SUBSTANCE USE

Smoking Cessation Guideline

Prevalence and Impact

Substance Use Guidelines Committee, February 2008

RECOMMENDATION
  • Clinicians should use evidence-based interventions to promote smoking cessation in HIV-infected patients.

Smoking prevalence among both HIV-infected persons and substance users is much higher than in the general population; more than 50% of HIV-infected patients and more than 75% of substance users are estimated to be current smokers [1-3]. Smoking-related diseases are the leading cause of death in patients previously treated for alcoholism or other non-nicotine drug dependence [4] and also pose unique health risks to HIV-infected patients. These include increased risks of HIV-associated pulmonary infections and oropharyngeal lesions [5-6] and higher incidences of AIDS-defining and non-AIDS-defining malignancies [7]. Smoking is also an established risk factor for atherosclerosis and has been associated with coronary events in patients receiving PI therapy [8].

KEY POINT
Cigarette smoking is highly prevalent among both HIV-infected patients and substance users.

The high prevalence of smoking among HIV-infected substance users and the particular health risks it poses to HIV-infected persons make interventions to promote smoking cessation imperative in this population. Previous studies of smokers seeking treatment for drug or alcohol dependence have found that many are interested in quitting smoking and believe that doing so will not have a negative impact on their sobriety [9-13]. For HIV-infected substance users, quitting smoking could decrease the risk of HIV-associated infections and malignancies and reduce the incidence of ARV-associated complications. Quitting smoking at any age is associated with improvements in health.

Screening for nicotine addiction is an important part of HIV primary care. The Fagerstrom Test for Nicotine Dependence has been used to assess nicotine addiction and may help guide the patient toward smoking cessation. Heavy smoking often accompanies other drug or alcohol dependence and should prompt the clinician to screen for other addictions.

Smoking cessation interventions delivered during routine visits will reach many smokers who are already receiving care for their HIV infection.

References:
  1. Burns DN, Hillman D, Neaton JD, et al. Cigarette smoking, bacterial pneumonia, and other clinical outcomes in HIV-1 infection. Terry Beirn Community Programs for Clinical Research on AIDS. J Acquir Immune Defic Syndr Hum Retrovirol 1996;13:374-383. [Abstract]
  2. Niaura R, Shadel WG, Morrow K, et al. Human immunodeficiency virus infection, AIDS, and smoking cessation: The time is now. Clin Infect Dis2000;31:808-812. [Abstract]
  3. Hughes JR. Treatment of smoking cessation in smokers with past alcohol/drug problems. J Subst Abuse Treat 1993;10:181-187. [Abstract]
  4. Hurt RD, Offord KP, Croghan IT, et al. Mortality following inpatient addictions treatment: Role of tobacco use in a community-based cohort. JAMA1996;275:1097-1103. [Abstract]
  5. Miguez-Burbano MJ, Burbano X, Ashkin D, et al. Impact of tobacco use on the development of opportunistic respiratory infections in HIV seropositive patients on antiretroviral therapy. Addict Biol 2003;8:39-43. [Abstract]
  6. Shiboski CH, Neuhaus JM, Greenspan D, et al. Effect of receptive oral sex and smoking on the incidence of hairy leukoplakia in HIV-positive gay men. J Acquir Immune Defic Syndr 1999;21:236-242. [Abstract]
  7. Castle PE, Wacholder S, Lorincz AT, et al. A prospective study of high-grade cervical neoplasia risk among human papillomavirus-infected women.J Natl Cancer Inst 2002; 94:406-1414. [Abstract]
  8. Duong M, Buisson M, Cottin Y, et al. Coronary heart disease associated with the use of human immunodeficiency virus (HIV)-1 protease inhibitors: Report of four cases and review. Clin Cardiol 2001;24:690-694. [Abstract]
  9. Lemon SC, Friedmann PD, Stein MD. The impact of smoking cessation on drug abuse treatment outcome. Addict Behav 2003;28:1323-1331. [Abstract]
  10. McClure JB, Wetter DW, de Moor C, et al. The relation between alcohol consumption and smoking abstinence: Results from the Working Well Trial. Addict Behav 2002;27:367-379. [Abstract]
  11. Humfleet G, Munoz R, Sees K, et al. History of alcohol or drug problems, current use of alcohol or marijuana, and success in quitting smoking.Addict Behav 1999;24:149-154. [Abstract]
  12. Frosch DL, Shoptaw S, Jarvik ME, et al. Interest in smoking cessation among methadone maintained outpatients. J Addict Dis 1998;17:9-19. [Abstract]
  13. Campbell BK, Wander N, Stark MJ, et al. Treating cigarette smoking in drug-abusing clients. J Subst Abuse Treat 1995;12:89-94. [Abstract]

