A 56-year-old male with a 60-pack-a-year history of cigarette smoking is admitted to the telemetry unit with an initial assessment of acute coronary syndrome. Because there is a no-smoking policy in the hospital, he is willing to comply but is concerned about tobacco withdrawal symptoms.
As of 2006, approximately 20.8% of U.S. adults smoke cigarettes.1 Responsible for approximately 438,000 deaths annually, cigarette smoking is the most important preventable cause of death and disease in the U.S.2
Smoking cessation reduces the risk of tobacco-related diseases; the potential health benefits are numerous. This is most evident in the reduction of cardiovascular disease events upon tobacco abstinence.3 Yet, it remains a constant struggle for smokers to quit and stay abstinent.
The main barrier to quitting is nicotine addiction, which causes tolerance and physical dependence. Upon cessation of tobacco use, withdrawal symptoms, such as irritability, restlessness, impatience, and depression may occur within a few hours, peak within the first several days, and then wane during the next few months.
The crucial time frame to prevent relapse is the first week of cessation. For smokers to stay off cigarettes, they must break from routines, behaviors, or cues that trigger the urge to smoke.4
Among patients with acute myocardial infarction (AMI) in a study done by Van Spall, et al., 39% of them still smoked.5 Indeed, smoking is associated with 1.5 to three times increased relative risk of AMI, and hospitalists increasingly must manage cardiovascular disease patients’ tobacco dependence during their hospital stay.
Intervention strategies: Methods for smoking cessation need to target two aspects that support tobacco use—physical and psychological factors. High-intensity counseling and systematic behavioral intervention followed by sustained contact—in person or by phone up to one month after discharge—are effective behavioral interventions for sustained tobacco cessation.6 Pharmacotherapy also helps when added to high-intensity counseling of a hospitalized patient. It especially is beneficial for controlling withdrawal symptoms.
In addition, with policies prohibiting smoking in almost all U.S. hospitals, temporary tobacco abstinence promotes smoking cessation for hospitalized patients. Unfortunately, most hospitalized patients go back to smoking soon after discharge. Hospitalization may be the opportune time to help patients try to quit and avoid relapse.
Some hospitals feature inpatient smoking cessation programs in which nurse practitioners and counselors educate and counsel patients. It is highly recommended that a multidisciplinary team be involved in a tobacco cessation program catered to an individual patient’s needs. However, most hospitals have no such program. Nevertheless, the hospitalist can help a patient with brief or low-intensity tobacco cessation counseling, pharmacotherapy for nicotine withdrawal symptom control if clinically indicated, and follow-up upon discharge for relapse prevention.
Counseling: Smoking cessation counseling in the hospital after an AMI has been found to be associated with a relative risk reduction of mortality by 37% in one year. The hospitalist should give a two-minute cessation message as the first step. If tobacco cessation counselors or nurse practitioners are available, their additional counseling also may improve outcomes of smoking cessation therapies.7 However, if no established inpatient tobacco cessation program is available to the hospitalist, the following may be used to aid in physician counseling of the hospitalized cardiac patient:
The first step in treating tobacco dependence is to identify and assess tobacco use status.
Tobacco users willing to quit should be treated using the 5 A’s (Ask, Advise, Assess, Assist, and Arrange) (see Figure 1, p. 30). Tobacco users not willing to quit at the time of interaction should be treated using the 5 R’s for motivational intervention:
- Relevance (indicate why quitting is personally relevant);
- Risks (have patient identify potentially negative consequences of smoking);
- Rewards (have patient identify potential benefits of quitting smoking);
- Roadblocks (have patient identify potential barriers to smoking cessation and provide patient problem-solving techniques and pharmacotherapy to overcome the barriers); and
- Repetition (repeat motivational intervention to unmotivated patient each visit).
Further, former smokers who recently quit using tobacco should be given relapse prevention treatment.8 For the hospitalized smoker with acute cardiovascular disease, providing bedside counseling, enhancing self-coping behavior change, and arranging follow-up after discharge to maintain behavior change can help sustain tobacco abstinence.
Pharmacotherapy: The most important purpose of pharmacotherapy for smoking cessation is to reduce withdrawal symptoms and cigarette cravings. Public Health Service clinical guidelines for smoking cessation mention five first-line agents. These are sustained-release bupropion and four nicotine-replacement therapies (NRT): transdermal patch, gum, nasal spray, and vapor inhaler. Further, there are two second-line agents: clonidine and nortriptyline. Since the clinical guidelines’ release in 2000, the Food and Drug Administration has approved a fifth NRT product, the nicotine lozenge, in 2002, and a partial nicotine agonist, varenicline, in 2006 (see Table 1, right).9,10
Current guidelines recommend that NRT be used with caution in patients with unstable angina, serious arrhythmias, or an MI within the previous two weeks due to limited supportive data on the safety of use in these patients.11 The transdermal patch delivers nicotine at a slow and constant rate in contrast to the other forms of NRT and has been used safely in patients with stable coronary artery disease. However, the use of any NRT, including the patch, in acute cardiovascular disease is not advised due to the nicotine-mediated hemodynamic effects, such as increase heart rate and arterial vasoconstriction, which lead to increased myocardial workload.
