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How much does smoking cessation cut CHD risk?
Significantly. Patients with coronary heart disease (CHD) who refrain from smoking over a 2-year follow-up period decrease their relative risk (RR) for morbidity and mortality by about one third (strength of recommendation [SOR]: A, meta-analysis of 20 cohort studies). People who maintain abstinence after coronary artery bypass surgery are more likely to avoid angina, repeat revascularization, significant physical impairment, and CHD-related hospital admissions than patients who continue to smoke (SOR: A, 4 cohort studies with 1- to 20-year follow-up).
Evidence summary
The influence of cigarette smoking on the development of CHD has been well documented.1,2 RR ranges from 1.5 to 3, depending on variables such as age, sex, and quantity of tobacco used.3 Quitting smoking reduces overall mortality more than other forms of secondary prevention, including aspirin, β-blockers, angiotensin-converting enzyme inhibitors, and cholesterol-lowering statins.3 In the wake of such evidence-based findings, the American Heart Association and American College of Cardiology Task Force developed clinical practice guidelines that recommend complete smoking cessation for secondary prevention of CHD in cardiac patients.4
0 cigarettes=lower mortality and morbidity
A Cochrane Heart Group meta-analysis examining all-cause CHD mortality in 20 cohort studies (n=12,603 patients), found a 36% reduction in mortality risk for CHD patients who quit smoking compared with those who didn’t (RR=0.64; 95% confidence interval [CI], 0.58-0.71).3 The review also noted a reduction in risk for nonfatal myocardial infarctions (RR=0.68; 95% CI, 0.57-0.82).3 The authors didn’t report how soon after smoking cessation mortality risk declined.
The authors acknowledge several limitations of the review, including the use of observational data and crude estimates, as well as potential publication bias and the misclassification of smoking status. Notably, however, their findings are consistent with the landmark prospective, community-based cohort Framingham Heart Study (N=1422), which indicates that smoking status predicts overall and morbidity-free survival at age 85.5
Smoking cessation has also been found to significantly affect morbidity among cardiac patients. Short-term benefits have been demonstrated in CHD patients after a myocardial infarction or coronary artery revascularization.6 Smoking status at 1-year follow-up was associated with a significant reduction in subsequent cardiac events (myocardial infarction, ischemic cerebrovascular event, revascularization, or death from CHD) when smokers who quit after an initial CHD event were compared with continuing smokers (odds ratio=0.71; 95% CI, 0.38-1.33).6
Going the distance is worth it
Regarding the role of extended abstinence on subsequent cardiac events, long-term quit status in post-coronary artery bypass graft (CABG) surgery patients has been found to predict decreased morbidity and lower rates of repeat revascularization surgery. Findings from the Coronary Artery Surgery Study show that, at 10-year follow-up, nonsmokers were more likely to be free of angina (54% of nonsmokers vs 42% of smokers; P=.02, NNT=8.3) and less likely to experience moderate to severe physical limitations (13% of non-smokers vs 24% of smokers; P=.0004; NNT=9.1). Nonsmokers also had fewer CHD-related admissions than smokers (2.6 vs 3.8; P<.0001).7
Another study found similar results at 20-year follow-up: Patients who had quit smoking underwent fewer repeat CABGs than smokers (RR=1.41; 95% CI, 1.02-1.94).8 The difference between post-CABG survival curves for quitters versus smokers increased from 3% at 5 years (98% vs 95%) to 15% at 15 years (70% vs 55%; P<.0001; NNT=6.7).8
Recommendations
The US Department of Health and Human Services recommends smoking cessation as an integral part of both primary and secondary prevention of CHD. Quitting reduces development of atherosclerosis and lowers the incidence of initial and recurrent myocardial infarction, thrombosis, cardiac arrhythmia, and death from cardiovascular causes.2
1. US Department of Health and Human Services. The Health Consequences of Smoking: What It Means to You. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2004. Available at: www.cdc.gov/tobacco/data_statistics/sgr/sgr_2004/00_pdfs/SGR2004_Whatitmeanstoyou.pdf. Accessed September 9, 2008.
2. US Department of Health and Human Services. The Health Benefits of Smoking Cessation: A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. DHHS Publication No. (CDC) 90-8416;1990.
3. Critchley J, Capewell S. Smoking cessation for the secondary prevention of coronary heart disease. Cochrane Database Syst Rev. 2004;(1):CD003041.-
4. AHA ACC National Heart Lung and Blood Institute, et al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update endorsed by the National Heart, Lung, and Blood Institute. J Am Coll Cardiol. 2006;47:2130-2139.
