. Funding/Support and role of the sponsor: None.

Med 2012;55(Suppl):S33–40. [20] Heil SH, Higgins ST, Bernstein IM, et al. Effects of voucher-based incentives on abstinence from cigarette smoking and fetal growth among pregnant women. Addiction 2008;103:1009–18. [21] Lai DCT, Cahill K, Qin Y, Tang JL. Motivational interviewing for smoking cessation. Cochrane Database Syst Rev 2010:CD006936. [22] Stead LF, Lancaster T. Group behaviour therapy programmes for smoking cessation. Cochrane Database Syst Rev 2005:CD001007.

References

[23] Koopmann A, Dinter C, Grosshans M, et al. Psychological and hormonal features of smokers at risk to gain weight after smoking

[1] Koob GF. Neurobiology of addiction. FOCUS 2011;9:55–65.

cessation—results of a multicenter study. Horm Behav 2011;60:

[2] Quitting smoking among adults — United States, 2001–2010. MMWR

58–64.

2011;60:1513–9. http://www.cdc.gov/mmwr/preview/mmwrhtml/

[24] Asthana A, Smith S, Piper M, Baker T, Fiore M, Stein J. Smoking

mm6044a2.htm?s_cid=%20mm6044a2.htm_w. Accessed October

cessation and the risks of diabetes mellitus and impaired fasting

13, 2014.

glucose: three year outcomes from a randomized clinical trial. J Am

[3] Hughes J, Keely J, Naud S. Shape of the relapse curve and long-term abstinence among untreated smokers. Addiction 2004;99:29–38. [4] Heyman G. Addiction and choice: theory and new data. Front Psychiatry 2013;4:1–5. [5] Lopez-Quintero C, Hasin D, de los Cobos J, et al. Probability and predictors of remission from life-time nicotine, alcohol, cannabis or cocaine dependence: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Addiction 2011;106: 657–69.

Coll Cardiol 2013:61. [25] Kolsgaard ML, Joner G, Brunborg C, Anderssen SA, Tonstad S, Andersen LF. Reduction in BMI z-score and improvement in cardiometabolic risk factors in obese children and adolescents. The Oslo Adiposity Intervention Study-a hospital/public health nurse combined treatment. BMC Pediatrics 2011;11:47–55. [26] Danielsen KK, Svendsen M, Mæhlum S, Sundgot-Borgen J. Changes in body composition, cardiovascular disease risk factors, and eating

[6] Best practice in drug interventions, European Monitoring Centre for

behavior after an intensive lifestyle intervention with high volume

Drugs and Drug Addiction Web site. http://www.emcdda.europa.

of physical activity in severely obese subjects: a prospective clinical

eu/best-practice/treatment. Accessed October 13, 2014.

controlled trial. J Obes 2013:325464.

[7] Stead LF, Perera R, Bullen C, Mant D, et al. Nicotine replacement

[27] Grant B, Hasin D, Chou S, Stinson F, Dawson D. Nicotine dependence

therapy for smoking cessation. Cochrane Database Syst Rev 2012;

and psychiatric disorders in the United States: results from the

11:CD000146.

national epidemiologic survey on alcohol and related conditions.

[8] Cahill K, Stead L, Lancaster T. A preliminary benefit-risk assessment of varenicline in smoking cessation. Drug Safety 2009;32: 119–35.

Arch Gen Psychiatry 2004;61:1107–15. [28] Fu S, McFall M, Saxon A, et al. Post-traumatic stress disorder and

[9] Aubin HJ, Karila L, Reynaud M. Pharmacotherapy for smoking

smoking: a systematic review. Nicotine Tob Res 2007;9:1071–84.

cessation: present and future. Curr Pharm Des 2011;17:1343–50.

[29] Lasser K, Boyd J, Woolhandler S, Himmelstein D, McCormick D, Bor

[10] Hughes JR, Stead LF, Hartmann-Boyce J, Cahill K, Lancaster T. Antidepressants for smoking cessation. Cochrane Database Syst Rev 2014;1:CD000031. [11] Gonzales D, Rennard SI, Nides M, et al. Varenicline, an a4b2 nicotinic acetylcholine receptor partial agonist, vs sustained-re-

D. Smoking and mental illness. JAMA 2007;284:2606–10. [30] Van Voorhees E, Mitchell J, McClernon F, Beckham J, Kollins S. Sex, ADHD symptoms, and smoking outcomes: an integrative model. Med Hypotheses 2012;78:585–93. [31] Kim S, Han D, Joo S, Min K. The effect of dopamine partial agonists

lease bupropion and placebo for smoking cessation: a randomized

on the nicotine dependency in patients with schizophrenia. Hum

controlled trial. JAMA 2006;296:47–55.

Psychopharmacol 2010;25:187–90.

[12] Reda AA, Kotz D, Evers SM, van Schayck CP. Healthcare financing

[32] Su A, Buttenheim A. Maintenance of smoking cessation in the

systems for increasing the use of tobacco dependence treatment.

postpartum period: which interventions work best in the long-

Cochrane Database Syst Rev 2012;6:CD004305.

term? Matern Child Health J 2014;18:714–28.

[13] Verbiest ME, Chavannes NH, Crone MR, et al. An increase in primary

[33] Shaw E, Levitt C, Wong S, Kaczorowski J. Systematic review of the

care prescriptions of stop-smoking medication as a result of health

literature on postpartum care: effectiveness of postpartum support

insurance coverage in the Netherlands: population based study.

to improve maternal parenting, mental health, quality of life, and

Addiction 2013;108:2183–92. [14] Kaper J, Wagena EJ, Willemsen MC, Van Schayck CP. Reimburse-

physical health. Birth 2006;33:210–20. [34] Zhou X, Nonnemaker J, Sherrill B, et al. Attempts to quit smoking

ment for smoking cessation treatment may double the abstinence

and relapse: factors associated with success or failure from the

rate: results of a randomized trial. Addiction 2005;100: 1012–20.

ATTEMPT cohort study. Addict Behav 2009;34:365–73.

[15] Metz VE, Brandt L, Unger A, Fischer G. Substance abuse/depen-

[35] Hyland A, Borland R, Li Q, et al. Individual-level predictors of

dence treatment: a European perspective. Subst Abus 2014;35:

cessation behaviours among participants in the International

309–20. [16] Dutra L, Stathopoulou G, Basden S, Leyro T, Powers M, Otto M. A meta-analytic review of psychosocial interventions for substance use disorders. Am J Psychiatry 2008;165:179–87.

Tobacco Control (ITC) Four Country Survey. Tobacco Control 2006;15(Suppl 3):83–94. [36] Nutt D, King L, Phillips L. Drug harms in the UK: a multicriteria decision analysis. Lancet 2010;276:1558–65.