Over the Counter

Breaking up With Your Cigarette

February 14, 2024

Introduction

Tobacco consumption is a leading risk factor for morbidity and mortality in Canada.¹ Each year, smoking is estimated to contribute to the death of 45,000 people across Canada, including 75% of all lung cancer deaths. Smoking is also a well-documented risk factor for many other cancers and chronic diseases.² Although there has been a remarkable reduction in tobacco usage rates in Canada, public health concerns regarding tobacco use continue to persist. Reports from Health Canada estimate that approximately 10.9% of Canadians aged 15 and older reported smoking in 2022.^3,4

Quitting smoking is notoriously difficult for many patients, and is caused, in large part, by the addictive properties of nicotine. Addiction to smoking stems from the rapid delivery of nicotine to the reward pathways in the brain and the development of tolerance.⁵ In addition, nicotine has a short half-life of about two hours and produces dependence, and withdrawal symptoms shortly after the individual’s last cigarette or dose of nicotine.⁶

Given the unique properties of tobacco dependence, it is critical that a patient has access to a support system that will optimize their chances of success. As the most accessible healthcare providers, pharmacy professionals are well-positioned to help patients navigate this challenging journey.

Interventions

Interventions by healthcare professionals has shown to improve quit rates, with pharmacist interventions increasing smoking cessation rates by 40%.^8,9 Interventions by health care professionals are not only critical to improving quit rates, they also are remarkably efficient. Even a brief interaction to ask and record smoking status, advise on potential health benefits, and acting on a patient’s response may motivate more patient attempts to stop smoking than not mentioning it at all.¹⁰ In fact, evidence shows that counselling lasting just 3 minutes or less, can increase smoking cessation and abstinence rates.⁸

Nicotine replacement therapy (NRT), bupropion and varenicline are treatments approved for smoking cessation in Canada. All are considered first-line monotherapy treatment choice.¹¹ Given its effectiveness, combination therapy with bupropion or varenicline and NRTs, or a combination of long and short-acting NRTs, may also be considered as a first line option for all patients.^8,11 Combination therapy may be particularly effective in cases where the patient has had previous treatment failure or has attempted to quit multiple times, as well as in those with high baseline levels of smoking dependence. Combination therapy can also be useful in managing breakthrough cravings.^8,11 Ultimately, the products selected as part of a treatment plan should take into account patient specific factors and be guided by the pharmacist’s professional judgement. Regardless of the regimen chosen, the goal of any smoking cessation treatment plan is to have the patient quit smoking by reducing motivation to smoke, and alleviating and/or preventing symptoms of withdrawal.

NRT provides a clean alternative to cigarettes and has a less efficient mechanism of nicotine delivery (i.e.: oral, topical), which makes NRTs a non-addictive, safe alternative to cigarettes. Meta-analyses conducted in 2018 and 2023 reported NRTs increase the quitting rate up to 1.6x and found combination NRT (fast‐acting form plus patch) resulted in higher long‐term quit rates than monotherapy and with similar quit rates when compared to varenicline.^12,13,18

Bupropion acts on noradrenergic and/or dopaminergic mechanisms and is a weak inhibitor of the neuronal uptake of norepinephrine, serotonin, and dopamine.¹⁴ A 2020 meta-analysis reported bupropion increases the likelihood of quitting up to approximately 1.7x.^15,16

Varenicline has partial agonist activity at the nicotinic acetylcholine receptor, while simultaneously having antagonist activity preventing nicotine binding, thus it maintains moderate levels of dopamine, which reduces withdrawal symptoms and smoking satisfaction.¹⁷This option is likely the most efficacious as monotherapy, increasing the likelihood of quitting by 2.3x.^16,18

Initiating NRT for Smoking Cessation

When a patient is identified as an appropriate candidate for NRT, clinicians can consider the strategy below, which was developed by educational expert, Michael Boivin, RPh¹⁹

Step 1: Frequently Ask patients about their tobacco status.

Step 2: Start patient-centred NRT.

NRT delivers measured doses of nicotine, which helps to relieve the cravings and withdrawal symptoms often experienced by people trying to quit.
Gums, inhalers, lozenges, and sprays are immediate release dosages which have rapid onset to the brain but slower than cigarettes. With the patch, nicotine levels rise gradually in the bloodstream over hours instead of seconds through inhalation, resulting in a slower onset of action.
Using NRT maintains physical dependence on nicotine but is not associated with the negative health outcomes that are a result of the carcinogens in cigarettes.

Step 3: Slowly taper tobacco and, if needed, slowly titrate NRT products.

Quitting tobacco suddenly may work for some, but consider tapering tobacco use after starting NRT.
If withdrawal symptoms or cravings develop, consider titrating the dose of NRT or combination (ie: gum with patch) therapy.
Frequent follow-up is recommended to adjust therapy and to manage challenges when needed.

