CME

Smoking cessation: Identifying readiness to

quit and designing a plan
Angela Olenik, PharmD, BCPS; Cortney M. Mospan, PharmD, BCACP, BCGP
Downloaded from https://journals.lww.com/jaapa by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 12/21/2020

ABSTRACT
Clinicians must be prepared to identify tobacco use among
patients and implement behavioral interventions to help
patients quit. By understanding behavioral interventions and
pharmacologic options, clinicians can design an optimal quit
plan for each patient. This article reviews foundations of
tobacco cessation, pharmacotherapy updates, and the emer-
gence of e-cigarettes as desirable cessation tools for patients.
Keywords: smoking cessation, tobacco products, e-cigarettes,

© KITTIPAK ARUNRAT | 123RF

nicotine replacement therapy, varenicline, physician assistant

Learning objectives
Identify key guidelines and public health resources focused
on reducing tobacco-related illness.
Discuss point-of-care tools to help identify tobacco
dependence and assess patient readiness to quit.
Describe risks and benefits of commonly prescribed drug Identifying patients who are tobacco users and appro-
therapies used in tobacco cessation plans. priately prescribing cessation therapy are essential to reach
Healthy People 2020 objectives. The 2008 Agency for
Healthcare Research and Quality (AHRQ) guidelines

T
obacco-related health risks have been known since
1964; however, it remains the leading cause of
preventable disease and death. Smoking rates have
declined from 20.9% in 2004 to 16.8% in 2014, largely
due to population-based interventions such as tobacco
price increases and smoke-free laws.1,2 But significant work
is required to reach the Healthy People 2020 objective of
12%.3 Additional tobacco-related objectives from Healthy
People 2020 include increasing the number of smoking
cessation attempts made by adult patients who smoke,
increasing the number of successful attempts, increasing
the frequency of tobacco screening and counseling for
patients in ambulatory care settings, and reducing smoking
among high school students.3
(Treating Tobacco Use and Dependence: 2008 Update)
identify tobacco use as a chronic disease; clinicians can
intervene with the 70% of smokers who visit their offices
every year.4
The most recent guidelines on smoking cessation, released
in 2015 by the US Preventive Services Task Force (USPSTF),
recommend that all adults be asked about tobacco use, be
advised to stop using tobacco, and that clinicians imple-
ment behavioral interventions and FDA-approved smok-
ing cessation therapies in adults who use tobacco.5
IDENTIFYING AND ASSESSING
TOBACCO DEPENDENCE
The Transtheoretical Model for Readiness to Change
© JOSHUAHE | DREAMSTIME.COM

emphasizes that not all patients will be equally motivated

Angela Olenik is a primary care clinical pharmacy specialist at
Kaiser Permanente of the MidAtlantic States in Springfield, Va.
Cortney M. Mospan is an assistant professor of pharmacy at
Wingate (N.C.) University School of Pharmacy. The authors have
disclosed no potential conflicts of interest, financial or otherwise.
DOI:10.1097/01.JAA.0000520530.80388.2f
Copyright © 2017 American Academy of Physician Assistants
to quit smoking.6,7 Prochaska described patient readiness
to change within five fluid stages: precontemplation, con-
templation, preparation, action, and maintenance.6 His
transtheoretical model is an integrative, biopsychosocial
model to conceptualize the process of intentional behavior
change. In the precontemplation stage, patients are not
ready to make change, but clinicians can use motivational

