Guidelines 2016 – Smoking Cessation
Guidelines for Nurse Practitioners in Gynecologic Settings 2016
I. DEFINITION
Smoking is the leading cause of preventable illness and premature death in the United States, causing approximately 480,000 deaths annually. of these deaths, 201,773 are among women, including deaths from secondhand smoke. an estimated 40 million americans smoke, and it has been estimated that of this number, approximately 70% want to quit. approximately 40% of this number have tried to quit smoking in the previous 12 months. Quitting involves the process of fighting both the physical and psychological dependence of smoking. it is believed that nicotine is as addictive as cocaine, opiates, amphetamines, and alcohol. tobacco use disorder (previously nico- tine dependence) is not limited to smoking cigarettes, but is also associated with cigars; smokeless tobacco such as loose-leaf pouches, plugs, twists, or snuff; and chewing tobacco. tobacco use disorder is classified as a sub- stance use disorder in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; american Psychiatric association, 2013).
II. ETIOLOGY
a. the nicotine contained in inhaled cigarette smoke reaches the brain in approximately 10 seconds. once received in the brain, nicotine causes the brain to release dopamine and norepinephrine. When nicotine is inhaled in a regular fashion, the brain accepts the chemicals by increasing the number of nicotine receptor sites. this mechanism is believed to underlie nicotine dependence. When inhaled nicotine binds to these receptor sites, it causes arousal, stimulation, increased heart rate, and increased blood pressure. these physical reactions cause the smoker to experience mood elevation, reduced anxiety, and stimulation within seconds of inhalation. Signs and symptoms of withdrawal may begin within a few hours of the last cigarette, peak at 48 to 72 hours, and return to baseline 3 to 4 weeks after quitting.
B. Problems associated with smoking and exposure to secondhand smoke
1. Pregnancy complications: low birth weight, miscarriage, preterm delivery, placenta previa, placenta abruption, premature rupture of membranes, sudden infant death syndrome
2. increased asthma and other respiratory problems in children exposed to secondhand smoke
3. increased risk for developing cataracts and macular degeneration
4. increased risk for cancer (lung, esophageal, bladder, kidney, pan- creatic, leukemia, breast, gynecologic)
5. gastric and duodenal ulcers
6. Premature wrinkling of the skin
7. Decreased bone density, osteoporosis, fractures
8. impotence and other reproductive effects
9. Pneumonia, chronic obstructive pulmonary disease, poor asthma control, coughing, wheezing, dyspnea
10. Decreased high-density lipoprotein (HDL)
11. Peripheral vascular disease
12. Periodontal and dental diseases, oral cancers
13. Depression
14. Contributes to early onset of menopause
15. Risks of secondhand smoke to family members and others shar- ing closed spaces
III. BARRIERS TO SMOKING CESSATION
a. Physical dependence/nicotine addiction syndrome
1. Withdrawal symptoms
a. Depressed mood/anxiety
b. insomnia
c. irritability
d. Difficulty concentrating
e. increased appetite/weight gain
f. anger
g. Restlessness
h. Frustration
i. increased heart rate
B. Psychological dependence
1. Behaviors associated with smoking become integrated into a person’s routine.
2. Smoking, once integrated into a routine, becomes associated with pleasure and enjoyment.
3. Smoking may also be used to cope with stress or lessen negative emotions.
IV. HISTORY
a. Risk assessment: ask all patients at annual visit:
1. Do you smoke? For how long?
2. How many cigarettes a day?
3. How soon after awakening do you smoke your first cigarette?
4. Do you wake at night to smoke?
5. is it difficult for you to observe “no smoking” rules?
6. Which cigarette would be hardest to give up?
7. Do you smoke more cigarettes in the first hours of your day than at other times?
8. Have you ever attempted to stop smoking?
9. if yes, what got in your way?
10. a smoking assessment questionnaire may be used (e.g., the Fagerström1 test for nicotine dependence).
