P1. Risk factor reduction

P1.1 Smoking cessation

A comprehensive review of smoking cessation in patients with respiratory diseases has been published by the European Respiratory Society (www.ersnet.org/ers/lr/browse/viewPDF.aspx?id_attach=17030).¹⁵³ A successful smoking cessation strategy involves integration of public policy, information dissemination programs and health education through the media and schools.⁷ Smoking prevention and cessation programs should be implemented and be made readily available^7,154 [evidence level I].

Smoking cessation (see Box 3) has been shown to halt the accelerated decline in lung function seen with COPD^8,16,17  [evidence level I]. People who continue to smoke despite having pulmonary disease are highly nicotine dependent and may require treatment with pharmacological agents to help them quit.^155,156

Smoking cessation interventions have been shown to be effective in both sexes, in all racial and ethnic groups tested, and in pregnant women.⁷ International data show that smoking cessation strategies are cost effective, but with a 10-fold range in cost per life-year gained depending on the intensity of the program and the use of pharmacological therapies.⁷

Brief counselling is effective [evidence level I] and every smoker should be offered at least this intervention at every visit.⁷ Currently accepted best practice is summarised in the 5-A strategy: ⁷

Ask and identify smokers.

Advise smokers about the risks of smoking and benefits of quitting and discuss options.

Assess the degree of nicotine dependence and motivation or readiness to quit.

Assist cessation — this may include specific advice about pharmacological interventions or
             referral to a formal cessation program if available.

Arrange follow-up to reinforce messages.

Cessation of smoking is a process rather than a single event, and smokers move between various stages of being not ready, unsure, ready, quitting and relapsing before achieving long-term success. The aim of initial intervention is to advance one stage in the cessation cycle. The most strenuous efforts should be made with those smokers ready to quit or quitting. Cessation rates increase with the amount of support and intervention, including practical counselling and social support arranged outside of treatment.

Pharmacotherapies for nicotine dependence, including nicotine replacement and bupropion (sustained-release), are effective [evidence level I].^158-166 At least one of them should be added to counselling if necessary and in the absence of contraindications⁷ [evidence level I]. Caution is recommended in people with medical contraindications, light smokers (< 10 cigarettes a day) who may become dependent on nicotine replacement therapy, pregnant women and adolescent smokers.⁷

All forms of nicotine replacement therapy (NRT) appear to be useful in aiding smoking cessation.¹⁶⁰ NRT is most suitable for highly dependent smokers who are motivated to quit. There is little evidence for its role in those who smoke up to 15 cigarettes daily. The choice of type of NRT depends on patient preference, needs and tolerance.

NRT is more effective when combined with counselling and behavioural therapy.¹⁶⁵ NRT is safe in patients with stable cardiac disease such as angina pectoris [evidence level I].^7,156 NRT produces lower peak levels of nicotine than active smoking, so, theoretically, should be safer than smoking, even in patients with unstable disease.

P1.1.1 Nicotine replacement therapy

Nicotine transdermal patch: A steady nicotine level (about half that of smoking) is maintained to reduce withdrawal symptoms. However, the patch does not provide the peak nicotine levels of smoking which reinforce the addiction. Addition of a self-administered form of nicotine, such as gum, inhaler or lozenge, improves abstinence rates.^160,161

The strength of patch used depends on the degree of nicotine dependence, indicated by number and strength of cigarettes smoked daily. Three strengths are available — 7 mg, 14 mg and 21 mg — and both 24-hour and 16-hour patches are available. The 24-hour patches achieve higher blood nicotine levels and provide more relief of morning cravings, but both patches have about the same efficacy. Patch use doubles the success rates of attempts to quit compared with placebo. Six to eight weeks of use are generally required, with tapering of the nicotine dose every two weeks.¹⁶²

The only significant side effect is skin irritation, which is generally mild and rarely leads to cessation of use.

Nicotine gum: Nicotine is rapidly absorbed through the oral mucous membrane, so gum should be chewed only two to three times per minute to avoid excessive salivation, swallowing of nicotine and gastrointestinal side effects. The blood levels achieved by nicotine chewing gum are one-third (2 mg gum) or two-thirds (4 mg gum) those of smoking. Patients should taper the dose gradually, but dependence on the gum can occur in up to 20% of users. Most patients should have stopped using the gum within three months.

Nicotine lozenge: Nicotine lozenges are available in 2 mg and 4 mg doses. No special technique is required — the lozenge is held in the mouth and moved around periodically until it dissolves. As the lozenge dissolves, it releases about 25% more nicotine than the equivalent dose of gum. Patients should reduce the number of lozenges they are using over 12 weeks, remaining on the same strength lozenge throughout. Lozenges may be preferable for denture wearers who wish to use oral NRT.

Nicotine inhaler: The nicotine inhaler consists of a plastic mouthpiece and cartridge containing 10 mg of nicotine. The inhaler produces nicotine concentrations that are a third those achieved with smoking. The inhaler is useful for smokers who miss the hand-to-mouth action of smoking, or who have problems with the gum. The recommended maximum period of use is 16 weeks.

P1.1.2 Bupropion

Bupropion hydrochloride, in conjunction with counselling and support, doubles the quit rates achieved by placebo, with or without nicotine replacement therapy as an adjunct.^163-166 It is recommended as first-line pharmacotherapy for smoking cessation alongside NRT [evidence level I],⁷ but there are currently insufficient data to recommend its use in preference to NRT, or vice versa. The recommended dose is 150 mg orally once daily for three days, then 150 mg twice daily (at least eight hours apart) for between seven and nine weeks, in combination with counselling. A quit date should be set (eg, Day 5–10). The drug works equally well in smokers with and without a past history of depression. It is also effective in people who have relapsed and are motivated to quit again.

Bupropion is contraindicated in patients with epilepsy, bulimia or a history of head trauma. It may interact with other antidepressants, especially monoamine oxidase inhibitors, which require a 14-day washout. There is a relative contraindication in other conditions that may lower the seizure threshold, such as diabetes mellitus. It should only be prescribed to patients at an advanced stage of readiness to quit. Some deaths have been reported in patients taking bupropion in routine clinical practice, but there is no evidence that bupropion was responsible for these deaths.¹⁵⁶ The contradictions and adverse effects for bupropion hydrochloride are shown in Box 11.

P1.2 Prevent smoking relapse

Counselling sessions, possibly involving professional psychological support and use of nicotine patches and bupropion, increase the chances of successful quitting by 5%–30% compared with control groups.⁷

Family, friends and workmates should be advised of the intention to quit and provide understanding and support. The relapse rate is increased if there are other smokers in the household. Success is more likely if all the smokers agree to quit together. Suggest the patient ring the Quit Line or other local services

Ex-smokers who attend for follow-up are more likely to be successful in the long term. Support is most needed in the first few weeks, so regular follow-up visits then and over the first three months should be encouraged.