Assessment for Readiness to Quit

RECOMMENDATIONS
  • Clinicians should routinely assess HIV-infected patients’ smoking status and readiness to quit.
  • Clinicians should identify and discuss barriers to quitting smoking for HIV-infected smokers who are not interested in stopping in the immediate future, but may consider it at a later time.

Readiness to quit may be assessed by asking whether the patient is interested in quitting smoking within the next month. Clinicians should offer smoking cessation assistance, including pharmacotherapy, to patients who are ready to quit [1]. For HIV-infected smokers who are not interested in quitting within the next month, clinicians should determine their stage of readiness to change their smoking behavior. For those contemplating change (meaning they are interested in quitting but not in the next month), barriers to quitting should be identified and addressed. These barriers may include nicotine dependence, lack of social support, or depression.

Substance users in recovery may also have concerns about relapse to other substance abuse if they quit smoking. For pre-contemplative smokers (those who are not at all interested in quitting), motivational interviewing techniques should be used to identify ambivalence, elicit pros and cons of smoking cessation, correct misconceptions, and probe resistance to behavior change.

Reference:
  1. A clinical practice guideline for treating tobacco use and dependence: A US Public Health Service report. The Tobacco Use and Dependence Clinical Practice Guideline Panel, Staff, and Consortium Representatives. JAMA 2000;283:3244-3254. [Abstract]

Smoking Cessation Assistance

RECOMMENDATIONS
  • Clinicians should advise all smokers to quit.
  • For smokers who are interested in quitting, clinicians should:
    • Offer smoking cessation assistance including pharmacotherapy
    • Help set a quit date
    • Refer to a counseling program
    • Educate patients about symptoms of nicotine withdrawal

Assistance with smoking cessation is a cost-effective intervention that is underused by primary care clinicians and inadequately covered by health insurers [1]. For HIV-infected substance users to benefit from recent advances in understanding and promoting smoking cessation, routine medical practice should include effective treatment for tobacco dependence.

Smoking cessation interventions of demonstrated efficacy are now available and easily implemented in healthcare settings [2]. Although these interventions have not been specifically tested in HIV-infected substance users, there is strong agreement about what constitutes effective treatment of tobacco use and dependence.

Patients who are interested in quitting within the next month should be helped to set a quit date, offered pharmacotherapy with nicotine replacement, bupropion, or varenicline [3,4], and referred to a counseling program. Because current guidelines regard nicotine replacement and bupropion as roughly equivalent and experience with varenicline is currently limited, the choice of pharmacotherapy should be based on the patient’s preferences and any prior experience. See Drugs Used for Smoking Cessation for dosing, side effects, and advantages and disadvantages of each. Symptoms of nicotine withdrawal (tension, agitation, depression, disturbed sleep) and side effects of nicotine replacement therapy, bupropion, or varenicline should be explained to patients. If the smoker has severe withdrawal symptoms, cravings, or difficulty maintaining abstinence, a general approach is to start with one agent and add a second. Adding pharmacotherapy to in-person or telephone behavioral counseling markedly increases the cessation rate, but counseling is also effective by itself [5].