JAAPA Journal of the American Academy of Physician Assistants www.JAAPA.com 13

Copyright © 2017 American Academy of Physician Assistants

CME

Key points TABLE 1. Fagerström Test of Nicotine Dependence9

Patients attempting tobacco cessation frequently require A score of 7 or more is considered high dependence.
multiple quit attempts to be successful and should be
Patient-focused Point values for responses
asked about quitting at every visit.
question
Dual nicotine replacement therapy, bupropion, and
varenicline are associated with the greatest cessation How soon after you wake • Within 5 minutes (3)
rates. up do you smoke your first • 5-30 minutes (2)
Limited evidence supports e-cigarettes as cessation cigarette? • 31-60 minutes (1)
agents, and their use is discouraged due to emerging Do you find it difficult • Yes (1)
health concerns. not to smoke in places • No (0)
where you shouldn’t,
such as a movie theater?
interviewing to explore patient ambiguity to smoking ces- Which cigarette would you • First in the morning (1)
sation. In the contemplation stage, patients acknowledge hate to give up? • Other (0)
that tobacco use is a problem and that they would consider How many cigarettes • 31 or more (3)
quitting. In the preparation stage, the patient and clinician do you smoke in a day? • 21-30 (2)
determine a treatment plan by setting a quit date, evaluat- • 11-20 (1)
ing the use of pharmacotherapy, and determining available • 10 or fewer (0)
social support. The action stage is the quit attempt. The
Do you smoke more in the • Yes (1)
patient should have frequent contact with the healthcare
morning? • No (0)
team for support and solutions for managing triggers. The
patient enters the maintenance phase when cessation is Do you still smoke if you are • Yes (1)
maintained; clinicians should continue to reinforce absti- so sick that you are in bed? • No (0)
nence from tobacco.8 When designing a cessation plan, the
clinician should assess the level of nicotine dependence to quitting. For example, “I heard you mention that your
guide pharmacotherapy selection for patients attempting shortness of breath makes it difficult for you to spend time
to quit smoking. The Fagerström Test of Nicotine Depen- with your grandchildren. If you are able to quit smoking,
dence (Table 1) is a tool commonly used in practice.9 your shortness of breath may improve and you can spend
Ask every patient about tobacco use at every visit using quality time with your family.”
one of two models: the Five As or Ask, Advise, Refer.4 Assess. At every visit, assess the patient’s motivation and
Patients who use smokeless tobacco often are forgotten readiness to quit smoking and identify barriers to quitting.
during screening of nicotine use; be prepared to screen, Discuss previous quit attempts and patient timeline. If the
advise, and initiate pharmacotherapy in these patients as patient is not yet ready to quit, incorporate behavioral
well. Ensure that officewide interventions to facilitate change techniques into the visit (such as the Transtheo-
smoking cessation are in place and can be delivered by any retical Model for Readiness to Change and the 5R’s).4,6
member of the healthcare team. Once patients who use Consider asking, “What do you dislike about being a
tobacco are identified, promptly implement interventions. smoker?”10
The Five As Model Ask. Asking about tobacco use at Assist. If the patient is ready to quit, help him or her
every visit improves screening and cessation rates. Approach develop a quit plan using the STAR method: Set a quit
patients in a nonaccusatory and nonjudgmental manner.4 date (ideally, within 2 weeks); Tell family, friends, and
This step can be completed by another member of the team coworkers and ask for support; Anticipate challenges;
when the patient’s vital signs are recorded.4 Questions Remove tobacco products. Help patients identify their
should be designed to identify current, former, and never- triggers and strategies for coping.11 Provide information
smokers. Patients who quit in the past 6 to 12 months about quitlines (such as 1-800-QUIT-NOW) and develop
should be assessed for challenges and offered support.4 a pharmacologic treatment plan. Encourage all patients to
Simply asking “Are you a smoker?” may not identify use quitlines, which have a two to three times greater effect
occasional or light smokers.10 Instead, ask a patient, “How on smoking cessation than counseling alone in the primary
much do you smoke?” or “Do you ever use any type of care setting.12
tobacco?” Arrange. Contact patients during the first week of a ces-
Advise. Tobacco users should be urged to quit in a clear, sation attempt, ideally on the planned quit date. A second
strong, and personalized message that highlights the ben- follow-up is recommended within the first month. Con-
efits of cessation. Clinicians may use influential social gratulate patients who have remained abstinent; encourage
factors (such as children, grandchildren, or financial ben- patients who have used tobacco again to quit and make
efits) to help patients determine the personal benefits of recommendations to address challenges. If patients are

