De-Addiction Strategies In Heavy Smokers- Review

The role of the clinician

Clinician intervention can increase the chances of patients quitting smoking. The goal is to regularly identify smokers and provide them with evidence-based support to quit. (2)

The 5A's approach — It has been well established that assessing patient’s smoking behaviour can be beneficial. Clinicians can either opt for recording patient’s smoking status as a vital sign or use the 5A's. (3)

The 5A’s are as follows:

• Ask about tobacco use
• Advise quitting
• Assess readiness to quit
• Assist smokers ready to quit
• Arrange follow-up

Fighting the menace:

Combination of behavioral therapy and pharmacotherapy: Most effective — It is recommended that patients who wish to quit smoking should be managed with a combination of behavioral and pharmacological treatments. (4)

According to meta-analyses of clinical trials, combining behavioral counselling and pharmacotherapy increases the efficacy of helping smokers quit. (5,6)

Behavioural therapy needs to be incorporated into the patient’s regimen. They can be enrolled in a specialized clinic or smoking cessation programme. Face-to-face counselling by clinicians has also been proven effective. (2)

Although almost all of the toxicity of smoking is attributed to other components in cigarettes, the pharmacological effects of nicotine lead to tobacco addiction; hence Nicotine replacement therapy (NRT) remains the central pillar of the tobacco de-addiction strategy. The rationale for its use is that most tobacco users wish to quit as they know cigarette smoking is detrimental to their health, but they find it challenging to do so as nicotine is very addictive. (7)

Hence, NRT came into existence, temporarily replacing much of the nicotine from tobacco to reduce motivation to consume tobacco and decrease nicotine withdrawal symptoms. As a result, NRT makes the switch from smoking cigarettes to abstinence easier. Various alternative nicotine sources (gum, transdermal patch, nasal spray, inhaler, and sublingual tablets/lozenges) have been incorporated into tobacco cessation programs. (7)

A transdermal patch is a slow, sustained-release form of nicotine delivery. Other products like gum, nasal spray, oral inhaler, and tablet are acute dosing forms of nicotine. They provide general craving relief and breakthrough craving relief with the immediate release of nicotine. (7)

The crucial advantage of nicotine patches over acute NRT formulations is that compliance is easy to achieve; rather than actively utilising a product all day, the patient simply applies the patch to their body in the morning. They are available in different doses and deliver between 5mg and 22mg of nicotine over 24 hours, resulting in plasma levels similar to the trough levels seen in heavy smokers. (7)

Dosing and instructions for nicotine patch – When the patch is first applied, the initial dosage is calculated by the patient's weight and the number of cigarettes smoked per day. (8):

• >10 cigarettes per day: apply 21 mg/day patch
• ≤10 cigarettes per day: apply 14 mg/day patch

Nicotine Lozenge: The lozenge is available in 2mg and 4mg dosage forms. For people who require intermittent and controllable nicotine doses yet do not find chewing gum acceptable, the lozenge offers an alternative to gum. (7)

Combined Patch Plus Acute Forms

Combining a medication that allows for passive nicotine delivery (such as a transdermal patch) with a medication that allows for ad libitum nicotine delivery is one method for increasing the effectiveness of NRT (e.g., gum, nasal spray, inhaler). The rational basis for combining NRT medications is that smokers may require a slow delivery system to achieve a constant concentration of nicotine to relieve cravings and withdrawal symptoms, in addition to a quicker-acting therapy that can be used on demand to eliminate cravings and withdrawal symptoms instantly. (7)

Compared to using the nicotine patch alone, utilising it in conjunction with an oral NRT has increased quit rates by 34-54%. (7)

Efficacy of NRT:

Studies show that NRT is effective for smoking cessation. Few trials have directly compared one product with another; however, in randomized trials, all individual NRT products were superior to placebo, increasing quit rates up to twofold. (9)

Patient Compliance with NRT

Many NRT users might stop their medication prematurely. Poor compliance is frequently brought on by misinformation about NRT. (10) It has been noted that one of the most frequent causes of low NRT compliance is that it works. Patients may believe that the treatment is no longer required when craving and withdrawal are well managed with medication. (7). This can be significantly reduced by giving clinicians scientific information on patients receiving NRT. (7)

Key takeaways:

1. Nicotine addiction is the major factor impeding smoking cessation and long-term abstinence.

2. Today, several nicotine medications are available in different forms, doses, and flavours, and their use has been recommended for all tobacco consumers.

3. Maximum efficacy is achieved by combining a short-acting formulation with a long-acting one, for e.g. nicotine gums with a transdermal patch.

4. Current evidence suggests that all of the commercially available forms of NRT (gum, transdermal patch, nasal spray, inhaler and sublingual tablets/lozenges) increase their chances of successfully stopping smoking by 50 to 70%. (11)

5. Given the potential of NRT, clinicians should educate smokers more about how it successfully aids in quitting, underlining the importance of adherence.

References:

1. Hatsukami DK, Stead LF, Gupta PC. Tobacco addiction. Lancet. 2008 Jun 14;371(9629):2027-38. doi: 10.1016/S0140-6736(08)60871-5.

2. Nancy A Rigotti. Overview of Smoking Cessation Management in adults- UpToDate 2021

3. Siu AL, U.S. Preventive Services Task Force. Behavioral and pharmacotherapy interventions for tobacco smoking cessation in adults, including pregnant women: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2015; 163:622.

4. United States Public Health Service Office of the Surgeon General; National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. Smoking Cessation: A Report of the Surgeon General [Internet]. Washington (DC): US Department of Health and Human Services; 2020. Chapter 6, Interventions for Smoking Cessation and Treatments for Nicotine Dependence. Available from: https://www.ncbi.nlm.nih.gov/books/NBK555596/

5. Suls JM, Luger TM, Curry SJ, et al. Efficacy of smoking-cessation interventions for young adults: a meta-analysis. Am J Prev Med 2012; 42:655.

6. Stead LF, Koilpillai P, Fanshawe TR, Lancaster T. Combined pharmacotherapy and behavioural interventions for smoking cessation. Cochrane Database Syst Rev 2016; 3:CD008286.

7. Wadgave, U., & Nagesh, L. (2016). Nicotine Replacement Therapy: An Overview. International journal of health sciences, 10(3), 425–435.

8. Nancy A Rigotti. Pharmacotherapy for Smoking Cessation in Adults- UpToDate. 2022

9. Carpenter MJ, Jardin BF, Burris JL, et al. Clinical strategies to enhance the efficacy of nicotine replacement therapy for smoking cessation: a review of the literature. Drugs. 2013;73(5):407-426. doi:10.1007/s40265-013-0038-y

10. Mendelsohn C. Optimising nicotine replacement therapy in clinical practice. Aust Fam Physician. 2013 May;42(5):305–9

11. Stead LF, Perera R, Bullen C, Mant D, Lancaster T. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev. 2008;1:CD000146.