See the following resources for smoking cessation products and programs:

References:
  1. Cromwell J, Bartosch WJ, Fiore MC, et al. Cost-effectiveness of the clinical practice recommendations in the AHCPR guideline for smoking cessation. Agency for Health Care Policy and Research. JAMA 1997;278:1759-1766. [Abstract]
  2. Rigotti NA. Clinical practice. Treatment of tobacco use and dependence. N Engl J Med 2002;346:506-512. [Abstract]
  3. Gonzales D, Rennard SI, Nides M, et al. Varenicline Phase 3 Study Group. Varenicline, an α4ß2 nicotinic acetylcholine receptor partial agonist, vs sustained-release bupropion and placebo for smoking cessation: A randomized controlled trial. JAMA 2006;296:47-55. [Abstract]
  4. Jorenby DE, Hays JT, Rigotti NA, et al.; Varenicline Phase 3 Study Group. Efficacy of varenicline, an α4ß2 nicotinic acetylcholine receptor partial agonist, vs placebo or sustained-release bupropion for smoking cessation: A randomized controlled trial. (Published Erratum in: JAMA 2006;296:1355). JAMA 2006;296:56-63. [Abstract]
  5. Hughes JR, Goldstein MG, Hurt RD, et al. Recent advances in the pharmacotherapy of smoking. JAMA 1999;281:72-76. [Abstract]

Relapse and Relapse Prevention

RECOMMENDATIONS
  • Clinicians should monitor the progress of patients who are trying to quit, and view relapses not as failures but as opportunities to learn from what happened and to change tactics.
  • If patients relapse, clinicians should be nonjudgmental. Relapses should be followed up with discussions of new strategies for the next attempt to quit.

Relapses should not be viewed as failures but rather as opportunities to learn from what happened and to change tactics.

