Smoking Cessation: Helping Patients Who Use Tobacco

Full update September 2020

In the toolbox below are practical tips and resources to help your patients have success with tobacco cessation. Helpful information about caring for patients who continue to use tobacco is also included.

Goal	Strategies and Resources
Educate patients about the risks associated with tobacco use.	Reinforce the serious risks that are commonly associated with cigarette smoking such as lung cancer (risk increased by 25x), cardiovascular disease (risk increased by up to 4x), and COPD (risk of death from COPD increased by 12 to 13x). Also let patients know these risks are reduced after smoking cessation, such as the risk of heart attack which drops significantly after one year, and the risk of stroke which returns to the same as a nonsmoker’s risk after two to five years. CDC Health Effects of Cigarette Smoking at https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smoking/index.htm, provides overview and statistics on different health conditions Chart, Lifestyle Changes to Reduce Cardiovascular Risk Toolbox, Improving COPD Care Toolbox, Preventing and Treating Community-Acquired Pneumonia Let patients know that tobacco use can actually increase the risk of a number of conditions other than those that are commonly known. Chart, Treatments for Dry Mouth
Use strategies for interacting with patients about smoking cessation.	Consider the “5 A’s” model (Ask, Advise, Assess, Assist, and Arrange follow-up), a simple and efficient way to identify patients who smoke, provide counseling, and refer patients to additional resources if necessary. Ask about tobacco use Advise the patient to quit in a clear, strong, and personalized way Assess willingness to make a quit attempt at the time Assist in a quit attempt Help patients set a quit date, ideally within 2 weeks Arrange follow-up with the patient, preferably the first week after the quit date, and again within the first month Consider the “Ask-Advise-Refer” model, a condensed version of the “5 A’s model.” This model is useful for busy practitioners or those who may not have an extensive clinical background in smoking cessation. Ask about tobacco use Advise the patient to quit in a clear, strong, and personalized way Refer the patient to additional resources such as free telephone quitlines, online help, or local support groups Longer counseling sessions appear to be more effective, but brief interventions (less than three minutes) can improve quit rates. Use strategies to motivate patients and get their buy-in for this important step in improving their health. Government of Canada. Tips to help someone quit smoking (https://www.canada.ca/en/health-canada/services/smoking-tobacco/quit-smoking/tips-help-someone-quit-smoking.html), including online resources about quitting smoking by province or territory. CDC Best Practices for Comprehensive Tobacco Control Programs, Cessation Interventions (http://www.cdc.gov/tobacco/stateandcommunity/best_practices/pdfs/2014/sectionA-III.pdf) CDC Healthcare Providers: Tools and Resources (https://www.cdc.gov/tobacco/campaign/tips/partners/health/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Ftobacco%2Fcampaign%2Ftips%2Fpartners%2Fhealth%2Fpharmacist%2Findex.html). Includes resources such as quitline information, posters, videos, and 800-quit-now notepads, etc. CE, The Pharmacist’s Role in Promoting Tobacco Cessation CE, Medication Adherence: What You Need to Know CE, Strategies for Communicating Effectively with Patients CE, Strategies for Effective Telephone Communication CE, Motivational Interviewing to Promote Change Rx for Change (http://rxforchange.ucsf.edu). Includes tailored curriculum materials for the 5 A’s, Ask-Advise-Refer, as well as materials for psychiatry, cardiology, mental health, respiratory, and surgical providers.
Implement a smoking cessation process into your workflow.	Encourage teamwork and designate a champion for this initiative. Consider how staff can participate, such as having pharmacy technicians ask patients about their current smoking status. See our Technician Tutorial, Patient Profiles 101 (pharmacy technician subscribers) Consider setting up a collaborative practice agreement between prescribers and pharmacists to increase patient access to smoking cessation medications (http://www.cdc.gov/dhdsp/pubs/docs/Translational_Tools_Pharmacists.pdf) For pharmacies, use our CE, The Pharmacist’s Role in Promoting Tobacco Cessation. For prescribers, consider resources such as the American Academy of Family Physicians Treating Tobacco Dependence Practice Manual (http://www.aafp.org/dam/AAFP/documents/patient_care/tobacco/practice-manual.pdf). Includes a useful patient visit flow chart.
Stay current on recommendations for drug therapy (OTC and Rx) for smoking cessation.	Help choose the best option for the patient and educate about proper use. CE, Pharmacotherapy for Smoking Cessation Chart, Smoking Cessation Drug Therapy Understand the risk of mental health side effects associated with varenicline (Chantix [U.S.], Champix [Canada]) and bupropion (Zyban) is lower than previously thought. See the FDA Safety Communication at https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-revises-description-mental-health-side-effects-stop-smoking?source= Technician Tutorial, The Ins and Outs of Transdermal Patches (pharmacy technician subscribers) U.S. Department of Health and Human Services Quick Reference Guide for Clinicians. Treating Tobacco Use and Dependence: 2008 Update (https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/clinicians-providers/guidelines-recommendations/tobacco/clinicians/references/quickref/tobaqrg.pdf) Explain that smoking cessation medication PLUS counseling works better than either strategy alone.