5. Terry DF, Pencina MJ, Vasan RS, et al. Cardiovascular risk factors predictive for survival and morbidity-free survival in the oldest-old Framingham Heart Study participants. J Am Geriatr Soc. 2005;11:1944-1950.
6. Twardella D, Küpper-Nybelen J, Rothenbacher D, et al. Short-term benefit of smoking cessation in patients with coronary heart disease: estimates based on self-reported smoking data and serum cotinine measurements. Eur Heart J. 2004;25:2101-2108.
7. Cavender J, Rogers W, Fisher L, et al. for the CASS Investigators. Effects of smoking on survival and morbidity in patients randomized to medical or surgical therapy in the Coronary Artery Surgery Study (CASS): 10-year follow-up. J Am Coll Cardiol. 1992;20:287-294.
8. Van Domburg RT, Meeter K, van Berkel DF, et al. Smoking cessation reduces mortality after coronary artery bypass surgery: a 20-year follow-up study. J Am Coll Cardiol. 2000;36:878-883.
Significantly. Patients with coronary heart disease (CHD) who refrain from smoking over a 2-year follow-up period decrease their relative risk (RR) for morbidity and mortality by about one third (strength of recommendation [SOR]: A, meta-analysis of 20 cohort studies). People who maintain abstinence after coronary artery bypass surgery are more likely to avoid angina, repeat revascularization, significant physical impairment, and CHD-related hospital admissions than patients who continue to smoke (SOR: A, 4 cohort studies with 1- to 20-year follow-up).
Evidence summary
The influence of cigarette smoking on the development of CHD has been well documented.1,2 RR ranges from 1.5 to 3, depending on variables such as age, sex, and quantity of tobacco used.3 Quitting smoking reduces overall mortality more than other forms of secondary prevention, including aspirin, β-blockers, angiotensin-converting enzyme inhibitors, and cholesterol-lowering statins.3 In the wake of such evidence-based findings, the American Heart Association and American College of Cardiology Task Force developed clinical practice guidelines that recommend complete smoking cessation for secondary prevention of CHD in cardiac patients.4
0 cigarettes=lower mortality and morbidity
A Cochrane Heart Group meta-analysis examining all-cause CHD mortality in 20 cohort studies (n=12,603 patients), found a 36% reduction in mortality risk for CHD patients who quit smoking compared with those who didn’t (RR=0.64; 95% confidence interval [CI], 0.58-0.71).3 The review also noted a reduction in risk for nonfatal myocardial infarctions (RR=0.68; 95% CI, 0.57-0.82).3 The authors didn’t report how soon after smoking cessation mortality risk declined.
The authors acknowledge several limitations of the review, including the use of observational data and crude estimates, as well as potential publication bias and the misclassification of smoking status. Notably, however, their findings are consistent with the landmark prospective, community-based cohort Framingham Heart Study (N=1422), which indicates that smoking status predicts overall and morbidity-free survival at age 85.5
Smoking cessation has also been found to significantly affect morbidity among cardiac patients. Short-term benefits have been demonstrated in CHD patients after a myocardial infarction or coronary artery revascularization.6 Smoking status at 1-year follow-up was associated with a significant reduction in subsequent cardiac events (myocardial infarction, ischemic cerebrovascular event, revascularization, or death from CHD) when smokers who quit after an initial CHD event were compared with continuing smokers (odds ratio=0.71; 95% CI, 0.38-1.33).6
Going the distance is worth it
Regarding the role of extended abstinence on subsequent cardiac events, long-term quit status in post-coronary artery bypass graft (CABG) surgery patients has been found to predict decreased morbidity and lower rates of repeat revascularization surgery. Findings from the Coronary Artery Surgery Study show that, at 10-year follow-up, nonsmokers were more likely to be free of angina (54% of nonsmokers vs 42% of smokers; P=.02, NNT=8.3) and less likely to experience moderate to severe physical limitations (13% of non-smokers vs 24% of smokers; P=.0004; NNT=9.1). Nonsmokers also had fewer CHD-related admissions than smokers (2.6 vs 3.8; P<.0001).7
Another study found similar results at 20-year follow-up: Patients who had quit smoking underwent fewer repeat CABGs than smokers (RR=1.41; 95% CI, 1.02-1.94).8 The difference between post-CABG survival curves for quitters versus smokers increased from 3% at 5 years (98% vs 95%) to 15% at 15 years (70% vs 55%; P<.0001; NNT=6.7).8
Recommendations
The US Department of Health and Human Services recommends smoking cessation as an integral part of both primary and secondary prevention of CHD. Quitting reduces development of atherosclerosis and lowers the incidence of initial and recurrent myocardial infarction, thrombosis, cardiac arrhythmia, and death from cardiovascular causes.2
Significantly. Patients with coronary heart disease (CHD) who refrain from smoking over a 2-year follow-up period decrease their relative risk (RR) for morbidity and mortality by about one third (strength of recommendation [SOR]: A, meta-analysis of 20 cohort studies). People who maintain abstinence after coronary artery bypass surgery are more likely to avoid angina, repeat revascularization, significant physical impairment, and CHD-related hospital admissions than patients who continue to smoke (SOR: A, 4 cohort studies with 1- to 20-year follow-up).
