Where there's smoke, there's likely been an attempt to quit.
Internists have been asking patients about smoking and advising them to quit for decades, but an estimated 47.1 million U.S. adults used any tobacco product in 2020, according to an MMWR report published in March 2022.
During 2015, 68% of adult smokers wanted to stop, while 55% made a quit attempt in the past year and 7% recently quit smoking, according to a study published in January 2017 in MMWR. Slightly more than 57% had been advised to quit by a health professional, yet only 31% used any evidence-based treatment such as cessation counseling and/or medication when trying to quit.
This is an important treatment gap to close in health care, because asking patients about smoking and advising them to quit is not enough to set them up for success, said Nancy A. Rigotti, MD, MACP, a professor of medicine at Harvard Medical School and director of the Tobacco Research and Treatment Center at Massachusetts General Hospital in Boston.
“We're not connecting smokers to treatment resources that can maximize the chance of success at the quit attempt that we've just inspired them to make,” she said. “We need to do a better job of connecting people into treatment—not necessarily delivering it ourselves on a granular level, but rather guiding people to the right resources.”
But clinicians alone aren't responsible for the underutilization of evidence-based pharmacotherapies, noted Michael B. Steinberg, MD, MPH, FACP, a professor of medicine, chief of the division of general internal medicine, and vice-chair for research at Rutgers Robert Wood Johnson Medical School in New Brunswick, N.J.
Many people who use tobacco may see it as just a bad habit and not as something one gets help for, and there's also the pervasive myth that people just need willpower to quit, he noted.
“This thinking ignores the fact that tobacco use is the most addictive, chronic behavior in our society and only with the assistance of evidence-based treatment can we increase abstinence rates from 3% for unaided attempts to as high as 40% to 60% for comprehensive treatment,” said Dr. Steinberg, who is also director of the Rutgers Tobacco Dependence Program.
Internists are well positioned to increase the number of smokers who quit by using evidence-based treatment, experts said, offering tips and resources to help them help patients.
Choosing a cessation treatment
In 2021, the U.S. Preventive Services Task Force (USPSTF) reinforced its 2015 A-grade statement recommending that clinicians ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and FDA-approved pharmacotherapy for cessation to those who use tobacco.
The three types of first-line medications approved by the FDA to help with smoking cessation include bupropion, varenicline, and five nicotine replacement therapy (NRT) products: patch, gum, lozenge, oral inhaler, and nasal spray. The initial treatment duration is typically 12 weeks.
Each of these medications has been proven to be safe and effective in clinical trials spanning nearly four decades, Dr. Steinberg noted, “so there is no longer any doubt that we have evidence-based treatments available.”
Current data suggest that varenicline is the most effective single medication. The Evaluating Adverse Events in a Global Smoking Cessation Study (EAGLES) compared the effectiveness of treatment with the nicotine patch, varenicline, and bupropion. At weeks 9 through 24, abstinence rates were 21.8% (varenicline), 16.2% (bupropion), 15.7% (nicotine patch), and 9.4% (placebo), according to results published in April 2016 by The Lancet.
As for NRT products, not every physician knows it's better to use them in combination rather than individually, said Dr. Rigotti, who was lead author of a clinical review of smoking cessation treatment published in February by JAMA. “The basic approach is to use a patch, which supplies nicotine for a 24-hour period, but there still may be breakthrough cravings during the day, and then the smoker doesn't really have anything to do other than going out and smoking to relieve those cravings,” she said.
In those cases, giving the patient a supply of short-acting NRT (lozenge, gum, or inhaler) can help with breakthrough cravings in the short term, Dr. Rigotti said, adding that patients don't end up overdosing on nicotine. “Smokers know how to control how much nicotine they're taking and don't take more than they need to be comfortable.”
NRT patches, gum, and lozenges are available over the counter, and the other cessation treatments are available by prescription only. When helping patients select a treatment, internists should consider access and cost, as well as patients' preferences and previous experiences, said Dr. Steinberg.
In general, the least costly of the medications is a generic form of an over-the-counter NRT, he said. As for the others, generic forms of bupropion are typically not extremely costly; however, varenicline and prescription NRT can be very expensive for those paying out of pocket, often costing hundreds of dollars for a one-month supply, Dr. Steinberg said.
“Therefore, if someone has access to a prescriber and has health insurance that covers tobacco treatment medications, this is a significant benefit to take advantage of,” he said. “In general, coverage for tobacco medications has greatly improved over the past several years, including states' Medicaid coverage, which reaches an especially vulnerable group of people who, for various reasons, tend to smoke at higher rates.”
