#11 Smoking Cessation: It’s Not a Drag

September 15, 2022 | By Natalie Stahl

Audio

With Dr. Panagis Galiatsatos

Tackle smoking cessation by offering your patients evidence-based treatment options. We discuss pharmacotherapy, mindfulness, and practical tips on how to manage short-acting nicotine replacement therapy to help your patient stop smoking. We are joined by Dr. Panagis Galiatsatos from Hopkins (@Panagis21).

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Production Partner: ACAAM

Show Segments

• Intro, disclaimer, guest bio –  00:30
• Guest one-liner –  05:51
• Case from Kashlak; Definitions – 07:11
• Approach to discussing tobacco use – 08:25
• Mindfulness in smoking cessation – 14:10
• Pharmacotherapy for tobacco use – 23:00
• Counseling on medications  – 29:30
• Expert Opinion on dosing of NRT patches – 38:26
• Tips on short-acting NRT – 44:30
• Menthol – 58:36
• Outro 01:30:30

 Smoking Cessation Pearls

1. Set the stage for discussing smoking cessation by creating a non-judgemental space and AVOID lecturing the patient to just “quit smoking.” 
2. Assess an individual’s tobacco use by asking at what age they started smoking, as well as tobacco quantity, quality (e.g. what brand of cigarettes do they smoke?), how they smoke, and prior quit attempts. 
3. Three long-acting medications are FDA-approved for smoking cessation; these include varenicline, bupropion, and nicotine replacement patches. Select a medication based on a patient’s prior experiences and co-morbidities.
4. When prescribing short-acting nicotine replacement therapy like gum or lozenges, be sure to counsel patients on “parking” the formulation inside their cheek to ensure optimal absorption.
5. Mindfulness can be an important component of smoking cessation and can play a key role in relapse prevention. Dr. Galiatsatos recommends integrating mindfulness techniques when counseling a patient on smoking cessation. 
6. For patients who report that their nicotine patch falls off, consider applying surgical tape and wrapping it around the patch to ensure that it adheres to the skin. 
7. Encourage patients to call smoking cessation quitlines; this can be one mechanism to access free pharmacotherapy.

Smoking Cessation – Notes

Approach to Discussing Tobacco Use

First, set the stage and ensure the patient is comfortable. Create a non-judgemental environment when discussing tobacco use with your patients. Dr. Galiatsatos likes to reframe the smoking cessation journey as learning how to become a non-smoker. Dr. Galiatsatos recommends AVOIDING telling a patient to “Quit smoking;” instead, help set them up to manage their tobacco use through motivational interviewing and mindfulness. Dr. Galiatsatos reframes the goal to his patients – “It’s not about quitting, it’s about becoming a non-smoker.”

Assessing Tobacco Use

In Dr. Galiatsatos’ expert opinion, he does not view the smoking pack year history as helpful as compared to asking the following questions to get a better sense of an individual’s nicotine dependence.

• How many cigarettes a day on average do they smoke? It’s important to assess the quantity and frequency of tobacco use. 
• How many cigarettes do they smoke on a stressful day (“bad day”) vs a “good day”? This can help your patient be more mindful about their cigarette use.
• When did they start smoking? People who initiate smoking at a younger age often have more entrenched smoking behaviors making it harder to reduce or stop smoking. 
• Which brand of cigarettes do they smoke? This can provide information about the “burn rate” of a cigarette.
• How have they tried to stop smoking in the past? How did they approach it? This can help inform which pharmacotherapy to choose. 

Pharmacotherapy for Tobacco Use

To start developing a treatment plan, ask what the patient wants out of a medication for smoking cessation. Ask what they have tried in the past, and what impact that strategy had. Check whether there are interactions with any of the patient’s medications, or medical comorbidities (such as hemodialysis, or history of seizures) that could limit the pharmacotherapy options for that individual. Dr. Galiatsatos recommends using a combination of pharmacotherapy and mindfulness to help a patient stop or cut back on cigarettes.

Three long-acting “controller” medications are approved for smoking cessation: Varenicline, Bupropion, and nicotine replacement therapy (NRT) patches. A variety of short-acting NRT agents are also available including gum, lozenges, inhalers, and nasal spray.