Evidence summary
The influence of cigarette smoking on the development of CHD has been well documented.1,2 RR ranges from 1.5 to 3, depending on variables such as age, sex, and quantity of tobacco used.3 Quitting smoking reduces overall mortality more than other forms of secondary prevention, including aspirin, β-blockers, angiotensin-converting enzyme inhibitors, and cholesterol-lowering statins.3 In the wake of such evidence-based findings, the American Heart Association and American College of Cardiology Task Force developed clinical practice guidelines that recommend complete smoking cessation for secondary prevention of CHD in cardiac patients.4
0 cigarettes=lower mortality and morbidity
A Cochrane Heart Group meta-analysis examining all-cause CHD mortality in 20 cohort studies (n=12,603 patients), found a 36% reduction in mortality risk for CHD patients who quit smoking compared with those who didn’t (RR=0.64; 95% confidence interval [CI], 0.58-0.71).3 The review also noted a reduction in risk for nonfatal myocardial infarctions (RR=0.68; 95% CI, 0.57-0.82).3 The authors didn’t report how soon after smoking cessation mortality risk declined.
The authors acknowledge several limitations of the review, including the use of observational data and crude estimates, as well as potential publication bias and the misclassification of smoking status. Notably, however, their findings are consistent with the landmark prospective, community-based cohort Framingham Heart Study (N=1422), which indicates that smoking status predicts overall and morbidity-free survival at age 85.5
Smoking cessation has also been found to significantly affect morbidity among cardiac patients. Short-term benefits have been demonstrated in CHD patients after a myocardial infarction or coronary artery revascularization.6 Smoking status at 1-year follow-up was associated with a significant reduction in subsequent cardiac events (myocardial infarction, ischemic cerebrovascular event, revascularization, or death from CHD) when smokers who quit after an initial CHD event were compared with continuing smokers (odds ratio=0.71; 95% CI, 0.38-1.33).6
Going the distance is worth it
Regarding the role of extended abstinence on subsequent cardiac events, long-term quit status in post-coronary artery bypass graft (CABG) surgery patients has been found to predict decreased morbidity and lower rates of repeat revascularization surgery. Findings from the Coronary Artery Surgery Study show that, at 10-year follow-up, nonsmokers were more likely to be free of angina (54% of nonsmokers vs 42% of smokers; P=.02, NNT=8.3) and less likely to experience moderate to severe physical limitations (13% of non-smokers vs 24% of smokers; P=.0004; NNT=9.1). Nonsmokers also had fewer CHD-related admissions than smokers (2.6 vs 3.8; P<.0001).7
Another study found similar results at 20-year follow-up: Patients who had quit smoking underwent fewer repeat CABGs than smokers (RR=1.41; 95% CI, 1.02-1.94).8 The difference between post-CABG survival curves for quitters versus smokers increased from 3% at 5 years (98% vs 95%) to 15% at 15 years (70% vs 55%; P<.0001; NNT=6.7).8
Recommendations
The US Department of Health and Human Services recommends smoking cessation as an integral part of both primary and secondary prevention of CHD. Quitting reduces development of atherosclerosis and lowers the incidence of initial and recurrent myocardial infarction, thrombosis, cardiac arrhythmia, and death from cardiovascular causes.2
1. US Department of Health and Human Services. The Health Consequences of Smoking: What It Means to You. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2004. Available at: www.cdc.gov/tobacco/data_statistics/sgr/sgr_2004/00_pdfs/SGR2004_Whatitmeanstoyou.pdf. Accessed September 9, 2008.
2. US Department of Health and Human Services. The Health Benefits of Smoking Cessation: A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. DHHS Publication No. (CDC) 90-8416;1990.
3. Critchley J, Capewell S. Smoking cessation for the secondary prevention of coronary heart disease. Cochrane Database Syst Rev. 2004;(1):CD003041.-
4. AHA ACC National Heart Lung and Blood Institute, et al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update endorsed by the National Heart, Lung, and Blood Institute. J Am Coll Cardiol. 2006;47:2130-2139.