Stay current on alternative therapies for smoking cessation.	Help patients discern what alternative therapies may or may not work. Cytisine (Cravv), a licensed natural health product in Canada, has been shown to work about as well as NRT. For more details on alternative therapies, such as those below, go to our Natural Medicines database. A small study suggests L-tryptophan may be effective as an aid to smoking cessation, in doses of 50 mg/kg/day. Preliminary data suggest that acupuncture may possibly be effective in smoking cessation. There is insufficient evidence to show that acupressure or hypnotherapy is effective for smoking cessation.
Provide educational materials about smoking cessation for patients.	Access helpful resources, including: Quit for Life (https://www.quitnow.net/mve/quitnow). Includes coaching calls, text and email messages, action plans, and a way to connect with others who are trying to quit. American Cancer Society (https://www.cancer.org/healthy/stay-away-from-tobacco/guide-quitting-smoking.html). Includes plans to quit, as well as how to stay tobacco-free after quitting. American Heart Association (https://www.heart.org/en/healthy-living/healthy-lifestyle/quit-smoking-tobacco/help-i-want-to-quit-smoking). Includes quitlines, online resources, and information about available medications. American Lung Association (https://www.lung.org/quit-smoking). Includes link to smoking cessation program for patients, Freedom From Smoking. Canadian Cancer Society Smokers’ Helpline (http://www.smokershelpline.ca). Includes online quit program with self-directed tools and a calculator to see how much money can be saved by quitting. CDC (https://www.cdc.gov/tobacco/quit_smoking/). Includes tips from former smokers, resources, and more. Health Canada On the Road to Quitting: Guide to Becoming a Non-Smoker (https://www.canada.ca/en/health-canada/services/publications/healthy-living/road-quitting-guide-becoming-non-smoker.html). Includes ways to choose the right method to quit, action plans, and tips for facing roadblocks.
Recommend other valuable resources such as free telephone quitlines, messaging services, and apps.	Help your patients by suggesting mechanisms that will work best for each individual, such as: CDC (800-QUIT-NOW, https://www.cdc.gov/tobacco/quit_smoking/index.htm) National Cancer Institute (877-44U-QUIT, https://www.cancer.gov/about-cancer/causes-prevention/risk/tobacco/smokeless-fact-sheet [for smokeless tobacco]) Smokefree.gov offers quit plans that can be personalize (https://smokefree.gov/build-your-quit-plan), texting programs (https://smokefree.gov/tools-tips/text-programs), apps (https://smokefree.gov/tools-tips/apps), and more. Government of Canada (https://www.canada.ca/en/health-canada/services/smoking-tobacco/quit-smoking.html) Canadian Cancer Society Smokers’ Helpline (877-513-5333, https://www.smokershelpline.ca/, text “iQuit” to 123456) Break It Off (https://breakitoff.ca/) offers coaching, links to locate support within each province, an app, and more. quitSTART app (https://smokefree.gov/tools-tips/apps/quitstart) is a free app for android and iPhone users with ways to manage cravings, monitor progress, and other helpful tips. Teens are the target audience, but useful for adults too. QuitNow app (free) for android (https://play.google.com/store/apps/details?id=com.EAGINsoftware.dejaloYa&hl=en_US) and iPhone (https://apps.apple.com/us/app/quitnow/id483994930) provides users with tips, challenges, tracking milestones, and more. Quitguide app (https://smokefree.gov/tools-tips/apps/quitguide) is a free app for android and iPhone users with motivational and inspirational messages, help tracking mood and smoking triggers, and monitors progress toward becoming smoke free.
Understand billing for tobacco cessation services and products.	Document appropriately (nature and duration of counseling) to get paid for your tobacco cessation interventions. In the U.S.: American Academy of Family Physicians Treating Tobacco Dependence Practice Manual (http://www.aafp.org/dam/AAFP/documents/patient_care/tobacco/practice-manual.pdf). Includes more detailed information on billing. CMS (http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7133.pdf) Use CPT codes 99406 (for counseling sessions of 3 to 10 minutes) and 99407 (for counseling sessions greater than 10 minutes) for tobacco cessation counseling. For Medicare, these codes can only be used for symptomatic patients. In Canada: Information about province-specific billing by pharmacists is available at https://cfpnet.ca/bank/document_en/140-2019-provincial-services-chart.pdf. Let patients know that tobacco use can be associated with higher health insurance premiums. As of January 1, 2014, smoking cessation medications are required to be covered by Medicaid. Check your state’s current status on Medicaid coverage of smoking cessation medications (https://www.cdc.gov/statesystem/factsheets/medicaid/Cessation.html#anchor_1562854604).