14 www.JAAPA.com Volume 30 • Number 7 • July 2017

Copyright © 2017 American Academy of Physician Assistants

 Smoking cessation: Identifying readiness to quit and designing a plan
using pharmacologic treatments, PAs should assess for
adherence, adverse reactions, and the patient’s perception
of the drug’s usefulness.12
Ask, Advise, Refer (AAR) approach The AAR model is
a condensed, simpler approach to the 5As model that may
be helpful for busy practitioners who are unable to complete
all five steps of the 5As model. The steps are as follows:
• Ask patients about tobacco use.
• Advise patients to quit.
• Refer patients to resources, including quitlines and sup-
port groups.
Remember that with either approach, other members
of the healthcare team can assist. For example, a clinical
assistant can ask the patient about tobacco use while
checking vital signs and can document the patient’s answers
in the medical record for follow-up during the clinician’s
visit.
The 5R’s Model This tool highlights areas of motivational
interventions for patients not ready to quit.4
Relevance. Encourage the patient to indicate how quit-
ting is personally relevant. Motivational information has
the greatest effect if relevant to a patient’s disease status
(for example, chronic obstructive pulmonary disease
[COPD]), family or social situation (such as children at
home), health concerns, age, sex, and other patient char-
acteristics such as personal barriers to cessation or previous
quitting experience.
Risks. Encourage the patient to identify potential negative
consequences of tobacco. Risks may include cardiovascular
disease, lung cancer, and COPD.
Rewards. Ask the patient to identify potential relevant
benefits of stopping tobacco use. Examples include
improved sense of smell, saving money, lack of tobacco
smell, healthier mouth, and improved personal and family
health.
Roadblocks. Ask the patient to identify barriers to quit-
ting and provide options to address barriers. Barriers may
include withdrawal symptoms, fear of failure, weight gain,
lack of support, and being around other tobacco users.
Teach patients coping skills to address barriers to smoking
cessation, recognize situations that increase their risk for
smoking, and develop a plan to quit.13-15
Repetition. Repeat the assessment of readiness to quit.
If the patient still is not ready to quit, repeat the interven-
tion at a later date. Ongoing counseling and motivation
strategies play a key role in helping patients quit tobacco
use.
DESIGNING A PHARMACOTHERAPY REGIMEN
Table 2 provides first-line pharmacologic options for
smoking cessation. Clonidine and nortriptyline are con-
sidered second-line treatments because they are not FDA-
approved for smoking cessation and have undesirable
adverse reactions.4 Second-line treatments can be used if
patients fail or cannot use first-line treatments, as both
JAAPA Journal of the American Academy of Physician Assistants
Copyright © 2017 American Academy of Physician Assistants
have been found to double the likelihood of sustained
abstinence compared with placebo.4
The recommended dose of nortriptyline is 75 to 100 mg
a day; clonidine does not have an established dosage range,
although studies have used doses between 0.1 mg and 0.75
mg in both oral and transdermal forms. If clonidine is used,
ensure that adherence is not an issue for the patient—if
the drug is abruptly stopped, the patient’s catecholamine
level can cause BP to rise rapidly.4
Patients who use two nicotine
replacement agents are more
likely to quit smoking.
Guidelines do not preferentially recommend a therapy,
although varenicline has consistently shown the greatest
sustained cessation. Bupropion and dual nicotine replace-
ment therapy have the next highest cessation rates.4,16 No
differences in cessation rates have been found among
nicotine replacement therapies.16 Tell patients not to eat
or drink for at least 15 minutes before taking nicotine
replacement therapy products that are administered orally;
eating or drinking elevates oral pH and reduces nicotine
absorption.17,18
CHOOSING AN OPTIMAL TREATMENT
If an over-the-counter (OTC) nicotine replacement therapy
is chosen, provide the patient with a prescription in case
his or her insurance covers the medication, thus removing
cost as a barrier to cessation. When recommending nico-
tine replacement agents, suggest two nicotine replacement
agents (referred to as combination or dual nicotine replace-
ment therapy) for the greatest likelihood of a successful
cessation attempt. Nicotine patches provide prolonged
nicotine release to minimize likelihood of withdrawal
symptoms, and nicotine gum or lozenges can be used for
breakthrough symptoms.19 Gum and lozenges can also be
used for breakthrough cravings in patients who are using
varenicline or bupropion. Table 2 describes advantages
and disadvantages of each pharmacotherapy option. Most
therapies are recommended for 3 to 6 months; however,
for most patients, the risks of continued tobacco use are
much greater than the risks of continuing nicotine replace-
ment therapy to support smoking cessation.
In terms of successful cessation, evidence shows sig-
nificant variation for efficacy of therapies. Without inter-
vention, patients have a success rate of 5% to 11%;
adding behavioral therapy alone increases the success rate
to 19% to 21%.4
Despite variation in efficacy rates in the literature, all
nicotine replacement therapy products are considered
www.JAAPA.com 15
CME

