You may or may not consider smoking cessation to be part of your job description. But tobacco use disorder is a psychiatric syndrome, per DSM-5. To officially diagnose it, you have to establish a "problematic pattern" of tobacco use leading to "significant distress" which lasts at least 12 months. DSM lists 11 criteria, and the more criteria that apply, the more severe the problem (2 is mild, 4 is moderate, and 6 is severe).

The benefits of quitting in terms of cancer and heart disease risks are well known. But from a psychiatric perspective, nicotine is a stimulant and can worsen anxiety and mood disorders. Since it is an inducer of the 1A2 P450 metabolic enzyme, it can complicate dosing of medications, most notably olanzapine and clozapine. In short, there are good reasons for you to add smoking cessation skills to your therapeutic portfolio. Here's a brief guide to help you do it.

Assessment

The first thing you want to do is to assess what your patients are ingesting, how much, and how addicted they are. Answering these questions will help you come up with the best method of attacking the problem.

1. Determine the daily nicotine load. Ask about packs per day of cigarettes, but make sure to ask about e-cigarettes, chewing tobacco, and hookah pipes, all three of which are increasingly popular options. While we know that the nicotine content of the average cigarette is pretty standard at 1 mg, it's harder to figure out how much your patients are getting through other options. E-cigarettes used to deliver less nicotine than tobacco cigarettes but that's no longer always true. For chewing tobacco, a rule of thumb is that one pouch is the equivalent of about a quarter of a pack of cigarettes. Ask: "How many times do you refill your e-cigarette cartridge?" "How many packets of chewing tobacco do you go through per day?"


2. Determine the usage pattern. You want to get a feel for the degree of tolerance and addiction. When do you have your first cigarette of the day? If they wake up, take a shower, have breakfast, and then light up afterwards, it's less concerning than the patient who shuts off the alarm with one hand and lights up a cigarette with the other. Do you smoke when you're sick? Those who do are more physically dependent. A good resource is the Fagerstrom test, which has a list of questions you can ask to assess your patient's degree of tolerance.


3. Has anything else worked for them in the past—or not worked? You might hear things like, "I tried the patch but it gave me nightmares," or "I did the best when I quit cold turkey." The response will help guide your treatment.

Treatment

Non-pharmacologic treatment

In this article we focus on pharmacologic treatment, but we should say a few words about other approaches. Studies have shown that simply advising your patients to quit along with agreeing on a quit date can be helpful. Even more effective are behavioral therapy and motivational interviewing—but these may not be available to certain patients, depending on where they live and what kind of insurance they have (see TCRBH July/Aug 2012 for more information on motivational interviewing). Fortunately, there are a number of free resources, some of which are paid for by manufacturers of smoking cessations treatments. The best portal is the phone number 1-800-QUIT-NOW, and there are various affiliated websites. Your patients can get diaries and calendars to support their efforts, and they can get a phone call on their quit date. While these programs are designed to be used in conjunction with Nicotine Replacement Therapy (NRT) or other pharmacologic treatment, they are helpful for anyone.

Pharmacologic Treatment

Nicotine Replacement Therapy (NRT). NRT supplies an alternative source of nicotine to help your patients decrease their smoking, and ultimately, to quit entirely. We recommend starting with NRT before moving to bupropion or varenicline, because it's widely available and readily acceptable to most smokers.

Which NRT to choose? There are lots of options, but generally you should start with the patch, because it delivers a constant nicotine level throughout the day, hopefully preventing episodes of craving. (For really light smokers, you can start with nicotine gum, see below). Patches used to be pretty expensive but prices have come down as more chain pharmacies have created their own products. At this point, a month supply will generally cost about $1/per day (cheaper than the smoker’s cigarette habit itself).

Which dose of the patch should you prescribe? That depends on what you found out when you asked about their nicotine consumption. A typical 1 ppd (pack per day) smoker is consuming about 20 mg of nicotine per day, so prescribe the 21 mg patch in that case. A 2 ppd smoker may need 2 patches, but this could be too much for some patients who will simply discontinue if they have adverse effects. It's good to counsel patients that they can reduce the dose if needed.

We tell patients to place the patch at the same time each day, usually in the morning. One potential exception is the smoker who wakes up with a strong craving to smoke. That patient can try applying the patch close to bedtime on the theory that the residual morning nicotine will prevent that craving. A common problem with night-time administration is vivid dreams or nightmares, so warn your patient: You might notice some funky dreams.

In terms of where to place the patch, tell your patient to start by placing it just above the heart, (theupper anterior chest), then the next day move it left to the upper arm, then the left upper back, right upper back, right shoulder, right chest, ending back above the heart. This rotation helps to prevent skin irritation due to the adhesive. If there's some irritation anyway, 0.5% cortisone cream helps. Usually no shaving is required. Swimming with the patch is fine, and patients who think they'll be embarrassed by wearing a patch on the beach can be reassured that patches are clear now and pretty hard to spot.