B. the patient may present with
1. nagging, chronic cough
2. Sinus congestion
3. Shortness of breath
4. Fatigue
5. elevated blood pressure
6. inability to meet physical challenges (run for a bus, play with young children)
7. Decreased fertility
8. osteoporosis, decreased bone density
9. Premature wrinkling
10. gum disease
C. additional areas to be explored
1. Pregnancy complications
2. History of abnormal Pap smears
3. History of, or presently existing, cancer
4. Fractures
5. Cataracts/glaucoma
6. Problems with cold hands or feet or leg pain
7. Diabetes
8. gastric or duodenal ulcer
9. Current medicines, including herbals, homeopathics, vitamins
10. Use of smokeless preparations
11. exposure to secondhand smoke currently or in the past
V. PHYSICAL EXAMINATION
a. Vital signs
1. temperature
2. Pulse, respirations
3. Blood pressure
B. Skin
1. observe for color, tone, and premature wrinkling
C. eyes, ears, nose, throat
1. thorough examination of oral cavity; observe dental cavities, stained teeth, tongue or buccal lesions, gum disease, foul breath
D. Lungs
1. Listen for adventitious sounds (wheezes, rales, crackles)
e. Breast examination
F. abdominal examination
g. gynecologic examination (Pap smears if indicated, cultures, bimanual exam)
H. extremities
1. observe extremities for signs of circulatory or peripheral vessel involvement, pulses, and pedal edema.
VI. LABORATORY EXAMINATION
a. Complete blood count (elevated hematocrit, white blood cells, platelets; decreased leukocytes)
B. Lipid level (decreased HDLs)
C. Consider
1. Vitamin C level (decreased)
2. Serum uric acid (decreased)
3. Serum albumin (decreased)
4. Pulmonary function tests
5. Blood, urine, saliva, or hair tests for cotinine
VII. DIFFERENTIAL DIAGNOSIS
a. Per physical findings
B. Depression
C. anxiety
VIII. TREATMENT
a. intervention needs to be multifaceted and tailored to each patient’s needs. multiple nicotine medication interventions may be used simultaneously without adverse effect.
B. any approach needs to include information regarding the following:
1. a clear, strong stop smoking message
2. Risks associated with smoking
3. Benefits of cessation; advise all users to stop
4. addictive components of smoking
5. What to expect during withdrawal period
6. Potential risk of relapse
C. Personalize the risks to each individual. Relate the individual’s current health problems or findings on physical examination to the effects of smoking.
D. emphasize how smoking cessation can reward the individual.
e. if the patient indicates a willingness to quit, form a contract for a quit date. this date should be within a short time frame (1–2 weeks). a notation of this date should be made, and the clinician should reinforce the contract with a phone call.
F. Factors involved in successful cessation efforts include
1. timely intervention and motivation by clinician
2. individual’s desire and motivation
3. multifaceted program
4. individualization of method and program to patient’s situation
g. methods (may be used individually or in conjunction with each other)
1. Behavioral
a. Draft a list of reasons to quit smoking and the rewards of quitting. this list should be kept with the person and reviewed when the urge to smoke “hits” and she is in need of reinforcement. it can be helpful to have patient also choose a reward for reaching the goal.
b. inform family and friends and ask for their support and encouragement.
c. the smoker should be encouraged to keep a journal. in the pre-cessation stage, the smoker can use the journal to record each cigarette smoked, the social cues experienced, the setting, the intensity of the craving, and the time of day. this can help identify the individual’s triggers and assist the smoker to adapt
strategies and coping skills to get past the triggers. keeping a journal during cessation is helpful for expressing feelings and recording the steps of the journey.
d. Patient should avoid alcohol, which weakens resolve
e. Patient should throw out all cigarettes, ashtrays, and so forth
f. Patient should avoid being around smokers
g. if possible, patient should establish a “no smoking” living space
h. Patient should increase exercise level (walking, weight lifting, yoga). exercise assists in weight management, stress reduction, and sense of well-being.
i. Consider use of meditation or relaxation tapes
j. Patient should learn cognitive and behavioral strategies to reduce negative mood
2. nicotine replacement: the theory behind nicotine replacement therapy is that by replacing the nicotine, the smoker can deal with the emotional factors and use behavioral changes without having to deal with the full impact of physical withdrawal at the same time. all packaging contains detailed instructions for use. Patients should be instructed to read the instructions carefully prior to using a product of choice.
a. gum offers episodic satisfaction for nicotine craving as it arises.
i. nicotine polacrilex (nicorette)—2 mg per piece (maximum 30 pieces per day); for use if the first cigarette is smoked more than 30 minutes after waking
ii. nicotine polacrilex (nicorette DS)—4 mg per piece (maximum 20 pieces per day); for use if first cigarette is smoked less than 30 minutes after waking
iii. adverse effects
a) mouth sores
b) Dyspepsia
c) Hiccup
d) Jaw ache
e) of those who use gum, 10% may become dependent, requiring long-term use (1–2 years) to remain abstinent.