Sustained-release bupropion generally is well tolerated by hospitalized patients with cardiovascular disease, but there may be a delay in control of withdrawal symptoms. In addition, blood pressure must be monitored especially if combined with NRT as there have been anecdotal reports of increase in blood pressure with bupropion alone.12 Bupropion must be used cautiously in patients with recent MI. Other contraindications include history of seizure, conditions that potentially can increase risk for convulsions, and use of monoamine oxidase inhibitors (MAOI) within 14 days.
The new drug varenicline has not been studied in hospitalized patients or patients with acute coronary syndrome. However, since it does not have any important hemodynamic effects, it may be useful in this setting and in selected patients with close monitoring for mood changes since there have been anecdotal case reports of psychotic events in patients with underlying psychiatric disorders.13 Its routine use currently is not recommended.
Follow-up after discharge: Pharmacotherapy may be added for withdrawal control, as well as relapse prevention for the hospitalized patient who recently quit smoking. However, inclusion of intensive tobacco cessation counseling during the hospital stay is the most effective intervention given the setting and patient condition, and follow-up support up to at least one month after discharge has been found to be more effective in sustaining tobacco abstinence than pharmacotherapy alone. In order to maximize long-term quit rates among patients who recently abstained from smoking, the hospitalist should arrange access to ongoing outpatient post-discharge support and tobacco cessation treatment.
Back to the Case
After appropriate cardiac testing, the patient was found to have a non-cardiac etiology for his symptoms. From the start of his hospital stay, he was counseled by the hospitalist and started on sustained-release bupropion, but withdrawal symptoms and cravings persisted.
Prior to his discharge home, the patient wanted to discontinue bupropion and be provided an alternative. The patient was given a nicotine patch, and a follow-up appointment at the tobacco cessation clinic within one week of discharge from the hospital was arranged. The patient has been compliant with his quit-smoking treatment and has followed-up for continued tobacco cessation counseling. He hasn’t smoked cigarettes for a year. TH
Dr. Palisoc is a preventive medicine resident at the University of Colorado Denver. Dr. Prochazka works at the Denver VA and is a professor of medicine at the University of Colorado Denver.
- CDC. Cigarette Smoking Among Adults, United States, 2006. MMWR Morbidity Mortality Wkly Rep. 2007;56(44):1157-1161. Available at www.cdc.gov/mmwr/preview/mmwrhtml/mm5644a2.htm. Last accessed March 4, 2008.
- CDC. Annual Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity, United States, 1997-2001. MMWR Morbidity Mortality Wkly Rep. 2005;54(25):625-628.
- Thomson CC, Rigotti NA. Hospital- and clinic-based smoking cessation interventions for smokers with cardiovascular disease. Prog Cardiovasc Dis. 2003;45(6):459-479.
- Rigotti NA. Treatment of tobacco use and dependence. N Engl J Med. 2002;346(7):506-512.
- Van Spall HGC, Chong A, Tu JV. Inpatient smoking-cessation counseling and all-cause mortality in patients with acute myocardial infarction. Am Heart J. 2007;154(2):213-220.
- Rigotti NA, Munafo MR, Stead LF. Interventions for smoking cessation in hospitalized patients. Cochrane Database Syst Rev. 2007;Issue 3.
- Ludvig J, Miner B, and Eisenberg, MJ. Smoking cessation in patients with coronary artery disease. Am Heart J. 2005;149(4):565-572.
- Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence: clinical practice guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service 2000.
- Rigotti NA, Thorndike AN, Regan S, et al. Bupropion for smokers hospitalized with acute cardiovascular disease. Am J Med. 2006;199:1080-1087.
- Jorenby DE, Hays JT, Rigotti NA, et al. Efficacy of varenicline, an alpha4beta2 nicotinic acetylcholine receptor partial agonist, vs. placebo or sustained-release bupropion for smoking cessation: a randomized controlled trial. JAMA. 2006;296(1):56-63.
- Joseph AM, Fu SS. Safety issues in pharmacotherapy for smoking in patients with cardiovascular disease. Prog Cardiovasc Dis. 2003;45(6):429-441.
- FDA. Prescribing information of Zyban (bupropion hydrochloride) sustained release tablets. June 2007. Available at www.fda.gov/medwatch/safety/2007/ Aug_PI/Zyban_PI.pdf. Last accessed March 6, 2008.
- FDA. Early Communication About an Ongoing Safety Review: Varenicline (marketed as Chantix). November 2007. Available at www.fda.gov/cder/drug/early_comm/varenicline.htm. Last accessed March 6, 2008.