Have them use the initial dose for 4-6 weeks, then use the next lower strength for 4 weeks, and so on. However, some patients need a longer taper—for example, they may need 3 months on the initial dose, and then a very slow taper thereafter. Advise patients not to smoke while using the patch, but let's face it—some will, so be realistic and tell them that if they do smoke they may well develop nausea, which is the first symptom of nicotine toxicity.

Combination NRT. Some patients find that they have cravings throughout the day even while using the patch—if so, prescribe one of the short-acting agents, such as the gum, lozenge, or spray. In fact, light smokers may do well starting with one of these and skipping the patch entirely.

A word on nicotine gum: patients have to use a different chewing technique than they use for Juicy Fruit. You start by chewing a few times to activate the release of the nicotine, and you know it's releasing because it starts tasting bad and peppery. At that point you park it between the cheek and the gum, and switch sides every several minutes or so. One piece of gum releases a total of either 2 mg or 4 mg of nicotine, and it takes about 30 minutes.

While the gum is the most popular short-acting treatment, some patients will prefer other options. The lozenge is easy. But both the spray and the inhaler are available by prescription only, and the FDA recommends not using these formulations for more than 3 months at a time.


Table: FDA-Approved Treatments for Tobacco Use Disorder
Click to view full-size table as a PDF.

Varenicline (Chantix). Chantix acts as a partial agonist at nicotinic receptors, so its mechanism is physiologically closer to nicotine—which is our rationale for choosing it over other pills, such as bupropion. Some patients will move on to Chantix after an unsuccessful trial of NRT, but others want to start with the pill right away, which is reasonable.

While the manufacturer has a certain dosing recommendation, different clinicians have their own preferences based on experience. We start patients with 0.5 mg per day for 3 days, then 0.5 mg twice daily, and instruct them to plan to stop smoking 7 to 10 days after starting the medication. They then increase the dose to 1 mg twice daily for 3 months. However, a recent study found that patients don’t have to quit that soon after starting Chantix to respond to the drug—these smokers were asked to reduce their smoking gradually over 3 months while taking Chantix, and their long term abstinence rates were robust—27% at one year vs. 9.9% on placebo (Ebbert J et al, JAMA 2015;313:687–695.) This is good news because some patients panic when you tell them they have to try quitting in a week. Chantix’s potential psychiatric side effects have been widely covered but in our opinion are overblown. A recent metaanalysis of 39 randomized controlled trials covering 10,761 patients found that there was no difference between Chantix and placebo in rates of depression, suicidal ideation, or aggression (Thomas KH et al., BMJ 2015; 350:h1109).

However, Chantix did cause more insomnia and abnormal dreams in these studies, which jibes with our experience. Tell patients about the possibility of vivid dreams, and nightmares (though nightmares aren't very common). Make sure they take the pills in the morning if this is a problem.

Bupropion (Wellbutrin SR, Zyban). One large study reported that bupropion SR led to a 23% one year quit rate vs. 12% for placebo (Hurt RD, NEJM 1997;337(17):1195). While the manufacturer recommends starting at 150 mg per day for 3 days then increasing to 150 mg BID, studies have shown that continuing with 150 mg/day is just as effective as the higher dose—with fewer side effects. Most psychiatric prescribers are quite familiar with bupropion's common side effects of insomnia and anxiety. A potentially good side effect is weight loss, since people trying to quit smoking often substitute food for cigarettes, gaining weight in the process. Note that bupropion is contraindicated in patients with a seizure disorder or with a history of either bulimia or anorexia nervosa.

Off-label Meds

Some other meds have varying degrees of efficacy evidence for smoking cessation—while we won't go into any detail, the American Cancer Society lists them online.

It's Hard To Quit

Unfortunately, most patients relapse, even with the fanciest of meds and behavioral therapy; let them know that there's no shame in failing to quit. We say things like, "You may have to try this several times. And that's okay, like Mark Twain said, 'Giving up smoking is the easiest thing in the world, I know because I've done it thousands of times.'"

The first week after quitting is the hardest in terms of craving. A typical smoker gets about 10 puffs out of a cigarette, meaning that a 1 ppd smoker gets 200 doses of nicotine over the course of a day. This means that there is a lot of habituation and reinforcement to overcome. Triggers for craving are everywhere—seeing the ashtray, having coffee, having a drink, going to the corner store, etc…

Distraction techniques can work well, because nicotine cravings generally don't last more than 10 to 20 minutes. Patients can do things like drink a large glass of cold water, play a video game, or other techniques to get their minds off the urge.

We recommend warning patients that they are likely to cough temporarily after they quit—this is a normal response as the cilia of the lungs are "waking up" and getting rid of mucus. If not alerted to this, some patients will worry unnecessarily.

In our experience, even with the high rate of relapse, patients who are willing to stick it out with you over time will have at least a 50% chance of prolonged abstinence.

CATR Verdict: Learn the basics of tobacco cessation, and offer them to your patients. Perseverance pays off.