Pharmacologic and Nonpharmacologic Approaches to Smoking Cessation

Additional Info

• Audio File:uab/ua175.mp3
• Doctors:Staples, Emily
• Featured Speaker:Emily Staples, DO
• CME Series:Quality and Outcomes
• Post Test URL:https://cmecourses.som.uab.edu/mod/quiz/view.php?id=4254
• Guest Bio:Emily Staples, DO is an Assistant Professor whose Specialties include Family Medicine.
  
  
  Learn more about Emily Staples, DO
  
  Release Date: October 19, 2020
  Expiration Date: October 19, 2023
  
  Disclosure Information:
  
  Planners:
  Ronan O’Beirne, EdD, MBA
  Director, UAB Continuing Medical Education
  
  Katelyn Hiden
  Physician Marketing Manager, UAB Health System
  
  The planners have no commercial affiliations to disclose.
  
  Presenter:
  Emily Staples, DO
  Assistant Professor, Family Medicine
  
  Dr. Staples have no financial relationships related to the content of this activity to disclose.
  
  There is no commercial support for this activity.
• Transcription:Introduction: UAB Med Cast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of 0.25 AMA PRA category one credit. To collect credit, please visit UAB medicine.org/medcast, and complete the episodes Post-test. Welcome to UAB Med Cast, continuing education podcast for medical professionals, bringing knowledge to your world. Here's Melanie Cole.
  
  Melanie Cole: Welcome to UAB Med Cast. I'm Melanie Cole. And today I invite you to listen in, as we discuss pharmacologic and non-pharmacologic approaches to smoking cessation. Joining me is Dr. Emily Staples. She's a Family Medicine Physician and an Assistant Professor at UAB Medicine. Dr. Staples, it's such a pleasure to have you join us today. What are you seeing in the trends? Are people getting the message are less people smoking, and while you're answering that, can you tell us what happens when you quit smoking? What physiological changes take place that you've noticed?
  
  Dr. Staples: As you mentioned in our trends, we do see people interested in smoking cessation because of Coronavirus. It has been shown that smoking is a risk for more severe Coronavirus infections. We're trying to use this to our advantage, to inspire people, to quit smoking more, especially in the clinical setting. So you asked about some of the symptoms when I'm counseling patients on symptoms that they can see when they quit smoking. I like to emphasize that this is a month long process, but the worst of the changes in the first three days, if you can make it through the first three to four days, then it's downhill from there. The symptoms would include increased appetite, weight gain changes in mood, such as dysphoria or depression, insomnia, irritability, anxiety, difficulty concentrating, and or, restlessness. These symptoms are all very vague symptoms and can be attributed to a lot of other causes. But I like to stress for patients, if they can get through the first three to four days of these things will get better within the next four weeks. And eventually they should disappear after four weeks.
  
  Host: Thank you for that. So for providers that are counseling their patients, as I would feel that every provider is doing at some point in your career in medicine, tell providers some of the behavioral and non-pharmacologic techniques that can improve a patient success and can be employed by any medical professional. Tell us about the 5A techniques.
  
  Dr. Staples: I love that you asked about things that any medical professional can use, because it's important that we talk about smoking cessation in every setting that the patient comes into, not just primary care. I talk about it a lot because I am primary care, but I need the assistance of every other patient encounter that a patient goes into. So the 5A techniques is the most commonly used technique for smoking cessation. You oftentimes hear about this in medical school or even in your premed psychology classes. It stands for ask, advise, assess, assist, and arrange. You simply ask about tobacco use. Do you smoke cigarettes? Do you use chewing tobacco, not too hard to do there? The next step advise them might be a good idea to think about quitting. There's a lot of harmful effects and this doesn't mean an hour long lecture, simply one or two sentences is enough. You also need to assess their readiness to quit. And this can be as simple as a straightforward question. Are you ready to quit today? Are you interested in quitting? What do you think about quitting?
  
  Assist them if they are ready to quit, assist them in some of the techniques that we'll talk about later, but this could include simple things like setting a plan, telling their friends about it, as well as preparing them for the symptoms that they can expect. And then last but not least, arrange follow-up. So make sure that they have a plan and they have someone to touch base with someone who will keep them accountable and that they have access to any techniques that they might need or assistance. Now, it's sometimes hard to remember all five of these A's ask, advise, assess, assist, and arrange. So it's slightly easier pneumonic to remember, would be ask, assist and refer, AAR, ask, assist, and refer. So ask them about tobacco use, assist means offering advice on quitting and assistance with a plan, and then refer them onto someone else. If they need other support, whether that's to a primary care provider to prescribe pharmacologic assistance or to behavioral sources such as counseling or very easy resource, the 1-800-QUIT NOW telephone line. It's a number available to anyone within the United States. And that provides behavioral counseling for smoking cessation.
  
  Host: That was very comprehensive. And really that was so many practical things that providers can do. I'd like you to speak for a minute before we get into pharmacologic, some of the other non-pharmacologic ways that providers can look to and do their research on including cognitive behavioral therapy, mindfulness, meditation, group therapy, patches, gum acupuncture. There's so many of these. Do you like any of these forms and what do you think?
  
  Dr. Staples: To answer easily, yes to all of these above. All of them have some efficacy and what works for one person may not work for another. Group therapy may be great for someone, whereas another person might respond to acupuncture, which does have some evidence behind it. Group therapy. You already mentioned, I believe. And then also remembering that patients are going to go through different stages of change. Some people are in the what's called the pre contemplated stage. They're not ready to quit yet. Other people are in the contemplative stage. They're considering it, but not quite ready. Still others are actively preparing. Others are in the action stage. They're involved in a quitting attempt and then others are simply in the maintenance stage. And so using whatever forms of support you can for meeting the patient wherever they're at and trying to help move them forward through those stages of change is important.
  