5. Terry DF, Pencina MJ, Vasan RS, et al. Cardiovascular risk factors predictive for survival and morbidity-free survival in the oldest-old Framingham Heart Study participants. J Am Geriatr Soc. 2005;11:1944-1950.
6. Twardella D, Küpper-Nybelen J, Rothenbacher D, et al. Short-term benefit of smoking cessation in patients with coronary heart disease: estimates based on self-reported smoking data and serum cotinine measurements. Eur Heart J. 2004;25:2101-2108.
7. Cavender J, Rogers W, Fisher L, et al. for the CASS Investigators. Effects of smoking on survival and morbidity in patients randomized to medical or surgical therapy in the Coronary Artery Surgery Study (CASS): 10-year follow-up. J Am Coll Cardiol. 1992;20:287-294.
8. Van Domburg RT, Meeter K, van Berkel DF, et al. Smoking cessation reduces mortality after coronary artery bypass surgery: a 20-year follow-up study. J Am Coll Cardiol. 2000;36:878-883.
1. US Department of Health and Human Services. The Health Consequences of Smoking: What It Means to You. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2004. Available at: www.cdc.gov/tobacco/data_statistics/sgr/sgr_2004/00_pdfs/SGR2004_Whatitmeanstoyou.pdf. Accessed September 9, 2008.
2. US Department of Health and Human Services. The Health Benefits of Smoking Cessation: A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. DHHS Publication No. (CDC) 90-8416;1990.
3. Critchley J, Capewell S. Smoking cessation for the secondary prevention of coronary heart disease. Cochrane Database Syst Rev. 2004;(1):CD003041.-
4. AHA ACC National Heart Lung and Blood Institute, et al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update endorsed by the National Heart, Lung, and Blood Institute. J Am Coll Cardiol. 2006;47:2130-2139.
5. Terry DF, Pencina MJ, Vasan RS, et al. Cardiovascular risk factors predictive for survival and morbidity-free survival in the oldest-old Framingham Heart Study participants. J Am Geriatr Soc. 2005;11:1944-1950.
6. Twardella D, Küpper-Nybelen J, Rothenbacher D, et al. Short-term benefit of smoking cessation in patients with coronary heart disease: estimates based on self-reported smoking data and serum cotinine measurements. Eur Heart J. 2004;25:2101-2108.
7. Cavender J, Rogers W, Fisher L, et al. for the CASS Investigators. Effects of smoking on survival and morbidity in patients randomized to medical or surgical therapy in the Coronary Artery Surgery Study (CASS): 10-year follow-up. J Am Coll Cardiol. 1992;20:287-294.
8. Van Domburg RT, Meeter K, van Berkel DF, et al. Smoking cessation reduces mortality after coronary artery bypass surgery: a 20-year follow-up study. J Am Coll Cardiol. 2000;36:878-883.
Evidence-based answers from the Family Physicians Inquiries Network
What is the most effective nicotine replacement therapy?
No single nicotine replacement therapy is most effective for all smokers. All forms of nicotine replacement therapy (gum, transdermal patch, spray, inhaler, and lozenge) are equally effective, increasing smoking cessation rates by about 150% to 200%.1,2
A Cochrane Review found that 17% of smokers who had used nicotine replacement therapy successfully quit at follow-up vs 10% of smokers in the control group.1 Except in special circumstances (medical contraindications, smoking <10 cigarettes daily, pregnancy, or breastfeeding), all smokers attempting to quit should be offered nicotine replacement therapy (strength of recommendation [SOR]: A).3
Higher doses of nicotine gum or lozenge (4 mg vs 2 mg) increase quit rates in heavy smokers.1,2 Use of high-dose patches (>21 mg) may benefit heavy smokers or those relapsing due to nicotine withdrawal (SOR: B).3 For relapsed smokers, combination therapy improves long-term abstinence rates (estimated abstinence 28.6% vs 17.4% for monotherapy) (SOR: B).3
Evidence summary
A Cochrane Review of 110 trials evaluating the efficacy of nicotine replacement therapy in 35,600 smokers found higher quit rates among heavy smokers using 4-mg compared with 2-mg nicotine gum (odds ratio [OR], 2.67; 95% confidence interval [CI], 1.69–4.22).1 However, patients often chew too few pieces of nicotine gum daily, resulting in underdosing.3 Smokers should use the gum on a fixed schedule (at least 1 piece every 1 to 2 hours).3
The Cochrane Review finds borderline evidence of a small benefit in abstinence rates (OR, 1.21; 95% CI, 1.03–1.42) with higher-dose nicotine patches (>21 mg/24 hr or 15 mg/16 hr) for heavy or relapsed smokers.1 Combining methods that maintain constant drug levels (transdermal patch) with those having more rapid effects (gum, spray, inhaler, lozenge) is more effective than monotherapy (OR, 1.9; 95% CI, 1.3–2.6).3 Reserve combination therapy for smokers who relapse following monotherapy.
