Tobacco cessation

Educate the patient on lifestyle modifications such as salt restriction (maximum 2 to 4 grams per day), fluid restriction if appropriate, limitation of alcohol, tobacco cessation, participation in a cardiac rehabilitation and exercise program, and proper immunizations such as the pneumococcal vaccine and yearly influenza vaccine. 

Cardiovascular Keep doses of NSAIDs and glucocorticoids low, consider initiation of folic acid to reduce homocysteine level elevations induced by methotrexate, consider initiation of low-dose aspirin and/or HMG-CoA reductase inhibitors (statins), and encourage smokers to discontinue tobacco use and assist with the development of a tobacco-cessation plan.11,12... 

Every patient who uses tobacco should be offered at least brief treatment. All patients attempting tobacco cessation should be offered practical counseling (problem-solving/skills training), social support, stress management, and relapse prevention. 

Knowledge of the seriousness of adverse health effects due to tobacco use is helpful in motivating a user to quit, as well as maintaining abstinence. Physicians who advise their patients to quit smoking can produce cessation rates of 5-10%. Thus, education plays a critical role in tobacco cessation for all ages. A variety of self-help materials (books, tapes, pamphlets, newsletters, software, and Internet sites) are available to inform and aid in quitting tobacco use. 

The clinical manifestations of PAD are associated with reduction in functional capacity and quality of life, but because of the systemic nature of the atherosclerotic process there is a strong association with coronary and carotid artery disease. Consequently, patients with PAD have an increased risk of cardiovascular and cerebrovascular ischemic events [myocardial infarction (Ml), ischemic stroke, and death] compared to the general population (4,5). In addition, these cardiovascular ischemic events are more frequent than ischemic limb events in any lower extremity PAD cohort, whether individuals present without symptoms or with atypical leg pain, classic claudication, or critical limb ischemia (6). Therefore, aggressive treatment of known risk factors for progression of atherosclerosis is warranted. In addition to tobacco cessation, encouragement of daily exercise and use of a low cholesterol, low salt diet, PAD patients should be offered therapies to reduce lipid levels, control blood pressure, control blood glucose in patients with diabetes mellitus, and offer other effective antiatherosclerotic strategies. A recent position paper... 

All clinicians should take an active role in assisting patients with tobacco dependence in order to reduce the burden on the individual, his or her family, and the health care system. It is estimated that over 75% of smokers want to quit and that one-third have made a serious effort. Yet complete and permanent tobacco cessation is difficult. Counseling that is provided by clinicians is associated with greater success rates than self-initiated efforts. ... 

Three types of counseling and behavioral therapies were found to be especially effective and should be used with all patients who are attempting tobacco cessation ... 

Glover ED, Glover PN, Sullivan CR, et al. A comparison of sustained-release bupropion and placebo for smokeless tobacco cessation. Am J Health Behav 2002 26 386-393. 

Battaglia, C. et al.. Building a tobacco cessation telehealth care management program for veterans with posttraumatic stress disorder, Am Psychiatr Nurses Assoc Mar-Apr 19(2) 78-91,2013. 

Bars MP, Banauch GI, Appel DW, et al. TobaccoFree with FDNY -The New York City Fire Department World Trade Center tobacco cessation study. Chest 2006 129 979-987. 

Although their results were encouraging, these studies demonstrated how difficult it is to treat cannabis dependence. Experience with treating tobacco dependence has revealed that a combination of various psychotherapeutic techniques and pharmacotherapies is more effective than either approach alone in producing and maintaining cessation. Thus, the use of medication during the cessation period may significantly improve quit rates and maintenance of abstinence. 

Nicotine nasal spray delivers nicotine through the nasal mucosa. One advantage of nicotine nasal spray is that it relieves tobacco cravings quickly. One study found that nicotine nasal spray was 2.6 times more likely to produce smoking cessation, compared with placebo, at 1 year (Sutherland et al. 1992). The active spray was also the most beneficial among highly dependent smokers (Sutherland et al. 1992). 

General precautions for each medication that has been used for smoking cessation are listed in the sections describing each medication. All FDA-approved first-line medications for smoking cessation have a relatively good safety profile. Consensus opinions on the safety of the various medications for persons with cardiovascular disease, other medical conditions, and pregnancy are beyond the scope of this chapter but can be found elsewhere (Society for Research on Nicotine and Tobacco 2003). 

Counsel all women of childbearing potential regarding lifestyle modifications that may improve pregnancy outcome. These include healthy eating habits, multivitamin use, cessation of tobacco use, cessation of illicit substance use, and moderation of alcohol intake.15... 

Table 5.1. Adverse medical effects of tobacco smoking, and health benefits of smoking cessation.

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