Recognize needs of patients who continue to smoke.	Make sure smokers are current on vaccines, including a yearly seasonal influenza vaccine and for immunocompetent patients, a single dose of pneumococcal vaccine (PPSV23) between the ages of 19 and 64 years of age (18 and 64 years of age in Canada). CDC pneumococcal vaccine recommendations. https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html CE, Immunization Update Part 1 (includes links to CDC immunization schedules) (U.S.) CE, Immunization Update Part 2 CE, Immunization Update Part 3 Public Health Agency of Canada. Canadian Immunization Guide. Pneumococcal vaccine. https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-4-active-vaccines/page-16-pneumococcal-vaccine.html Technician Tutorial, The Basics of Immunization and Vaccines (pharmacy technician subscribers) Toolbox, Preventing and Treating Community-Acquired Pneumonia Consider potential drug interactions with cigarette smoking. Examples of drugs that may interact with smoking include hormonal contraceptives, caffeine, theophylline, olanzapine, fluvoxamine, clozapine, etc. See the University of California San Francisco resource (https://smokingcessationleadership.ucsf.edu/sites/smokingcessationleadership.ucsf.edu/files/A4%20DI%20TABLE.pdf) for a more comprehensive list, including possible mechanisms and impacts. Chart, Contraception for Women With Chronic Medical Conditions
Educate patients who use smokeless tobacco.	Inform patients who use chewing tobacco or snuff about the risks such as oral cancer and encourage them to quit. CE, The Pharmacist’s Role in Promoting Oral Health American Cancer Society (https://www.cancer.org/healthy/stay-away-from-tobacco/guide-quitting-smoking/deciding-to-quit-smokeless-tobacco-and-making-a-plan.html) includes information about setting a quit date, preparation tips, and medication options.
Educate patients and providers who use or have questions about e-cigarettes.	Chart, E-Cigarette and Vaping FAQs E-cigs are often not allowed while hospitalized. Consider including e-cigs in the nicotine replacement protocols. Use low-dose nicotine replacement and titrate as necessary in order to avoid potential withdrawal. Update hospital policies to address electronic cigarettes. See Joint Commission policy requirements at http://www.jointcommission.org/assets/1/23/jconline_February_11_15.pdf.
Considerations for nicotine replacement therapy (NRT) in acutely ill, hospitalized patients	Acute coronary syndrome (ACS) NRT benefits outweigh smoking risks in most stable ACS patients experiencing nicotine withdrawal.^1,7,9 Retrospective analyses show NRT use in stable hospitalized ACS patients or prescribed at discharge is NOT associated with adverse outcomes (e.g., mortality, myocardial infarction, repeat vascularization).^1,7,9,10 However, NRT use in the intensive care unit (ICU) in patients post-coronary artery bypass graft surgery has been weakly associated with increased mortality.⁸ Intensive Care Unit (ICU) patients Balance risks and benefits when considering NRT in ICU patients, as data are conflicting:^3,6 Some data indicate NRT has no effect or may reduce delirium, while other data link NRT use with increased delirium and use of antipsychotic medications.^2,3,6 At least one study found an association between NRT use and increased mortality, while a follow-up study at the same institution was unable to confirm this association.³ Subarachnoid hemorrhage (SAH) NRT benefits likely outweigh smoking risks in SAH patients experiencing nicotine withdrawal.⁴ Evidence suggests that NRT is NOT associated with an increased risk of vasospasm in SAH patients.⁴ NRT use in hospitalized SAH patients may be associated with improved outcomes (e.g., functional outcome, reduced risk of death).⁴ Wound healing NRT benefits likely outweigh smoking risks in most surgical patients experiencing nicotine withdrawal.⁵ Smoking increases risk for surgical site infections and impaired wound healing.⁵ Limited data suggest that nicotine levels associated with NRT are NOT associated with impaired wound healing.⁵ Dosing Determining a starting dose can be tough, as it can be difficult to get an accurate smoking history. If NRT is started, follow hospital protocols and adjust therapy as needed.
Help adolescents with smoking cessation	Addressing tobacco and nicotine use among adolescents is critical to ending the tobacco epidemic. Resource, Vaping Cessation Guide Chart, E-Cigarette and Vaping FAQs Use adolescent-specific resources to help adolescents stop using tobacco: Become a Smokefree Teen (https://teen.smokefree.gov/). Includes resources on quitting vaping, managing stress without smoking, how to quit smoking and still be social, and more. In the U.S., SmokefreeTXT for teens (text “QUIT” to 47848 keywords can also be used [e.g., “WANT” (cravings), “UH OH” (slipped and smoked), “BOOST” (bad mood)]). quitSTART app (https://smokefree.gov/tools-tips/apps/quitstart) free app for android and iPhone users. An app through smokefree.gov and the National Cancer Institute with ways to manage cravings, helpful tips, and monitor progress.
Educate patients who have questions about smoking marijuana for medicinal purposes.	Stay current on state or provincial laws as well as the benefits and risks of medical marijuana use. CE, Natural Medicines in the Clinical Management of Pain Chart, Drugs of Abuse Chart, Managing Cancer Pain in Adults Chart, Comparison of Cannabinoids: CBD vs THC