Regarding concerns about weight gain, all nicotine replacement therapies delay but do not prevent weight gain. There is a dose-response relationship between nicotine gum and weight gain: smokers who use more gum gain less weight.3 Although abstinence rates are comparable across the 5 available forms of nicotine replacement, smokers unwilling to give up oral and behavioral rituals of smoking may perceive the inhaler as being more helpful (Table 1).4
Decisions about the best form of therapy can be based on patient preference, on degree of nicotine dependence (a Fagerström Test of Nicotine Dependence Scale score ≥5 [Table 2], or habitually smoking the first cigarette within 30 minutes of awakening),5 or nicotine replacement therapy history, which includes number and outcome of previous quit attempts, specific method used, duration, side effects, and proper usage.
Recommendations from others
The Cochrane Review states: “All of the commercially available forms of nicotine replacement therapy are effective as part of a strategy to promote smoking cessation. They increase quit rates approximately 1.5 to 2 fold regardless of setting. Use of nicotine replacement therapy should be preferentially directed to smokers who are motivated to quit, and have high levels of nicotine dependency. Choice of which form to use should reflect patient needs, tolerability and cost considerations. Patches are likely to be easier to use than gum or nasal spray in primary care settings.”1
The US Department of Health and Human Services Clinical Practice Guideline states: “All patients attempting to quit should be encouraged to use effective pharmacotherapies for smoking cessation except in the presence of special circumstances.”3 Heavy smokers should use 4-mg nicotine gum. Combining the nicotine patch with a self-administered form of nicotine replacement therapy (gum or nicotine nasal spray) is more efficacious than a single form of therapy. Patients should be encouraged to use combined treatments if unable to quit using a single form of first-line pharmacotherapy.3
TABLE 1
Nicotine replacement therapy selection guide
| Moderate smokers (10–20 cigarettes/d) | Heavy smokers (>30 cigarettes/d) | Weight concerns | |
|---|---|---|---|
| Gum | (4 mg vs 2 mg gum enhances quit rates) | (All nicotine replacement therapies delay weight gain, specifically nicotine gum) | |
| Transdermal patch | (Small benefit of dosing >21 mg) | ||
| Inhaler | |||
| Nasal spray | |||
| Lozenge | (Reserve 4 mg for heavy smokers) | ||
| Combination |
TABLE 2
Fagerström test for level of nicotine dependence (abridged)
| How soon after waking do you smoke first cigarette? | ______ Points | |
| Less than 5 minutes: 3 points | ||
| 5 to 30 minutes: 2 points | ||
| 31 to 60 minutes: 1 point | ||
| How many cigarettes do you smoke per day? | ______ Points | |
| More than 30 per day: 3 points | ||
| 21 to 30 per day: 2 points | ||
| 11 to 20 per day: 1 point | ||
| ______ Total Points | ||
| Interpretation | ||
| Total points | Level of dependence | Nictotine replacement therapy |
| 5–6 points | heavy nicotine dependence | consider 21-mg nicotine patch |
| 3–4 points | moderate nicotine dependence | consider 14-mg nicotine patch |
| 0–2 points | light nicotine dependence | consider 7-mg nicotine patch or no patch |
Erik Lindbloom, MD, MSPH
Department of Family and Community Medicine, University of Missouri– Columbia
Now that nicotine replacement therapy is available over the counter, prescribers may not consider or discuss delivery options with patients as much as they did in the past. As this Clinical Inquiry illustrates, there are situations when one approach may be recommended over another.
For example, the relapsed smoker who has tried 1 nicotine replacement product may not even be aware that other methods, including combination therapy, are possible. Considering the enormous potential health improvement that is achieved through smoking cessation, this may be one of the most important topics to revisit regularly with patients.
1. Silagy C, Lancaster T, Stead L, Mant D, Fowler G. Nicotine replacement therapy for smoking cessation. The Cochrane Library, Volume (Issue 4), 2002.
2. Shiffman S, Dresler CM, Hajek P, Gilburt SJ, Targett DA, Strahs KR. Efficacy of a nicotine lozenge for smoking cessation. Arch Intern Med 2002;162:1267-1276.
3. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, Md: US Dept of Health and Human Services, Public Health Service, June 2000.
4. Schneider NG, Olmstead R, Nilsson F, Vaghaiwalla Mody F, Franzon M, Doan K. Efficacy of a nicotine inhaler in smoking cessation: a double-blind, placebo-controlled trial. Addiction 1996;91:1293-1306.
