Smoking Cessation

Tobacco use increases the risk of micro- and macro vascular complication of diabetes and is one of the most preventable causes of death worldwide. Each year, 430,000 deaths are attributable to tobacco use in U.S. alone, more than alcohol abuse, automobile accidents, AIDS, homicide, suicide, heroin and cocaine combined. compared to age – matched non smokers , persons who smoke 1 pack of cigarettes per day are 14 times more likely to die from cancer of the esophagus : twice as likely to suffer an MI or stroke : and twice as likely to die from heart diseases or cancer of the bladder. At any age, the risk of death is doubled in smokers compared with nonsmoking age-matched controls, and the risk associated with smoking is dose dependent. Despite these statistics, many physicians do not routinely ask patients about cigarette smoking or offer counseling about smoking cessation. The increased cardiovascular risk attributable to smoking returns to baseline soon after cessation of tobacco use, emphasizing the importance of intervention. By 12-18 months, most of the increased cardiovascular risk has disappeared, and by 3-5 years, the risk of vascular events is no different than that of a non smoker. As a physician, there is virtually nothing more effective at improving a patient’s long term prognosis than convincing and helping him or her to stop smoking .if a physician discusses this topic even briefly with the smoker and makes a strong statement about the medical necessity of discontinuing this habit, a person’s chances of permanent cessation of smoking is doubled.

Strategies to assist patients willing to quit smoking

Step 1: Strategies for implementation
Help the patient with a quit plan
1. Have patient set quit date, ideally within 2 weeks.
2. Have patient tell family, friends, and coworkers about quitting and request their understanding and support.
3. help patient anticipate withdrawal symptoms and discuss ways to resist urges and cravings (clean the house ;take 5 minutes walk ; do stretching exercise ; put a toothpick , cinnamon gum , or lemon drop in mouth ;take several slow deep breaths; brush teeth ; call a non smoking friend and talk).
4. Have patient remove tobacco products from their environment: throw out ashtrays; clean clothes, car, and carpets.
5. Encourage patients to learn as much about how to quit smoking as possible. Useful sources for reading materials include:

American heart association, 7272 Greenville Avenue, Dallas, TX 75231, (800) 242-8721; www.americanheart.org.
American cancer society ,1599 Clifton road, NE, Atlanta, A 30329,(800) 227-2345;www.cancer.org
National cancer institute ,Bethesda,MD 20894,(202) 4- cancer (422-6237);www.nci.nih.gov
For pregnant women : American college of obstetricians and gynecologists,409 12th street ,SW,Washington , DC 20024,(202) 638-5577; www.acog .org

Step 2:
Provided practical counseling
1. Total abstinence is essential.” not even a single puff after you quit.”
2. Identify what helped and hinders previous quit attempts.
3. Discuss challenges / triggers and how to overcome them.
4. Since alcohol can cause relapse, the patient should consider limiting /obtaining from alcohol while quitting.
5. Patients should encourage housemates to quit with them or not to smoke in there presence.
6. Provide a supportive clinical environment while encouraging the patient to quit:” My staff and I are available for you.

Step 3: Strategies for implementation
Recommend approved drug therapy
1. Recommend the use of first-line drug therapy (varenicline, bupropion,NRT) to all smokers trying to quit, except in special circumstances (e.g., medical contraindications, pregnant/breastfeeding women, adolescent smokers). If drug therapy is used with lighter smokers (10-15 cigarettes/day), consider reducing the dose of NRT; no dosage adjustment is necessary for sustained-release bupropion.
2. Some studies suggest that bupropion may be more effective than NRT for achieving permanent cessation of tobacco use, and that some synergism between the two approaches may exist. There are insufficient data to rank-order these medications, So initial therapy must be guided by factors such as clinician familiarity with the medications, contraindications foe selected patients, patients preference ,previous patient experience with a specific therapy (positive or negative), and patient characteristics (e.g., history of depression, concerns about weight gain). Sustained-release bupropion hydrochloride and NRT, in particular nicotine gum, have been shown to delay but not prevent weight gain. Sustained –release bupropion hydrochloride and nortriptyline hydrochloride are particularly well-suited for patients with a history of depression.
3. There is evidence that combining the nicotine patch with either nicotine gum or nicotine nasal spray increase long-term abstinence rates compared to a single form of NRT, based on a meta-analysis.
4. The nicotine patch in particular is safe in patients with cardiovascular disease. However, the safety of these products has not been established for the immediate post-MI period or in patients with severe or unstable angina.
5. Long-term therapy may be helpful for smokers who report persistent withdrawal symptoms. A minority of individuals who successfully quit smoking use NRT medications (gum, nasal spray, and inhaler) long term. The long-term use of these medications does not present a known health risk, and the FDA has approved the use of sustained-release bupropion hydrochloride for long-term maintenance.
6. Clonidine and nortriptyline may be considered when first-line medications are contraindicated or not helpful.