Smoking Cessation: Let’s Quit!

Smoking is Bad. Quitting is Good.

Smoking causes 480,000 premature deaths each year in the US alone (36% from cancer, 39% from heart disease and stroke, and 24% from lung disease). Plus mortality rates among smokers are 3x higher than non-smokers!

Health benefits of smoking cessation: 

  • Improves health status and enhances quality of life
  • Reduces the risk of premature death and can add as much as 10 years to life expectancy
  • Reduces the risk for many adverse health effects, including poor reproductive health outcomes, cardiovascular disease, COPD, and cancer
  • Benefits people already diagnosed with CAD or COPD
  • Benefits the health of pregnant women and their fetuses and babies
  • Reduces the financial burden that smoking places on people who smoke, healthcare systems, and society

Quitting is good, but hard!

Most adult cigarette smokers want to quit.

  • More than half of adult cigarette smokers report having made a quit attempt in the past year
  • Fewer than 1 in 10 adult cigarette smokers succeed in quitting each year
  • 4 out of 9 adult cigarette smokers who saw a health professional during the past year did not receive advice to quit despite the fact
  • Even brief advice to quit (<3 minutes) from a physician improves cessation rates and is highly cost-effective
  • Less than 1 in 3 adult cigarette smokers use cessation counseling or medications approved for cessation by the FDA when trying to quit smoking
    • In 2015, 6.8% of adult smokers (1.7 million) reported using counseling, 29.0% (7.1 million) reported using medication, and 4.7% (1.1 million) reported using both counseling and medication when trying to quit.
  • More than 3 out of 5 adults who have ever smoked cigarettes have quit.
    • In 2018, 61.7% of adult smokers (55.0 million adults) who ever smoked had quit.

Most health insurance plans cover different forms of treatment for smoking cessation!

Treatment for Smoking Cessation

Non-pharmacological therapy

  • Smoking cessation counseling
  • Telephone quitline
  • Physician interventions (brief advice to quit, brief counseling)

Nicotine Replacement Therapy (NRT)

  • Nasal spray
  • Lozenge
  • Inhaler
  • Patch (best adherence and longest duration of action, but but slowest onset)
  • Gum

Varenicline (Chantix)

Bupropion (Wellbutrin)

Key point: The likelihood of a successful quit attempt increases when non-pharmacological therapy is combined with pharmacotherapy. Great resources are available from CDC!

Varenicline: Background

Varenicline was approved by the FDA in 2006 for smoking cessation in adult patients ≥18yo

  • MOA: Partial agonist at α4β2 nicotinic acetylcholine receptor subtype
    • Mediates dopamine release and is thought to be the major receptor involved in nicotine addiction

Initial safety concerns: 

  • Neuropsychiatric effects including hostility, agitation, depression, and SI, which led to the FDA adding a black box warning in 2009 (later removed in 2016)
  • Cardiovascular disease in nicotine agonists or partial agonists

The above concerns led to the EAGLES trial (Evaluating Adverse Events in a Global Smoking Cessation Study), which did not show a significant increase in neuropsychiatric adverse events attributable to varenicline or bupropion relative to nicotine patch or placebo. Varenicline was more effective than placebo, nicotine patch, and bupropion in helping smokers achieve abstinence, whereas bupropion and nicotine patch were more effective than placebo.

  • An extension of the EAGLES trial showed no evidence that the use of smoking cessation pharmacotherapies increased the risk of serious cardiovascular adverse events during or after treatment was observed. 

Varenicline: Dosing & ADE

Option 1:

  • Pick quit date
  • Start varenicline 7 days before quit date
  • Quit on day 8
  • Continue maintenance therapy for 12 weeks

Option 2:

  • Start varenicline before a set quit date
  • Pick a quit date 8-35 days after starting
  • Quit on scheduled day
  • Continue maintenance therapy for 12 weeks

Option 3 (may be less effective):

  • Start varenicline
  • 50% smoking reduction by week 4
  • Additional 50% smoking reduction by week 8
  • Quit by week 12
  • Continue maintenance therapy for an additional 12 weeks

Dosing (CDC breakdown):

  • Titration:
    • 0.5 mg once daily on days 1-3
    • 0.5 mg twice daily on days 4-7
    • 1 mg twice daily for days 8+

  • Other notes
    • Take it with food
    • Adjust for renal dysfunction: 
      • If CrCl <30, then max dose should be 0.5 mg BID
      • If ESRD, then max dose should be 0.5 mg once daily
    • Not approved for children <18yo
    • Pregnancy class C
    • No data for breastfeeding mothers 
    • NRT can be used as adjunctive therapy to varenicline, but may not be more helpful than varenicline alone in achieving smoking cessation

ADE (dose-dependent): 

  • GI upset: nausea, vomiting, flatulence, and constipation
  • Sleep disturbances: abnormal/vivid dreams, insomnia

Take-Home Points!

  • Varenicline is a partial agonist of a nicotinic acetylcholine receptor
  • Varenicline can be prescribed to adults without fear of cardiovascular or neuropsychiatric side effects
  • Varenicline works best when a quit date is picked
  • ADE include GI upset (nausea!) and sleep disturbances, for which dose adjustments can be made

Blog post based on Med-Peds Forum talk by Sam Masur, PGY4

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