TABLE 2. First-line therapies for smoking cessation41

Drug Advantages Disadvantages Contraindications Dosing
OTC
Nicotine • Delays weight • Should not be used in Disease-related • 2 or 4 mg (4 mg for those who smoke
gum gain (4 mg patients with dentures concerns in 20 or more cigarettes per day)
strength) or temporomandibular patients with acute • Do not exceed 24 pieces/day
• Faster onset of joint disorders cardiovascular • “Chew and park” until taste
nicotine delivery • May cause dyspepsia, conditions disappears (about 30 min)
mouth irritation, or jaw
ache
• Patients may misuse
like regular gum
Nicotine • Delays weight • May cause sore mouth, Disease-related • 2 to 4 mg (4 mg for patients who
lozenge gain (4 mg throat irritation, or concerns in smoke their first cigarette within 30
strength) coughing patients with acute min of waking)
• Faster onset of • Chewing may cause cardiovascular • Do not exceed 20 lozenges per day
nicotine delivery nausea or headache conditions • Let the lozenge dissolve in mouth
(takes 10 to 20 min); do not chew
Nicotine Provides consistent • Local skin reactions Skin problems • Patients should be started on 21 mg
patch nicotine to prevent • Insomnia and vivid patch and behavioral counseling if
withdrawal dreams (can remove they smoke more than 10 cigarettes
symptoms patch 1-2 h before per day
bedtime) • Worn for 24 h
• Patch does not need to be removed
for sports
• Do not cut the patch
• Remove the patch before any MRI
procedures
Prescription
Nicotine Hand-to-mouth • May cause local • Caution in • Each cartridge lasts about 20 min
inhaler action mimics irritation of mouth and patients with with frequent puffing
smoking throat severe reactive • 16 cartridges can be used in a day;
• Short duration of airway disease each cartridge contains 4 mg of
benefit nicotine over 80 inhalations
Nicotine Fastest nicotine • Rapidly relieves • Caution in • 1 to 2 doses/h (1 dose = 1 spray in
nasal spray replacement withdrawal symptoms patients with each nostril)
therapy delivery • Highest risk for severe reactive • Do not exceed 10 sprays/h or 80
system dependence airway disease sprays per day (40 doses)
• May cause taste or • Not
smell disturbances recommended
in patients with
nasal disorders
• Nasal irritation
Sustained- • Consider for Insomnia (second • History of seizure 150 mg once daily for 3 days, then 150
released patients with dose should be taken (lowers seizure mg twice daily (take 8 h apart)
bupropion depression by 3 p.m.) threshold)
• Delays weight • History of eating
gain disorders
Varenicline Highest cessation • Most expensive Recently removed • Days 1 to 3: 0.5 mg once daily
rates for single • Concerns in patients in those with history • Days 4 to 7: 0.5 mg twice daily
therapy with cardiovascular of neuropsychiatric • Day 8 to week 12: 1 mg twice daily
or mental health events
conditions
• Vivid dreams

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Copyright © 2017 American Academy of Physician Assistants