Treat most patients with a long-acting controller medication and short-acting NRT (Barua, 2018). Combining two long-acting agents can be appropriate (e.g. varenicline + NRT patch) (Galiatsatos, 2022). Instruct patients to utilize short-acting NRT when they experience intense cravings. 

How to Counsel Patients on Pharmacotherapy

It is critical to counsel a patient on the side effects of these medications, as well as the expected time to effect.  Dr. Galiatsatos tells his patients, “You will likely continue to have cravings for 2 weeks before you notice anything different.”  Prepare patients for side effects such as vivid dreams and nausea. The medications can be dose adjusted as needed. 

NRT Counseling

NRT patches are intended to curb cravings, but they are poorly constructed to act like a cigarette as they do not reach peak nicotine levels in the same way a cigarette does (McNeil, 2010, figure 4). The NRT products will not kick in as quickly, or feel the same as a cigarette does. Make sure patients know that they need to give these products time to work, and encourage them to try the medications for at least 2 weeks. Counsel patients that nothing will fully replicate smoking, but that NRT can be used to help decrease the intensity of cravings.

Quit Dates and Medication Monitoring

In Dr. Galiatsato’s expert opinion, he does not recommend setting a quit date when starting the medication. This allows the patient to adjust to the medication, and then check in with them within a few weeks. 

In his expert opinion, he often starts NRT patches at 21mg patch for everyone and assumes that every patient has a high amount of nicotine dependence.  The goal is for the patient to have a 50% reduction in their smoking use, and once that occurs Dr. Galiatsatos will decrease the patient’s NRT dose from 21mg to 14mg. Then finally, decrease to 7mg when they stopped smoking and continue for 4-8 weeks after their last cigarette.

Dr. Galiatsatos recommends continuing varenicline and patches for weeks after the use of the last cigarette. Then continue to use short-acting NRT to curb any cravings. 

Common Pharmacotherapy Myths

• It is safe to smoke while using a nicotine patch. A patch combined with smoking should not cause symptoms of nicotine toxicity for people who are dependent on nicotine. 
• A patient can use 2 patches of 21mg  (42mg total dose) if needed (or consider 21mg + 7 mg). Dr. Galiatsatos monitors patients who require multiple patches to control cravings for adverse effects and decreases the dose over time.
• Psychiatric diagnoses are NOT a contraindication to taking varenicline (Anthenelli, 2016).

Other Practical Tips for NRT

Patches: Use surgical tape and wrap it around the patch for patients who report that the patch falls off. Some patients like that this method hides the patch. Patients can also place the patch under a bra or shirt.

Gum/Lozenges: Remember, gum and lozenges both must be parked in the cheek to allow nicotine to get absorbed into the venous system. If an individual just sucks/chews gum like candy, the patient is more likely to get nauseated. If the patient has dentures, tell them to break the lozenge into pieces, then park it on their gum, like chewing tobacco. 

Nasal Spray: Nasal spray is often expensive, and will burn the first few times that a patient uses it. This sensation often improves with repetition. Once individuals are used to it, it can be effective and convenient.

Cost and Access to Medications

Encourage your patient to use quitlines that can help them access free pharmacotherapy. Bupropion and varenicline can be helpful, and if prescribed, try to use the generic formulation to help keep costs low. Be familiar with local pharmacies that will carry the generic version of these medications. 

Links

1. Dr. Galiatsatos Smoking Cessation Course
2. Galiatsatos, 2022: Summary for Clinicians: An ATS Clinical Practice Guideline for Initiating Pharmacologic Treatment in Tobacco-Dependent Adults
3. Coming soon: Behind the Evidence: the Addiction Medicine Podcast

Goal

Listeners will be able to treat patients with tobacco use disorder using evidence-based medications and counseling strategies. 

Learning objectives

After listening to this episode listeners will…  

1. Assess the quantity, frequency, and severity of tobacco use.
2. Compare the 3 FDA-approved medications for tobacco use disorder: nicotine replacement therapy, bupropion, and varenicline
3. Describe different formulations and appropriate dosing of nicotine replacement therapy

Disclosures

Dr. Panagis Galiatsatos reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Stahl, N, Galiatsatos P, Mullins K, Morford K,  Chan, CA. “#11 Smoking Cessation: It’s Not a Drag with Dr. Panagis Galiatsatos”. The Curbsiders Addiction Medicine Podcast. http://thecurbsiders.com/addiction September 15th, 2022.