In practice, many patients will come in and say they've “tried everything and nothing works,” said Dr. Rigotti, but internists should probe deeper into what they've actually tried. “What you hear is that they've tried a lot of different medicines, often on their own, maybe not used them for very long … but they really haven't tried any behavioral program,” she said. “So the piece that can be helpful is guiding people to that resource.”
There are smoking cessation programs available to all free of charge. “The most well-known are the quit lines. Every state has a quit line funded by their public health department plus the CDC,” Dr. Rigotti said.
The quit lines offer free cessation counseling, and almost all also offer smokers a free sample of over-the-counter NRT, which can sweeten the deal. “My experience is that while patients may not be excited about calling to get behavioral support, they're often excited about the idea of calling to get a medicine for free,” Dr. Rigotti said. “So I often lead with that, and patients can get both.”
She cautioned that handing patients a card with a phone number to call is not likely to lead them to change their behavior, especially if they've smoked for many years. “What we know now is that you really need to make an active referral out of your office,” she said.
Some EHRs at larger organizations allow physicians to make an electronic referral directly to the state quit line, which would then call the patient and offer help and some free NRT, Dr. Rigotti said. If that's not available, she suggested trying to connect the patient to the quit line before they leave the office.
Someone in the office could go online and sign the patient up or have the patient call from the office for their first session of intake, she said. “They can actually get that connection going by acting in the moment and not letting time pass … and then, of course, remember to ask next time if that connection got made.”
Encouragement and e-cigarettes
Smoking cessation is especially critical in patients diagnosed with smoking-related diseases, such as lung cancer, as research shows that it's often not too late for them to experience the benefits of quitting.
Patients who quit smoking after being diagnosed with early-stage non-small-cell lung cancer had a 33% decrease in all-cause mortality and a 28% reduction in disease progression compared with those who continued smoking, according to a Russian prospective study published in July 2021 by Annals of Internal Medicine.
“That's a specific example of a time when it's really important to quit, because the [cancer] treatments that we use work better and have fewer side effects in people who are not smoking. … It's not just living longer, but you actually will have an easier time with treatment,” said Dr. Rigotti, who wrote an editorial accompanying the study.
Evidence shows that one-third of those diagnosed with cancer continue to smoke, leading to higher mortality and morbidity, higher recurrence of the primary cancer, higher rates of secondary malignancy, lower response to all forms of cancer treatment, and higher treatment-related toxicity, added Dr. Steinberg.
“In fact, the magnitude of clinical benefit for a patient with cancer who stops smoking is greater than the benefit of the cancer treatment itself,” he said. “Therefore, there is nothing more important for a patient with cancer to do than to stop smoking as soon as possible.”
Still, some people are just not ready to use FDA-approved medications to quit, Dr. Steinberg said. “In these cases, it is important for them to understand the benefit of combining counseling with medications. But if they are still resistant, one should continue to work with them using tools they are willing to employ.”
Nonpharmacological approaches include individual or group counseling, telephone support, web-based support, text/mobile phone messaging, and smartphone applications. “The NIH website smokefree.gov is an excellent resource,” he said. “Keep in mind, some people are also agreeable to use electronic nicotine delivery systems, such as e-cigarettes, to help them stop smoking tobacco cigarettes.”
While the USPSTF concluded that the current evidence on the use of e-cigarettes for tobacco smoking cessation in adults is insufficient, increasing evidence suggests they may be beneficial.
For instance, a September 2021 Cochrane systematic review of 61 studies (34 of which were randomized controlled trials) totaling 16,759 participants concluded with moderate certainty that e-cigarettes with nicotine increase quit rates compared to NRT or non-nicotine e-cigarettes. The review found no evidence of harm from nicotine e-cigarettes for up to two years of follow-up.
“I think we do have evidence that they can be effective,” said Dr. Rigotti. “But they're not FDA approved as smoking cessation aids, and therefore I still would recommend using FDA-approved medications first.”
That being said, if a patient is not otherwise able to quit smoking using other methods, there is strong evidence that making the switch to e-cigarettes reduces the harms of tobacco smoking compared to continuing to smoke, she said. A 2016 report from the Royal College of Physicians noted that the health hazard of long-term vapor inhalation was unlikely to exceed 5% of that from smoking tobacco.
“I would recommend using it to somebody who's really tried [to quit], or sometimes people just are not willing to do anything else,” said Dr. Rigotti.
Dr. Steinberg agreed. “Although evidence-based therapies should be the first line of recommendations, for those unwilling to use those treatments, e-cigarettes could present a less harmful alternative to combusted tobacco,” he said.