5. Heatherton TF, Kozlowski LT, Frecker RC, Fagerström KO. The Fagerström Test for Nicotine Dependence: a revision of the Fagerström Tolerance Questionnaire. Br J Addict 1991;86:1119-1127.
No single nicotine replacement therapy is most effective for all smokers. All forms of nicotine replacement therapy (gum, transdermal patch, spray, inhaler, and lozenge) are equally effective, increasing smoking cessation rates by about 150% to 200%.1,2
A Cochrane Review found that 17% of smokers who had used nicotine replacement therapy successfully quit at follow-up vs 10% of smokers in the control group.1 Except in special circumstances (medical contraindications, smoking <10 cigarettes daily, pregnancy, or breastfeeding), all smokers attempting to quit should be offered nicotine replacement therapy (strength of recommendation [SOR]: A).3
Higher doses of nicotine gum or lozenge (4 mg vs 2 mg) increase quit rates in heavy smokers.1,2 Use of high-dose patches (>21 mg) may benefit heavy smokers or those relapsing due to nicotine withdrawal (SOR: B).3 For relapsed smokers, combination therapy improves long-term abstinence rates (estimated abstinence 28.6% vs 17.4% for monotherapy) (SOR: B).3
Evidence summary
A Cochrane Review of 110 trials evaluating the efficacy of nicotine replacement therapy in 35,600 smokers found higher quit rates among heavy smokers using 4-mg compared with 2-mg nicotine gum (odds ratio [OR], 2.67; 95% confidence interval [CI], 1.69–4.22).1 However, patients often chew too few pieces of nicotine gum daily, resulting in underdosing.3 Smokers should use the gum on a fixed schedule (at least 1 piece every 1 to 2 hours).3
The Cochrane Review finds borderline evidence of a small benefit in abstinence rates (OR, 1.21; 95% CI, 1.03–1.42) with higher-dose nicotine patches (>21 mg/24 hr or 15 mg/16 hr) for heavy or relapsed smokers.1 Combining methods that maintain constant drug levels (transdermal patch) with those having more rapid effects (gum, spray, inhaler, lozenge) is more effective than monotherapy (OR, 1.9; 95% CI, 1.3–2.6).3 Reserve combination therapy for smokers who relapse following monotherapy.
Regarding concerns about weight gain, all nicotine replacement therapies delay but do not prevent weight gain. There is a dose-response relationship between nicotine gum and weight gain: smokers who use more gum gain less weight.3 Although abstinence rates are comparable across the 5 available forms of nicotine replacement, smokers unwilling to give up oral and behavioral rituals of smoking may perceive the inhaler as being more helpful (Table 1).4
Decisions about the best form of therapy can be based on patient preference, on degree of nicotine dependence (a Fagerström Test of Nicotine Dependence Scale score ≥5 [Table 2], or habitually smoking the first cigarette within 30 minutes of awakening),5 or nicotine replacement therapy history, which includes number and outcome of previous quit attempts, specific method used, duration, side effects, and proper usage.
Recommendations from others
The Cochrane Review states: “All of the commercially available forms of nicotine replacement therapy are effective as part of a strategy to promote smoking cessation. They increase quit rates approximately 1.5 to 2 fold regardless of setting. Use of nicotine replacement therapy should be preferentially directed to smokers who are motivated to quit, and have high levels of nicotine dependency. Choice of which form to use should reflect patient needs, tolerability and cost considerations. Patches are likely to be easier to use than gum or nasal spray in primary care settings.”1
The US Department of Health and Human Services Clinical Practice Guideline states: “All patients attempting to quit should be encouraged to use effective pharmacotherapies for smoking cessation except in the presence of special circumstances.”3 Heavy smokers should use 4-mg nicotine gum. Combining the nicotine patch with a self-administered form of nicotine replacement therapy (gum or nicotine nasal spray) is more efficacious than a single form of therapy. Patients should be encouraged to use combined treatments if unable to quit using a single form of first-line pharmacotherapy.3
TABLE 1
Nicotine replacement therapy selection guide
| Moderate smokers (10–20 cigarettes/d) | Heavy smokers (>30 cigarettes/d) | Weight concerns | |
|---|---|---|---|
| Gum | (4 mg vs 2 mg gum enhances quit rates) | (All nicotine replacement therapies delay weight gain, specifically nicotine gum) | |
| Transdermal patch | (Small benefit of dosing >21 mg) | ||
| Inhaler | |||
| Nasal spray | |||
| Lozenge | (Reserve 4 mg for heavy smokers) | ||
| Combination |
TABLE 2
Fagerström test for level of nicotine dependence (abridged)
| How soon after waking do you smoke first cigarette? | ______ Points | |
| Less than 5 minutes: 3 points | ||
| 5 to 30 minutes: 2 points | ||
| 31 to 60 minutes: 1 point | ||
| How many cigarettes do you smoke per day? | ______ Points | |
| More than 30 per day: 3 points | ||
| 21 to 30 per day: 2 points | ||
| 11 to 20 per day: 1 point | ||
| ______ Total Points | ||
| Interpretation | ||
| Total points | Level of dependence | Nictotine replacement therapy |
| 5–6 points | heavy nicotine dependence | consider 21-mg nicotine patch |
| 3–4 points | moderate nicotine dependence | consider 14-mg nicotine patch |
| 0–2 points | light nicotine dependence | consider 7-mg nicotine patch or no patch |
Erik Lindbloom, MD, MSPH
Department of Family and Community Medicine, University of Missouri– Columbia
Now that nicotine replacement therapy is available over the counter, prescribers may not consider or discuss delivery options with patients as much as they did in the past. As this Clinical Inquiry illustrates, there are situations when one approach may be recommended over another.