Step 4: Stop Tobacco and, if appropriate, slowly taper NRT.

Some patients will be able to stop using tobacco immediately, while others will need more time to stop.
Patients should be encouraged to not stop NRT too early and to use appropriate quantities of NRT over a sufficient duration of time.
When the patient is ready, smoking cessation products can be slowly tapered down until they are no longer needed or continue when needed for cravings.

Step 5: Reassess and frequently follow up. Restart treatment if the patient has a slip or relapse.

Following up with patients about their tobacco status is essential to identify early cases of relapses so that interventions can occur with any of the previous steps.
Slips and relapses are common, and it is important to support patients to reassess barriers and treatment plans to guide patients back on track.

Lastly, it is important to encompass the above interventions with motivational interviewing. This is an evidenced based and patient centric approach to support patients with behaviour changes.²⁰

The key principles include:

Avoiding Direct Confrontation and Rolling with Resistance: Avoid confrontation, arguments, and coercion to help maintain a positive relationship to guide the patient toward self-motivated change.
Expressing Empathy: Understand and empathize with the patient’s perspective to create a supportive and non-judgmental environment.
Developing Discrepancy: Probe to explore and highlight the discrepancy between the patient’s current behavior and their desired goals or values.
Supporting Self-Efficacy: support and recognize the patient’s ability, strengths, and successes to empower them to make positive changes.

Counselling

Physiological changes occur with smoking cessation, and thus dosage adjustment of CYP1A2 substrates may be necessary. As the medication experts, pharmacists can utilize their knowledge to help patients and prescribers manage common drug interactions caused by tobacco use. When considering the impact of smoking cessation on other drug therapies, pharmacy professionals can reference this practical tool developed by Ron Pohar, BScPharm, APA, to support decision-making around medication adjustments.²¹ It is also important to note that quitting smoking can increase the effects of caffeine.

Patients should be counselled that reducing caffeine intake by 50% can help prevent unpleasant side effects of excessive caffeine intake such as jitteriness, nervousness, headaches, insomnia, and tachycardia.

In addition, it is important to remind patients to expect other changes when they stop smoking. It is normal to experience withdrawal and cravings while quitting. Weight gain may in the first few months and an increase in appetite is also normal, so encouraging healthy snacks and physical activity is recommended.

Relapse

Nicotine’s potency in hijacking reward pathways in the brain, coupled with its short half-life and quick onset of uncomfortable withdrawal effects contribute to the difficulty of quitting smoking and its well-documented relapse rate. Just this past year, approximately 44.5% of tobacco users in Canada tried to quit, with 31.8% of these individuals stating they have tried more than once.³ In addition, over two-thirds of smokers who attempted to quit in the past year used some form of smoking cessation aid when attempting to quit tobacco use.³

Pharmacy professionals are encouraged to remind their patients that multiple attempts at quitting are a normal part of the smoking cessation journey. It’s important to recognize that quitting smoking is a journey, with setbacks common and not indicative of individual failure. Instead, this offers opportunities for the patient and pharmacist to reevaluate and reframe the treatment plan.

Addressing tobacco use disorder often necessitates a multifaceted approach, including pharmacologic and non-pharmacological options such as behavioural therapy and support groups. Not only do physical withdrawal symptoms act as powerful triggers pulling individuals back into tobacco use, but emotional, social, and behavioural cues are also factors that contribute to relapse. ⁷ Patient counselling should instead focus on the whole patient journey by celebrating success when possible and viewing setbacks as learning opportunities for the patient and pharmacist to reevaluate and reframe the treatment plan.

Conclusion

Smoking is a chronic relapsing disease and thus quitting is one of the single most important interventions to improve health outcomes, regardless of age or length of smoking history. Pharmacists can play an integral role in supporting patients on their cessation journey given our expertise, accessibility and often having the most frequent touchpoints with patients, making pharmacists an ideal provider for intervention.

This blog post is developed by the Ontario Pharmacists Association (OPA) and supported through an education grant from Kenvue. Health professionals can visit this page to learn more.

References

Canadian Institute for Health Information. (2022). Smoking. Retrieved January 26, 2024, from [https://www.cihi.ca/en/indicators/smoking]
Canadian Partnership Against Cancer. (2019). 2019-2029 Canadian Strategy for Cancer Control. Toronto, ON.
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Government of Canada. (2022). Canadian Tobacco and Nicotine Survey (CTNS): Summary of Results for 2022. Retrieved from [https://www.canada.ca/en/health-canada/services/canadian-tobacco-nicotine-survey/2022-summary.html]
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Hajizadeh, A., Howes, S., Theodoulou, A., Klemperer, E., Hartmann-Boyce, J., Livingstone-Banks, J., & Lindson, N. (2023). Antidepressants for smoking cessation. Cochrane Database of Systematic Reviews, 5, CD000031. https://doi.org/10.1002/14651858.CD000031.pub6
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