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Smoking Cessation - MD Exam Answer (10 Marks)

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1. CONCEPTUAL FRAMEWORK

• Smoking must be regarded as a primary addictive disorder, NOT a "habit" or lifestyle choice
• 75% of American smokers wish to quit; only 3% achieve prolonged abstinence per year - this reflects the involuntary nature of addiction
• It is a chronic relapsing disorder - a quit attempt = induction of remission; abstinent smoker always at risk for relapse
• "Cold turkey" (unsupported cessation) yields only 2-5% cessation at 1 year (Murray)
• Health consequences are secondary; health benefits of cessation are the therapeutic rationale

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2. NICOTINE ADDICTION MECHANISM (Murray, Ch. 66)

• Nicotine absorbed rapidly from smoke into pulmonary circulation - reaches brain in 10-15 seconds
• Acts on nicotinic cholinergic receptors (mesolimbic dopamine system) producing gratification
• Half-life ~2 hours
• Chronic exposure → upregulation of nicotinic receptors in multiple brain regions → tolerance and dependence
• When nicotine unavailable (even for hours) → withdrawal: anxiety, irritability, difficulty concentrating, restlessness, hunger, cravings, disturbed sleep, depression
• Smokers 2-3x more likely to have psychiatric comorbidity (schizophrenia, bipolar, PTSD, alcohol use disorder)
• Smoking and depression strongly linked; depressed smokers more nicotine-dependent and less likely to quit

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3. INITIAL ASSESSMENT

Fagerstrom Test for Nicotine Dependence (FTND) (Fishman's, Table 41-1)

• Most important single question: time to first cigarette - smoking within 30 min of waking = heavy addiction
• FTND score ≥7 + early morning smoking = benefit most from NRT and varenicline
• Past quit attempts should be reviewed for withdrawal severity and successful strategies

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4. THE "5 A's" FRAMEWORK (Murray, U.S. Public Health Service Guidelines)

1. Ask about tobacco use at every visit
2. Advise to quit (clear, strong message)
3. Assess readiness to quit
4. Assist in connecting to tobacco treatment
5. Arrange follow-up to review progress

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5. STAGES OF CHANGE MODEL (Prochaska & DiClemente - cited in Fishman's)

1. Precontemplation - not interested in quitting; provide brief counseling, plant seeds
2. Contemplation - aware of need, not ready; provide information
3. Preparation - planning to quit; set a quit date, choose therapies
4. Action - active quit attempt; intensive support
5. Maintenance - abstinent; relapse prevention focus

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6. NON-PHARMACOLOGIC APPROACHES (Fishman's + Murray)

• Individual counseling to identify smoking cues/triggers
• Cold turkey (abrupt cessation) is preferred; gradual reduction also used
• Avoid high-risk situations for first 3 weeks
• Brief physician advice: even minimal advice from a clinician increases quit rates
• Quit lines: 1-800-QUIT-NOW (US) - telephone counseling nearly doubles abstinence rates in RCTs; effective as referral when office time is limited
• Separate planned visit focused solely on smoking cessation is recommended
• Intensive programs: success increases with intensity of behavioral support

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7. PHARMACOTHERAPY (Fishman's + Murray)

FIRST-LINE AGENTS

A. Nicotine Replacement Therapy (NRT)

• OTC: Transdermal patch, polacrilex gum, lozenge
• Prescription: Nasal spray, inhaler

• 10 cigs/day: Start 21 mg/24h x 6 wk → 14 mg x 2 wk → 7 mg x 2 wk

• ≤10 cigs/day: Start 14 mg x 6 wk → 7 mg x 2 wk

• Started on quit day; replaces nicotine from cigarettes and reduces withdrawal intensity
• "Patch-plus" regimen (transdermal + ad lib formulation) is recommended for higher success
• FDA removed the warning against concurrent smoking during NRT use (benefits outweigh risks)
• Patients with low FTND who tolerate 4+ hours smoke-free may not need NRT

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B. Bupropion SR (First-line)

• Mechanism: Non-nicotine agent; inhibits neuronal reuptake of dopamine and norepinephrine; also blocks nicotinic receptors
• Dosing: 150 mg every morning x 3 days → 150 mg twice daily; begin 1-2 weeks before quit date; maintain 7-12 weeks (up to 6 months)
• Avoid bedtime dosing (insomnia); at least 8 hours between doses
• Contraindications: History of seizure disorder, current or prior eating disorders
• Adverse effects: Insomnia, dry mouth, neuropsychiatric symptoms (rare)
• Preferred in: Patients with history of depression

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C. Varenicline (Most Efficacious)

• Mechanism: Partial agonist of α4β2 neuronal nicotinic acetylcholine receptor - reduces craving/withdrawal AND blocks nicotine reward if patient smokes
• Dosing: 0.5 mg/day x 3 days → 0.5 mg twice daily x 4 days → 1 mg twice daily; begin 1 week before quit date (flexibility: quit date 1-5 weeks after starting)
• Duration: 3-6 months
• Contraindications: Renal impairment (dose adjustment required)
• Adverse effects: Severe nausea, trouble sleeping, abnormal/vivid dreams, neuropsychiatric symptoms (rare - class warning)
• Has the greatest efficacy of all cessation drugs (Fishman's)

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SECOND-LINE AGENTS (Off-label)

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Combination Therapy

• NRT patch + ad lib NRT (gum/lozenge) = most commonly recommended combination
• NRT + bupropion also used
• Combining non-pharmacologic support WITH pharmacotherapy optimizes success
• Hospitalized patients: counseling plus NRT is more effective than counseling alone; must include ≥1 month supportive contact post-discharge

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8. PRACTICAL MANAGEMENT DURING QUIT ATTEMPT (Fishman's)

• Restlessness, anxiety, poor concentration, irritability, frustration, depression, unrelenting cravings
• Cravings are the most persistent symptom and can recur long after initial cessation

1. Increase physical activity
2. Deep breathing / pursed-lip breathing exercises
3. Avoid high-risk situations for first 3 weeks
4. Use cinnamon gum or chewable candies
5. Remember: urge to smoke will pass whether one smokes or not

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9. BENEFITS OF QUITTING (Murray, Ch. 66 / Surgeon General's 2020 Report)

• CO and heart rate normalize within 24-48 hours
• Ciliary function begins recovering within weeks

• Cough, mucus, shortness of breath decrease
• Lung function improves

• 1 year: CHD risk halved vs. active smoker
• 5-15 years: Stroke risk reduces to that of a non-smoker
• 10 years: Lung cancer death rate halved
• 15 years: CHD risk equivalent to non-smoker
• COPD progression slows significantly (most important single intervention for COPD)

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10. EXAM HIGH-YIELD SUMMARY TABLE

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