 Smoking cessation: Identifying readiness to quit and designing a plan
equally effective.20 Nicotine replacement therapy can
improve cessation success by 50% to 70% compared with
quitting without assistance. Combination nicotine replace-
ment therapy is more effective than single-agent therapy.20
Single nicotine replacement therapy has shown cessation
rates of 17% to 23%, with prolonged nicotine gum use
(more than 14 weeks) increasing cessation rates to 26%.21,22
Combination pharmacotherapy and behavioral counsel-
ing is optimal, providing cessation rates of 21% to 27%.5,21
Varenicline provides the highest rates of cessation, 28%
to 33%.5,21,23-25 Bupropion generally is considered the next
most effective therapy, with cessation rates of 19% to
24%.5,21
PHARMACOTHERAPY UPDATES
Treating nicotine dependence remains challenging and
sometimes highly debated since the arrival of electronic
cigarettes (e-cigarettes) in 2007. Although potential thera-
pies have remained consistent, some dosing strategies and
safety warnings have changed.
Patients who use smokeless tobacco are candidates for
pharmacotherapy and behavioral interventions. A Cochrane
review specifically assessing cessation therapies in smoke-
less tobacco users found that bupropion, nicotine gum,
and nicotine patches did not significantly improve absti-
nence rates; however, behavioral interventions, varenicline,
and nicotine lozenges showed some level of improvement
in abstinence.11
The concomitant use of varenicline with nicotine replace-
ment therapy and a gradual reduction in number of ciga-
rettes smoked has been evaluated as a potential option for
patients. In a study of patients who were not ready to quit
but were motivated and willing to slowly reduce the num-
ber of cigarettes smoked until they were cigarette-free,
patients who use varenicline had significantly higher pro-
longed, continuous abstinence compared with those on
placebo.26 Although this approach should not be used in
all patients, it is a viable option for those not ready to quit
immediately.
Clinicians often struggle to select an appropriate and
effective cessation therapy in patients with mental health
comorbidities. A pivotal trial, the EAGLES study, evalu-
ated the safety and efficacy of varenicline and bupropion,
both of which contained black box warnings for neuro-
psychiatric adverse events.19,27 The EAGLES study found
that neither bupropion nor varenicline increased the
incidence of neuropsychiatric adverse events.27 The study
found that the patient’s mental health history had a
stronger influence on neuropsychiatric safety and efficacy;
incidence of moderate-severe adverse neuropsychiatric
adverse events ranged from 1.3% to 2.5% in patients
without a history of mental health comorbidities and
5.2% to 6.7% in patients with a history of mental health
comorbidities.27 As a result, the black box warnings were
removed by the FDA in December 2016.28 Although
JAAPA Journal of the American Academy of Physician Assistants
Copyright © 2017 American Academy of Physician Assistants
clinicians should feel more comfortable with using these
therapies in patients with mental health comorbidities,
patients should still be advised of potential risk and should
be monitored more closely.
Recommendations on the cardiovascular risk of vareni-
cline are mixed. A review of three systematic reviews
evaluated the cardiovascular risk of varenicline and found
a slight increase in serious cardiovascular adverse events;
however, only one review found a significantly increased
rate of common cardiovascular events.29 For all three
reviews, the number needed to harm (NNH) is about 454
patients.
Smoking cessation therapy has
been controversial in patients
with cardiovascular disease.
When nicotine replacement therapy was approved 30
years ago, data were lacking on the duration of safe use,
concomitant use of multiple nicotine replacement therapy,
or use of the therapy in patients who were still smoking.
New evidence has changed those warnings, which had
limited use of nicotine replacement therapy in some
patients.30 No significant safety concerns exist for use of
dual OTC nicotine replacement products, or use of nicotine
replacement therapy with another nicotine-containing
product, such as a cigarette.30 Clinicians should feel com-
fortable providing nicotine replacement therapy in patients
who are still smoking and not ready to quit but are moti-
vated. However, evidence is mixed as to whether nicotine
replacement therapy with a gradual decrease in the number
of cigarettes smoked actually helps patients quit smoking
and maintain cessation.31
SPECIAL POPULATIONS
Women who quit smoking before pregnancy or during
pregnancy reduce the risk of adverse outcomes, including
preterm birth (before 37 weeks), low birth weight, and
infant mortality. However, data are limited assessing phar-
macologic therapies in pregnant women with no data for
bupropion or varenicline. The USPSTF recommends that
behavioral interventions be the cornerstone of cessation
efforts in pregnant patients who smoke.5
Smoking cessation therapy has been controversial in
patients with cardiovascular disease. Nicotine replacement
therapy may trigger cardiac events in the immediate post-
myocardial infarction (MI) period. The American College
of Cardiology and American Heart Association recom-
