Prevention
Ending the Lifelong Love Affair with Tobacco

By Louise Gibson, BSN, RN, and Lynnette Kennison, MSN, ARNP

 
But you don't understand I like to smoke! I want to quit, but I love smoking." This is a frequent comment from smokers calling to sign up for a smoking cessation class. It illustrates the serious addiction tobacco embodies. According to the World Health Conference on Tobacco, "Tobacco addiction often leads to a situation where an otherwise rational, motivated, knowledgeable person who understands the serious risks of smoking makes the decision to continue smoking."1 Most smokers continue to smoke with the help of rationalization and minimization. They tell themselves that they will quit before threatening symptoms occur. They minimize the threats that smoking poses to their health. They hide their addiction from themselves and their loved ones.

The dependence-producing properties of tobacco have been evident for some time. In 1988 the U.S. Surgeon General's Report reached three key conclusions about dependence on tobacco use:
 
Cigarettes and other forms of tobacco are addictive;
Nicotine is the drug in tobacco which causes addiction;
The pharmacological and behavioral processes that determine tobacco addiction are similar to those associated with drugs such as heroin and cocaine.2

Most tobacco products deliver nicotine to the brain rapidly and effectively, bringing on the quick onset and maintenance of addiction. This results in a physiological need for tobacco as well as a psychological and behavioral need. "Nicotine is a powerful reward/enforcer, producing pleasurable feelings, relaxation of the muscles, reduced hunger, and improved attention and performance of certain cognitive tasks. Nicotine enhances release of neurotransmitters such as acetylcholine, norepinephrine, dopamine, serotonin, and beta-endorphin. Acetylcholine may produce pleasure; and beta-endorphin may lower anxiety, tension, and pain."3

According to the National Institute on Drug Abuse, stress and anxiety affect nicotine tolerance and dependence. Corticosterone reduces the effects on nicotine; so more nicotine must be consumed to achieve the same effect. This increases tolerance to nicotine and leads to increased dependence.

The majority of smokers in the United States want to quit, but only about 3 percent successfully quit each year. Tobacco dependence is a chronic disease with remission and relapse, and often requires repeated intervention. However, effective treatments do exist that can deliver long-term or permanent abstinence.

Brief physician advice to quit smoking produces cessation rates of 5 to 10% per year. More intense interventions, combining behavioral counseling and pharmacological treatment of nicotine addiction, can produce cessation rates of 20 to 25% per year. According to the U.S. Department of Health and Human Services, "There is a strong dose-response relationship between the intensity of tobacco dependence counseling and its effectiveness."2 Treatments involving person-to-person contact (via individual, group, or proactive telephone counseling) are consistently effective, and their effectiveness increases with treatment intensity (e.g. minutes of contact). Clinicians have a vital role to play in helping smokers quit the use of tobacco.

The single most important step in dealing with tobacco use is careful screening. After the clinician has asked about tobacco use and has assessed the willingness to quit, he or she can provide the appropriate intervention, either by assisting the patient in quitting (the 5 A's) (Table 1) or by supplying a motivational intervention, the (5 R's) (Table 2) for the patient who decides not to quit. [NOTE: Table 1 and Table 2 are available here as PDF files only.]

The Transtheoretical Model of Change

The following is an overview of the Transtheoretical Model of Change, which has been the basis for developing effective interventions to promote health behavior change.4 The model describes how people modify a problem behavior or acquire a positive behavior.
 
Stage of Change How to Help
Precontemplation: The smoker is not considering change. Acknowledge their fears; discuss the rewards of quitting.
Contemplation: The patient is thinking about quitting. Encourage the patient to think about the advantages and disadvantages of quitting.
Preparation: The smoker has decided to quit smoking. Help them make a plan; include pharmacological support.
Action: The patient has extended periods of abstinence. Acknowledge and reward their progress; maintenance.
Long period of stable abstinence. Help the patient identify behaviors that court relapse (overconfidence, daily temptation, and self-blame).
Relapse: The patient starts smoking again after a period of abstinence. Move as quickly as possible from Contemplation to Preparation.
Termination: The patient, at some point considers him/herself recovered. Congratulate them on their success and strongly encourage remaining abstinent.