b. transdermal patches. if a patient chooses to use the patch, there should be a contract not to smoke during its use. Patches are approved for use during pregnancy if a woman has been unsuccessful with smoking cessation prior to conception. Directions for application of the patch must be followed carefully. Successful use is dependent on proper application.
i. nicotine transdermal therapeutic system (Habitrol)—21 mg/d (24 hours) for 4 to 6 weeks, then 14 mg/d for 2 to 4 weeks, then 7 mg/d for 2 to 4 weeks
ii. nicotine transdermal system (nicoDerm CQ)—21 mg/d (24 hours) for 4 to 6 weeks, then 14 mg/d for 2 to 4 weeks, then 7 mg/d for 4 to 6 weeks
iii. nicotine transdermal system (nicotrol)—15 mg/d (16 hours) for 4 to 6 weeks
iv. nicotine transdermal system (ProStep)—22 mg/d (24 hours) for 4 to 8 weeks, then 11 mg/d for 2 to 4 weeks
v. adverse effects
a) Skin reactions
b) insomnia
c) Vivid dreams
d) myalgia
vi. if vivid dreams and/or insomnia are a problem, the patient may remove the patch prior to retiring and apply a new patch on arising. Note: if waking during the night is a problem, the 24-hour patches may provide more relief.
c. nasal spray has the advantage of being an accelerated delivery system, delivering nicotine on demand (within 10 seconds) as a cigarette does.
i. nicotine nasal spray (nicotrol nS)—one spray (0.5 mg) in each nostril (8–40 mg/day) to a maximum of 5 times per hour or 40 times per 24 hours. maximum: 3 months treatment. nicotine nasal spray requires a prescription, and the U.S. Food and Drug administration (FDa) recommends a prescription be for only 3 months at a time and that use be for no longer than 6 months.
ii. adverse effects
a) Higher incidence of dependence
b) nasal irritation
c) throat irritation
d) Rhinitis
e) Sneezing
f) Watering eyes
g) Coughing
iii. Contraindicated in women with nasal polyps or other chronic nasal disorders
iv. CAUTION! nicotine spray is absorbed through the skin as well as through mucous membranes and can cause serious damage to eyes and mouth. With any unintended exposure to skin and mucous membranes, the area should be washed immediately with copious amounts of clear water. Plastic or rubber gloves should be used to clean up spills. if children are inadvertently exposed to liquid, consultation with a poison control center is advised.
d. nicotrol inhaler (nicotine inhalation system)—10 mg/cartridge (4 mg delivered), 6 to 16 cartridges/day for up to 12 weeks, reduce gradually over 12 more weeks, then discontinue. maximum: 6 months treatment. Do not inhale into lungs; puff as you would a pipe. Vapor is delivered into the mouth, where it is absorbed
into the bloodstream. Contraindicated for women with reactive airway disorder.
i. CAUTION! Cartridges (new or used) can cause serious problems or be fatal if swallowed or chewed by children. immediate consultation with a poison control center is advised.
ii. adverse effects
a) Coughing
b) mouth or throat irritation
c) Upset stomach
e. Lozenges—2 to 4 mg each lozenge. maximum lozenges per day: 20 pieces. allow to slowly dissolve (20 minutes); do not chew or swallow. Change position to different areas of the mouth. no food or beverages for 15 minutes during or 15 minutes after the lozenge is dissolved. taper off as appropriate. maximum duration for use is usually 12 weeks.
i. adverse effects
a) trouble sleeping
b) nausea
c) Hiccups
d) Coughing
e) Heartburn
f) Headache
g) abdominal gas
h) Sensation of warmth or tingling in the mouth
f. oral medication
i. Bupropion hydrochloride (Zyban or Wellbutrin SR)—150 mg every day for 2 days, then 150 mg twice a day for 7 to 12 weeks. if longer period is necessary, Wellbutrin XL 300 mg daily may be initiated for convenience. initiate medication 1 week prior to starting date. this week allows the patient to initi- ate behavioral interventions and prepare psychologically for quitting. Bupropion hydrochloride is an antidepressant that acts as an inhibitor of the neuronal uptake of norepineph- rine, serotonin, and dopamine. the mechanism of action in smoking cessation is unknown, but it may serve to mimic the neurochemical effects of nicotine that serve as the pathway to addiction. may be used in conjunction with the patch, gum, or inhaler.
a) Contraindications
1) History of seizure disorder
2) Use with caution in women with prior history of eating disorder; should not be used in women with a current diagnosis of eating disorder.