Project Leader in preparation of this clinical resource (360908): Beth Bryant, Pharm.D., BCPS, Assistant Editor

References

Woolf KJ, Zabad MN, Post JM, et al. Effect of nicotine replacement therapy on cardiovascular outcomes after acute coronary syndromes. Am J Cardiol 2012;110:968-70.
Kerr A, McVey JT, Wood AM, Van Haren FM. Safety of nicotine replacement therapy in critically ill smokers: a retrospective cohort study. Anaesth Intensive Care 2016;44:758-61.
Wilby KY, Harder CK. Nicotine replacement therapy in the intensive care unit: a systematic review. J Intensive Care Med 2014;29:22-30.
Turgeon RD, Chang SJ, Dandurand C, et al. Nicotine replacement therapy in patients with aneurysmal subarachnoid hemorrhage: systematic review of the literature, and survey of Canadian practice. J Clin Neurosci 2017;42:48-53.
Nolan MB, Warner DO. Safety and efficacy of nicotine replacement therapy in perioperative period: a narrative review. Mayo Clin Proc 2015;90:1553-61.
Kowalski M, Udy AA, McRobbie HJ, Dooley MJ. Nicotine replacement therapy for agitation and delirium management in the intensive care unit: a systematic review of the literature. J Intensive Care 2016;4:69.
Kulik A, Ruel M, Jneid H, et al. Secondary prevention after coronary artery bypass graft surgery: a scientific statement from the American Heart Assocation. Circulation 2015;131:927-64.
Paciullo CA, Short MR, Steinke DT, Jennings HR. Impact of nicotine replacement therapy on postoperative mortality following coronary artery bypass graft surgery. Ann Pharmacother 2009;43:1197-202.
Meine TJ, Patel MR, Washam JB, et al. Safety and effectiveness of transdermal nicotine patch in smokers admitted with acute coronary syndromes. Am J Cardiol 2005;95:976-8.
American College of Cardiology. Clinician tool: tobacco cessation for patients with cardiovascular disease. November 2018. https://www.acc.org/~/media/0D3B2F4EE12A49D2995E8D7A734AC486.pdf. (Accessed August 10, 2020).

Cite this document as follows: Clinical Resource, Smoking Cessation: Helping Patients Who Use Tobacco. Pharmacist’s Letter/Prescriber’s Letter. September 2020.

Smoking Cessation: Helping Patients Who Use Tobacco

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