mend against use of nicotine replacement therapy while
patients are hospitalized for symptomatic MI; however,
data regarding adverse reactions are limited and a small
www.JAAPA.com 17
CME
analysis found no difference in short- or long-term safety
of nicotine replacement therapy compared with placebo
post-MI.32 Advise patients with serious cardiovascular
health concerns of the risks before starting nicotine
replacement therapy.
THE ROLE OF E-CIGARETTES
Although a growing number of patients are interested in
using e-cigarettes (also known as electronic nicotine deliv-
ery systems) as a method of quitting, the role of e-cigarettes
is widely debated. At issue is whether these devices deliver
a recreational drug or a medicine. An FDA final rule in
2016 drastically changed the landscape for e-cigarettes,
imposing significant access restrictions and giving the FDA
regulatory authority over all tobacco products, including
e-cigarettes.33 Contents of e-cigarette liquid were previously
unregulated, making much unknown about the chemicals
contained in the liquid.32 The nicotine content or dosage
is not tested, and e-cigarettes have been shown to release
toxic chemicals (such as glycerin and formaldehyde) when
heated.34 Further, a study has demonstrated development
of severe respiratory disease (bronchiolitis obliterans, com-
monly referred to as “popcorn lung”) in users of e-cigarettes
as a result of flavoring agents containing diacetyl, which
has been well associated with bronchiolitis.35
Much remains unknown
about the potential
health risks of e-cigarettes.
Clinicians should expect more patients to ask about using
e-cigarettes in cessation attempts. A recent study showed
15% of patients discussed e-cigarettes with their physician,
and 61% of physicians recommended e-cigarettes as ces-
sation tools despite limited evidence.36 Literature has shown
significant variation in the efficacy of e-cigarettes as cessa-
tion tools; controversy exists as to whether e-cigarettes
actually present a harm reduction strategy to combustible
cigarettes or if they are simply a different risk.
E-cigarettes have shown benefit in managing withdrawal
symptoms associated with quit attempts, such as anxiety
and irritability.37 However, evidence also shows that
patients who use e-cigarettes also use combustible cigarettes,
posing challenges to permanently quitting, and some stud-
ies show that e-cigarette users are actually less likely to
quit smoking.38 Trials also have shown the opposite, with
moderate benefit in cessation, but these rates have been
lower than success rates with traditional pharmacologic
cessation tools.39,40
If patients ask about e-cigarettes and their role in cessa-
tion, be honest and say that much remains unknown about
18 www.JAAPA.com
Copyright © 2017 American Academy of Physician Assistants
the potential health risks of these agents and evidence on
their efficacy as cessation agents is limited. E-cigarettes
should only be encouraged at this time as a cessation tool
if patients cannot or will not use pharmacologic treatment
options. The USPSTF concludes that the current evidence
is insufficient to recommend e-cigarettes for tobacco ces-
sation in adults.5
MONITORING AND FOLLOW-UP
The healthcare team should maintain contact (via telephone,
Internet, or in-person follow-up) with a patient who smokes
to ensure cessation is maintained and/or to facilitate a
future smoking cessation attempt when a patient is most
motivated to quit. Follow up within 1 week of the prede-
termined quit date, when the patient is at the highest risk
of relapse.4 Congratulate patients on their successes and
contact them at least four more times to improve abstinence
rates.4 Clinical studies have shown a positive correlation
between number of counseling sessions and abstinence
rate. Remember that the more counseling interventions a
clinician makes, the more likely a patient is to attempt and
maintain cessation.4
Reassess patients who are unsuccessful at quitting. Eval-
uate pharmacologic and nonpharmacologic strategies, and
set a new quit date if the patient is ready. Remind patients
that a relapse is an opportunity for them to learn what
tempted them to smoke and how to cope better with
similar situations in the future.10
CONCLUSION
Tobacco dependence often requires multiple quit attempts,
and patients may relapse after several years of cessation.
Assess patients for tobacco use at every clinic visit and be
prepared to make either behavioral interventions or initi-
ate pharmacotherapy based on the patient’s readiness to
quit. Recent guideline updates do not preferentially recom-
mend any one pharmacotherapy; however, e-cigarettes
still have significant concerns and limited safety data,
limiting their viability as a cessation tool until more long-
term cessation and safety data are available. JAAPA
Earn Category I CME Credit by reading both CME articles in this issue,
reviewing the post-test, then taking the online test at http://cme.aapa.
org. Successful completion is defined as a cumulative score of at least
70% correct. This material has been reviewed and is approved for 1 hour
of clinical Category I (Preapproved) CME credit by the AAPA. The term of
approval is for 1 year from the publication date of July 2017.
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