For example, the relapsed smoker who has tried 1 nicotine replacement product may not even be aware that other methods, including combination therapy, are possible. Considering the enormous potential health improvement that is achieved through smoking cessation, this may be one of the most important topics to revisit regularly with patients.
No single nicotine replacement therapy is most effective for all smokers. All forms of nicotine replacement therapy (gum, transdermal patch, spray, inhaler, and lozenge) are equally effective, increasing smoking cessation rates by about 150% to 200%.1,2
A Cochrane Review found that 17% of smokers who had used nicotine replacement therapy successfully quit at follow-up vs 10% of smokers in the control group.1 Except in special circumstances (medical contraindications, smoking <10 cigarettes daily, pregnancy, or breastfeeding), all smokers attempting to quit should be offered nicotine replacement therapy (strength of recommendation [SOR]: A).3
Higher doses of nicotine gum or lozenge (4 mg vs 2 mg) increase quit rates in heavy smokers.1,2 Use of high-dose patches (>21 mg) may benefit heavy smokers or those relapsing due to nicotine withdrawal (SOR: B).3 For relapsed smokers, combination therapy improves long-term abstinence rates (estimated abstinence 28.6% vs 17.4% for monotherapy) (SOR: B).3
Evidence summary
A Cochrane Review of 110 trials evaluating the efficacy of nicotine replacement therapy in 35,600 smokers found higher quit rates among heavy smokers using 4-mg compared with 2-mg nicotine gum (odds ratio [OR], 2.67; 95% confidence interval [CI], 1.69–4.22).1 However, patients often chew too few pieces of nicotine gum daily, resulting in underdosing.3 Smokers should use the gum on a fixed schedule (at least 1 piece every 1 to 2 hours).3
The Cochrane Review finds borderline evidence of a small benefit in abstinence rates (OR, 1.21; 95% CI, 1.03–1.42) with higher-dose nicotine patches (>21 mg/24 hr or 15 mg/16 hr) for heavy or relapsed smokers.1 Combining methods that maintain constant drug levels (transdermal patch) with those having more rapid effects (gum, spray, inhaler, lozenge) is more effective than monotherapy (OR, 1.9; 95% CI, 1.3–2.6).3 Reserve combination therapy for smokers who relapse following monotherapy.
Regarding concerns about weight gain, all nicotine replacement therapies delay but do not prevent weight gain. There is a dose-response relationship between nicotine gum and weight gain: smokers who use more gum gain less weight.3 Although abstinence rates are comparable across the 5 available forms of nicotine replacement, smokers unwilling to give up oral and behavioral rituals of smoking may perceive the inhaler as being more helpful (Table 1).4
Decisions about the best form of therapy can be based on patient preference, on degree of nicotine dependence (a Fagerström Test of Nicotine Dependence Scale score ≥5 [Table 2], or habitually smoking the first cigarette within 30 minutes of awakening),5 or nicotine replacement therapy history, which includes number and outcome of previous quit attempts, specific method used, duration, side effects, and proper usage.