Appendix: Drugs Used for Smoking Cessation

July 2009

Drugs Used for Smoking Cessation*
Product Daily Dose & Duration of TX Common Side Effects Advantages & Disadvantages Comments
Transdermal patch: 24 hr (e.g., Nicoderm CQ); 16 hr (e.g., Nicotrol)
  • 7-, 14-, or 21-mg patch worn for 24 hr
  • 15-mg patch worn for 16 hr
  • Duration: 8 weeks
  • Skin irritation
  • Insomnia
  • Steady level of nicotine
  • Easy to use
  • Unobtrusive
  • Available without prescription
  • Dose cannot be adjusted to satisfy craving
  • Nicotine released more slowly than in other products
  • Nicotine replacement therapy: 
  • FDA-approved as smoking-cessation aids and recommended by APHA as first-line drugs for smoking cessation.
  • The starting dose is 21 mg/d unless the smoker weighs less than 45.5 kg (100 lb) or smokes fewer than 10 cigarettes per day, in which case the starting dose is 14 mg/d. The starting dose should be maintained for 4 weeks, after which the dose should be decreased every week until it is stopped.
Nicotine polacrilex gum (Nicorette): 2 mg (<25 cigarettes/d); 4 mg (>25 cigarettes/d)
  • 1 piece/h (<24 pieces/d)
  • Duration: 8-12 weeks
  • Mouth irritation
  • Sore jaw
  • Dyspepsia
  • Hiccups
  • User controls dose
  • Oral substitute for cigarettes
  • Available without prescription
  • Proper chewing technique needed to avoid side effects and achieve efficacy
  • User cannot eat or drink while chewing the gum
  • Can damage dental work
  • Difficult for denture wearers to use
  • Low potential for interactions with PIs and NNRTIs
  • The user should chew the gum slowly until he or she experiences a distinct taste, indicating that nicotine is being released. The user should then place the gum between cheek and gum until the taste disappears to allow the nicotine to be absorbed through oral mucosa. The sequence should be repeated for 30 minutes before the gum is discarded. Acidic beverages (such as coffee and soft drinks) reduce the absorption of nicotine and should be avoided for 30 minutes before and during chewing.
Nicotine polacrilex lozenge: 2 mg (<25 cigarettes/d); 4 mg (>25 cigarettes/d)
  • 1 lozenge q1-2h for 6 wk, then q2-4h for 3 wk, then q4-8h for 3 wk, then PRN for 3 mo
  • Duration: 3-6 months
  • Headache
  • Heartburn
  • Hiccups
  • Nausea
  • Cough
  • User controls dose
  • Offers rapid delivery of high levels of nicotine
  • Side effects
  • Low potential for interactions with PIs and NNRTIs
Vapor inhaler (Nicotrol Inhaler)
  • 6-16 cartridges/d (delivered dose, 4 mg/ cartridge)
  • Duration: 3-6 months
  • Mouth and throat irritation
  • Cough
  • User controls dose
  • hand-to-mouth substitute for cigarettes
  • Frequent puffing needed
  • Device visible when used
  • Low potential for interactions with PIs and NNRTIs
Nasal spray (Nicotrol NS)
  • 1-2 doses/h (1 mg total; 0.5 mg in each nostril; max: 40 mg/d)
  • Duration: 3-6 months
  • Nasal irritation
  • Sneezing
  • Coughing
  • Teary eyes
  • User controls dose
  • Offers most rapid delivery of nicotine and the highest nicotine levels of all nicotine- replacement products
  • Most irritating nicotine replacement product to use
  • Device visible when used
  • Low potential for interactions with PIs and NNRTIs
  • Tolerance to local side effects develops during the first week of use.
Sustained-release bupropion (Zyban or Wellbutrin SR)
  • 150 mg/d for 3 days, then 150 mg bid
  • Duration: 7-12 wk up to 6 mo to maintain abstinence
  • Insomnia
  • Dry mouth
  • Agitation
  • Easy to use (pill)
  • No exposure to nicotine
  • Increases risk of seizure (<0.1%).
  • Treatment should be started 1 week before the quitting date.
  • Efavirenz may decrease bupropion serum concentrations. Titrate to effect.
  • Risk of serious neuropsychiatric symptoms, including changes in behavior, hostility, agitation, depressed mood, suicidal thoughts, and attempted suicide.
  • Patients should be counseled to stop taking bupropion and immediately contact their clinician if they experience any of these symptoms.
Varenicline HCl (Chantix)
  • 0.5 mg/d for 3 days, then 0.5 mg bid for 3 days, then 1 mg/d for 3 wk, then 1 mg bid
  • Duration: 12 weeks
  • Nausea
  • Insomnia
  • Abnormal dreams
  • Headache
  • Easy to use (pill), no exposure to nicotine
  • Blocks nicotine and therefore pleasure of smoking.
  • Treatment should be started 1 week before the quitting date.
  • Drug interaction unlikely.
  • Risk of serious neuropsychiatric symptoms, including changes in behavior, hostility, agitation, depressed mood, suicidal thoughts, and attempted suicide.
  • Patients should be counseled to stop taking varenicline and immediately contact their clinician if they experience any of these symptoms.
Nortriptyline
  • 75-100 mg/d
  • Duration: 12 weeks
  • Dry mouth
  • Sedation
  • Dizziness
  • Easy to use (pill)
  • No exposure to nicotine.
  • Side effects are common
  • Not FDA-approved as a smoking-cessation aid.
  • APHA recommends it as a second-line drug for smoking cessation.
  • Treatment should be started 10 to 28 days before the quitting date at a dose of 25 mg/d, and the dose should be increased as tolerated.
  • Serum concentrations may be increased with PI co-administration.
  • Use cautiously in patients with coronary heart disease
Clonidine
  • 0.1-0.3 mg bid
  • Duration: 3-10 weeks
  • Dry mouth
  • Sedation
  • Dizziness
  • No exposure to nicotine
  • Side effects limit use
  • Not FDA-approved as a smoking-cessation aid.
  • APHA recommends it as a second-line drug for smoking cessation.

*Notes:

 

All Recommendations

Substance Use Guidelines Committee, February 2008

ALL RECOMMENDATIONS: SMOKING CESSATION
Prevalence and Impact
  • Clinicians should use evidence-based interventions to promote smoking cessation in HIV-infected patients.
Assessment for Readiness to Quit
  • Clinicians should routinely assess HIV-infected patients’ smoking status and readiness to quit.
  • Clinicians should identify and discuss barriers to quitting smoking for HIV-infected smokers who are not interested in stopping in the immediate future, but may consider it at a later time.
Smoking Cessation Assistance
  • Clinicians should advise all smokers to quit.
  • For smokers who are interested in quitting, clinicians should:
    • Offer smoking cessation assistance including pharmacotherapy
    • Help set a quit date
    • Refer to a counseling program
    • Educate patients about symptoms of nicotine withdrawal
Relapse and Relapse Prevention
  • Clinicians should monitor the progress of patients who are trying to quit, and view relapses not as failures but as opportunities to learn from what happened and to change tactics.
  • If patients relapse, clinicians should be nonjudgmental. Relapses should be followed up with discussions of new strategies for the next attempt to quit.