3) Concurrent use of monoamine oxidase inhibitor
4) Should not be used in women with a current alcohol abuse problem.
b) Possible adverse reactions
1) Rash
2) nausea
3) agitation
4) migraine
c) Cautionary notes
1) neuropsychiatric events such as depression, suicidal ideation, and suicide attempt or completion have been linked to the use of this medication. their effects may be complicated by the coexisting symptoms of nicotine withdrawal.
2) all patients using bupropion for smoking cessation should be monitored regularly for changes in behav- ior, such as hostility, agitation, depressed mood, and suicide-related thinking or events.
3) Patients should be told to report any changes to their clinician.
ii. Varenicline (Chantix) acts on receptor sites by activating them and blocking nicotine from attaching to them. Dosage days 1 to 3; one white tablet (0.5 mg) orally each day, dos- age days 4 to 7; one white tablet (0.5 mg) orally twice a day (morning and evening) starting from Day 8 to end of treatment; one blue tablet (1 mg) orally twice a day (morning and evening).
a) important facts
1) Patients with kidney problem or undergoing dialysis treatment may need lower dose (see package insert).
2) Should be taken after meals with full glass of water
3) if a dose is missed, it should be taken as soon as remembered. if it is close to time of next dose, skip missed dose and take regular dose on time.
4) Patients taking other medications, such as blood thinner, insulin, and asthma medication, may need to have dosages altered after cessation of smoking.
b) Cautionary notes
1) all patients taking Chantix should be closely monitored for changes in behavior, hostility, agitation, depressed mood, and suicidal ideation, attempts, or gestures.
2) Patients with preexisting psychiatric disorders should be given varenicline after all other avenues have been exhausted and then only with caution and close monitoring.
3) Patients and members of their family need to be advised that if the aforementioned symptoms present themselves, then varenicline should be stopped immediately and the prescribing clinician notified.
4) Varenicline should be avoided by persons operating aircraft, driving buses, or using machinery where a lapse in alertness could have serious consequences. Clinicians should be aware of emerging information regarding increased risk of heart disease with Chantix use.
5) Chantix should not be used in conjunction with other quit-smoking products.
c) adverse effects
1) Headaches
2) nausea
3) Vomiting
4) insomnia
5) Unusual dreams
6) abdominal gas
7) Changes in taste
d) How to start
1) Choose a quit date.
2) Begin taking Chantix 7 days before the quit date. this allows Chantix to build up in the body. Patients can continue to smoke during this time but must stop smoking on Day 8.
3) most patients will take Chantix for up to 12 weeks. if medication has been successful, another 12 weeks may be prescribed to help patient remain cigarette free.
e) Patients may join get Quit by calling (877) 242-6849.
f) other modalities
1) Hypnosis
2) acupuncture
3) e-cigarettes—Latest evidence has indicated that use of e-cigarettes does not increase the rate of smoking cessation.
IX. COMPLICATIONS
a. Relapse: most people who return to smoking do so within a month of quitting. the longer persons have abstained, the more likely they are to continue to do so.
1. a patient may be doing well when a situation or stressor makes smoking too enticing to resist.
2. the patient may experience side effects from the product used and may lose resolve.
X. CONSULTATION
a. Question regarding possible medical contraindication to use of nico- tine replacement or bupropion hydrochloride
B. Referral to intensive group sessions, such as those offered by nicotine anonymous, american Cancer Society, american Lung association, or a local hospital
XI. FOLLOW-UP
a. telephone call to patient within 1 to 2 weeks of quit date
B. office follow-up at 1 and 3 months
C. if relapse occurs
1. Discuss and review problems and stressors that contributed to relapse
2. Review and reinforce strategies that smoker can use to meet future challenges
3. Renew smoker’s commitment to total abstinence
4. Review why patient wishes to quit; contract with patient to set another quit date
5. Reassure patient that success is often achieved only after five to six repeated attempts; success may take several years
See Appendix I for a patient information sheet for photocopying or adapting. See Bibliographies.
Websites: www.smokefree.gov; www.nida.nih.gov; www.cdc.gov/tobacco; www
.surgeongeneral.gov/tobacco; www.cancer.org; www.heart.org/HEARTORG; http:// www.lung.org/#; www.ctcinfo.org; www.tobacco.org; www.quitnet.com
NOTE
1. t. F. Heatherton, L. t. kozlowski, R. C. Frecker, & k. o. Fagerström. (1991). Fagerström test for nicotine Dependence: a revision of the Fagerström tolerance Questionnaire. British Journal of Addiction, 86(9):1119–1127. http://www.ncbi.nlm.nih.gov/pubmed/1932883