Recommendations from others
The Cochrane Review states: “All of the commercially available forms of nicotine replacement therapy are effective as part of a strategy to promote smoking cessation. They increase quit rates approximately 1.5 to 2 fold regardless of setting. Use of nicotine replacement therapy should be preferentially directed to smokers who are motivated to quit, and have high levels of nicotine dependency. Choice of which form to use should reflect patient needs, tolerability and cost considerations. Patches are likely to be easier to use than gum or nasal spray in primary care settings.”1
The US Department of Health and Human Services Clinical Practice Guideline states: “All patients attempting to quit should be encouraged to use effective pharmacotherapies for smoking cessation except in the presence of special circumstances.”3 Heavy smokers should use 4-mg nicotine gum. Combining the nicotine patch with a self-administered form of nicotine replacement therapy (gum or nicotine nasal spray) is more efficacious than a single form of therapy. Patients should be encouraged to use combined treatments if unable to quit using a single form of first-line pharmacotherapy.3
TABLE 1
Nicotine replacement therapy selection guide
| Moderate smokers (10–20 cigarettes/d) | Heavy smokers (>30 cigarettes/d) | Weight concerns | |
|---|---|---|---|
| Gum | (4 mg vs 2 mg gum enhances quit rates) | (All nicotine replacement therapies delay weight gain, specifically nicotine gum) | |
| Transdermal patch | (Small benefit of dosing >21 mg) | ||
| Inhaler | |||
| Nasal spray | |||
| Lozenge | (Reserve 4 mg for heavy smokers) | ||
| Combination |
TABLE 2
Fagerström test for level of nicotine dependence (abridged)
| How soon after waking do you smoke first cigarette? | ______ Points | |
| Less than 5 minutes: 3 points | ||
| 5 to 30 minutes: 2 points | ||
| 31 to 60 minutes: 1 point | ||
| How many cigarettes do you smoke per day? | ______ Points | |
| More than 30 per day: 3 points | ||
| 21 to 30 per day: 2 points | ||
| 11 to 20 per day: 1 point | ||
| ______ Total Points | ||
| Interpretation | ||
| Total points | Level of dependence | Nictotine replacement therapy |
| 5–6 points | heavy nicotine dependence | consider 21-mg nicotine patch |
| 3–4 points | moderate nicotine dependence | consider 14-mg nicotine patch |
| 0–2 points | light nicotine dependence | consider 7-mg nicotine patch or no patch |
Erik Lindbloom, MD, MSPH
Department of Family and Community Medicine, University of Missouri– Columbia
Now that nicotine replacement therapy is available over the counter, prescribers may not consider or discuss delivery options with patients as much as they did in the past. As this Clinical Inquiry illustrates, there are situations when one approach may be recommended over another.
For example, the relapsed smoker who has tried 1 nicotine replacement product may not even be aware that other methods, including combination therapy, are possible. Considering the enormous potential health improvement that is achieved through smoking cessation, this may be one of the most important topics to revisit regularly with patients.
1. Silagy C, Lancaster T, Stead L, Mant D, Fowler G. Nicotine replacement therapy for smoking cessation. The Cochrane Library, Volume (Issue 4), 2002.
2. Shiffman S, Dresler CM, Hajek P, Gilburt SJ, Targett DA, Strahs KR. Efficacy of a nicotine lozenge for smoking cessation. Arch Intern Med 2002;162:1267-1276.
3. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, Md: US Dept of Health and Human Services, Public Health Service, June 2000.
4. Schneider NG, Olmstead R, Nilsson F, Vaghaiwalla Mody F, Franzon M, Doan K. Efficacy of a nicotine inhaler in smoking cessation: a double-blind, placebo-controlled trial. Addiction 1996;91:1293-1306.
5. Heatherton TF, Kozlowski LT, Frecker RC, Fagerström KO. The Fagerström Test for Nicotine Dependence: a revision of the Fagerström Tolerance Questionnaire. Br J Addict 1991;86:1119-1127.
1. Silagy C, Lancaster T, Stead L, Mant D, Fowler G. Nicotine replacement therapy for smoking cessation. The Cochrane Library, Volume (Issue 4), 2002.
2. Shiffman S, Dresler CM, Hajek P, Gilburt SJ, Targett DA, Strahs KR. Efficacy of a nicotine lozenge for smoking cessation. Arch Intern Med 2002;162:1267-1276.
3. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, Md: US Dept of Health and Human Services, Public Health Service, June 2000.
4. Schneider NG, Olmstead R, Nilsson F, Vaghaiwalla Mody F, Franzon M, Doan K. Efficacy of a nicotine inhaler in smoking cessation: a double-blind, placebo-controlled trial. Addiction 1996;91:1293-1306.
5. Heatherton TF, Kozlowski LT, Frecker RC, Fagerström KO. The Fagerström Test for Nicotine Dependence: a revision of the Fagerström Tolerance Questionnaire. Br J Addict 1991;86:1119-1127.
Evidence-based answers from the Family Physicians Inquiries Network