Pharmacotherapy

Pharmacotherapy is a vital part of a multi-component approach to treat nicotine addiction. The Public Health Service's guidelines identify five first-line (bupropion SR, nicotine inhaler, nicotine nasal spray, nicotine gum and nicotine patch) and two second-line medications (clonidine and nortriptyline) for the treatment of tobacco use.

First-line pharmocotherapies have been found to be safe and effective for treating tobacco dependency and have been approved by the U.S. food and Drug Administration (FDA) for use. Second-line medications have shown evidence of efficacy for treating tobacco dependence, but they are not FDA approved and may cause potential side effects. Second-line drugs should be used on an individual basis only after first-line drugs have failed.

The use of nicotine replacement therapy (NRT) after quitting smoking provides a source of nicotine devoid of tars, carbon monoxide and respiratory irritants. Based on proven efficacy, the FDA has approved several forms of nicotine replacement: nicotine gum; nicotine skin patches; nicotine nasal spray and the nicotine oral inhaler. Very few studies have been done in which combinations of nicotine replacement therapy were used. "The USPHS Guideline suggests that combining the nicotine patch with a self-administered form of nicotine replacement therapy, such as nicotine gum, nicotine nasal spray, or nicotine vapor inhaler, is more effective than a single form of nicotine replacement. This approach should be encouraged if a patient cannot stop smoking by using a single first-line pharmacotherapy." 5

"Cardiovascular risk and the use of NRT have been systematically studied since the nicotine patch was released in 1991. Separate analyses have documented the lack of an association between use of the nicotine patch and acute cardiovascular events, even in patients who continue to smoke intermittently while using the nicotine patch. Because of inaccurate media coverage in the past, it may be important to inform patients who are reluctant to use NRT's that there is no evidence of increased cardiovascular risk with these medications." 6

Pearls of Wisdom

Having conducted smoking cessation classes for several years, the authors have heard a lot of good advice from participants:

"Respect your opponent. Take all your soldiers into battle." (Use many techniques, Zyban, NRT, hypnosis and counseling combined)

"The urges to smoke are like waves. At first they are like tidal waves and may feel threatening to any resolutions not to smoke; as time goes by the urges to smoke are like gentle waves that can serve as reminders of tobacco addiction. The gentle waves can also serve as triggers for thankfulness that one is currently not smoking."

"If you take a slow deep breath, the desire to smoke will go away whether you smoke or not."

"If you think it will be hard, it will be. If you think it will be easy, it will be."

"You are only one cigarette away from a pack-a-day habit again."

Smokers often say, "You don't understand; I love to smoke," when asked about intention to quit smoking. Of course smokers love to smoke; they are taking in a drug that stimulates the pleasure center. Cocaine addicts also love to use cocaine, but no one believes that excuse is a reason to delay cessation. Why do smokers assume that pleasure justifies continued abuse? Smoking is the number one public health hazard and should receive the highest priority for treatment.

REFERENCES

  1. 11th World Conference on Tobacco OR Health. August 6-11, 2000. Pp 1-3.
  2. Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence: clinical practice guideline. Rockville, MD: US Department of Health and Human Services, Public Health Service, 2000.
  3. Shipley RA. Leader's Handbook, QuitSmart.
  4. Velicer WF, Prochaska JO, Fava JL, et al. Smoking cessation and stress management: applications of the theoretical model of behavior change. Homeostasis; 38: 216-233.
  5. Hurt RD, Ebbert JO. Preventing lung cancer by stopping smoking. Clinics in Chest Medicine. 2002; 23: 27-34.
  6. Anderson JE, Jorenby DE, Scott WJ, et al. Treating tobacco use and dependence: an evidence-based clinical practice guideline for tobacco cessation. Chest 2002; 121: 932-941.

 

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