  Host: Well, it certainly is. And as an exercise physiologist, I've seen this over the years and it's, I mean, it's next to impossible, and some people cannot do it with any of those non-pharmacologic ways. So tell us about what you would do as far as medicational intervention that you found that really works well, tell us a little bit about some of the benefits and drawbacks that you've seen.
  
  Dr. Staples: Yeah, absolutely. So basically the symptoms of nicotine withdrawal are what we're trying to mitigate to help make the cessation process easier. And there's different approaches we can take, the most common one that you see commercials for and hear most about is Chantix also known as Veyron Klein. Now this one you can get really vivid dreams with. So you do have to be careful when prescribing it, but I see a lot of people who respond very well. The one hesitation I would have with this is if your patient's on a lot of other mental health medications, there can be some interactions. So you just have to be careful there. This helps to mitigate the desire for smoking and the addiction component of it. Another medication commonly used is known as Wellbutrin or bupropion. This also works on the brain torque to decrease the addiction component. And this is also used for depression. And so if you have someone who's coming in with both problems can be used for both at the same time. Last but not least, there's also just straightforward, nicotine replacement.
  
  The idea being, if you can replace the nicotine and take away the pharmacologic physiologic addiction, you can then work on the behavioral changes first and then taper slowly off of the nicotine and not have nearly as many withdrawal symptoms, but at the same time, try to take away the most harmful effects first by quitting the cigarette or quitting the tobacco, and then slowly taper off nicotine later. So there's a lot of different possibilities for nicotine replacement, such as patches, lozenges, inhalers, and even some e-cigarettes, which can give you nicotine as well. I would put in one word of caution on the e-cigarettes though, is that it has its own set of risks and difficulties, and while is an approved method for smoking cessation. You then have to later on address quitting the e-cigarettes, which is more difficult than quitting. Some of the other forms of nicotine replacement,
  
  Host: 100%. And I was going to ask you about e-cigs and their role in this. So I'm glad you got to that, now for some people it's the behavioral and some people, it is the physiological, the nicotine addiction, when you're counseling people on a great way to help with those. And especially those behavioral, what are some smoke swaps that you can recommend that you talk to your patients about whether they're holding onto something, tell us a little bit about the behavioral versus the physiological and how you can help with both of those.
  
  Dr. Staples: I think one of the easiest ways to hit both sides of the equation is simple nicotine lozenges. So I like to say, if you can find a piece of hard candy, sugar-free of course, or your dentist might hate me, but hard candy or gum. So nicotine gum and nicotine lozenges, or just plain, regular gum and hard candies are an easy way to give you something to do, to keep your mind occupied. That helps with the behavioral component. And if you were to do the nicotine version, it can help with the physiologic component as well. You just have to make sure that you counsel them appropriately on how often to be using these things. Because I do find people where you'll prescribe a lozenge or you'll prescribe the gum and they will do great and they'll come back and office and say, guess what? I quit smoking. I'm so proud of myself and I go, great. That's wonderful. How much are you using on the nicotine? And they're actually getting more nicotine with the replacement therapy than they were when they actually use cigarettes. And then we can work on tapering off on those things, but also reminding patients up front, what the appropriate dosage and the fact that we're trying to decrease the amount of nicotine that they're taking in, instead of increasing it
  
  Host: Before we wrap up, let's stick on that for just a second here. How can you tell if a patient is no longer addicted to nicotine? How can other providers tell, how can the patient themselves tell?
  
  Dr. Staples: I would say it's not an easy one. Answer fits all. But the biggest thing is that you find that when you go without it, you don't have withdrawal symptoms. You don't have the craving for it. You don't have the insomnia and irritability and anxiety and other symptoms that you noticed previously when you went without nicotine in the past. That's what I counsel patients on. And you can slowly taper off or try to go for a day without nicotine and see where you are, what your symptoms are and how you're doing in the process.
  
  Host: This is really such an informative episode, Dr. Staples, wrap it up for other providers, let them know what you would like them to know on smoking cessation, assisting their patients in quitting, pharmacologic and non-pharmacologic approaches.
  
  Dr. Staples: The biggest thing that I wanted to emphasize today for providers is that you don't have to be family medicine to help with smoking cessation, every single encounter counts. And it's actually been shown that the more that a patient is asked about smoking cessation, the more likely they are to quit. So whether you're a cardiologist or a pulmonologist, or even a dermatologist, just putting in that 30 seconds of, Hey, do you smoke? Have you considered quitting? Are you ready to quit? It doesn't take a long time to ask those questions and even having your office staff ask those questions as well. The front desk on intake, the MAs, when they're rooming, the patient, every little seed planted, moves the patient further along those stages of change. And if you can move them from pre-contemplation into contemplation, that's a success right there. You also don't have to be comfortable with prescribing pharmacological approaches to cessation. You can use some of those other techniques that we talked about, and always you can refer them to 1-800 QUIT NOW, or you can refer them back to their primary care physician or someone else for the pharmacologic side of things, but get involved since this is such an important topic in our patient's lives today.
  
  Host: Certainly is. Thank you so much Dr. Staples for joining us and giving us so much usable information. Thank you again. A community physician can refer a patient to UAB Medicine by calling the MIST Line at 1-800-UAB-MIST. That wraps up this episode of UAB Med Cast. For more information on resources available at UAB Medicine, please visit our website at UABmedicine.org/physician. Please also remember to subscribe, rate, and review this podcast and all the other UAB medicine podcasts. I'm Melanie Cole.
• Hosts:Melanie Cole, MS