WHAT THIS REPORT ADDS:

• Smoking cessation programs are more likely to be effective if polypharmacy is given; long-term treatment is probably also necessary.

ORLANDO, FLA—Despite considerable progress in limiting where people can smoke, tobacco use remains an important problem in the United States. Smoking rates remain above 20% in both sexes. Furthermore, rates of lung cancer and chronic obstructive pulmonary disease (COPD) are increasing markedly in women—a reflection of the sharp rise in tobacco use among women, which began in the 1950s.

However, new insights into the treatment of tobacco dependence offer hope that more people will be able to quit smoking. The key is to view tobacco dependence as a chronic condition that requires both polypharmacy and long-term treatment. These advances were discussed at a symposium during the recent annual meeting of the American College of Chest Physicians.[1]

SMOKING IN WOMEN

Because smoking became popular among women several decades after it did among men, only in the past few years have the adverse effects of tobacco use in women received widespread attention. Yet, women may be more susceptible than men are to the adverse effects of smoking.

For example, the lung cancer rate in men has fallen in the past 10 years; in women, however, it has been climbing for about five decades, reported Diane E. Stover, MD, Head of the Pulmonary Division at the Memorial Sloan-Kettering Cancer Center in New York City. One reason why the lung cancer rate is still rising in women, she suggested, is that there is a lag between smoking cessation efforts and the appearance of a decline in lung cancer rates.

In fact, women’s current attempts to quit smoking may not affect lung cancer mortality in the female population for 20 or 30 years. “Even if every woman smoker in the United States quit smoking today, we would see an increase [in lung cancer rates] until at least 2025,” said Dr. Stover.

Another reason why the lung cancer rate is still rising in women is that the risk of lung cancer is consistently higher for women than for men at every level of exposure to cigarette smoke. “Dose for dose, females are more susceptible to the effects of tobacco carcinogens than males,” Dr. Stover noted.

A possible explanation for this difference in susceptibility may be women’s elevated estrogen levels, especially those associated with early onset of menopause, short menstrual cycles, and estrogen replacement therapy. Indeed, a positive association has been observed between estrogen replacement, smoking, and adenocarcinoma of the lung in women, Dr. Stover said.

IRRATIONAL PHARMACOTHERAPEUTICS

Monotherapy for tobacco dependence is simply irrational, insisted David P. L. Sachs, MD, Director of the Palo Alto Center for Pulmonary Disease Prevention in California. “You can achieve much better results—as we do with our asthmatic patients—by using combination pharmacotherapy,” he maintained.

Unfortunately, the only combination therapy for smoking cessation that has received FDA approval is the sustained-release bupropion/nicotine patch combination, which has been tested in clinical trials. Administration of any other type of combination therapy in tobacco-dependent patients would therefore be considered an off-label use, Dr. Sachs cautioned. Nevertheless, published studies show such combinations could be quite effective in helping patients to quit smoking.

A useful way to think about smoking cessation products, he suggested, is to categorize them as controller or rescue medications—the same classifications used for asthma therapies. Sustained-release bupropion and the nicotine patch are controller medications, explained Dr. Sachs, because their onset of action is relatively slow, their duration of action is long, and their half-life is prolonged. In contrast, the nicotine inhaler, nasal spray, lozenge, and gum are rescue medications because they can provide relief from nicotine withdrawal symptoms within minutes.

Although any one of these drugs can double or triple a patient’s chances of being able to quit smoking, any pair of them may increase that probability by another 50% to 100%. Combinations that include more than two smoking cessation agents have not been studied systematically and probably never will be, he predicted, because of financial and practical constraints.

“However, clinical experience tells us that one or two controllers plus one or two relievers does, in fact, produce the best therapeutic outcome for our patients,” Dr. Sachs stated. He also noted that clinical trials have shown that combination therapy for smoking cessation does not increase the incidence of side effects.

A CHANCE FOR CHANGE

Although the September 11, 2001, terrorist attacks were a horrible disaster, their aftermath presented a prime opportunity to promote smoking cessation, pointed out David J. Prezant, MD, Deputy Chief Medical Officer for the New York City Fire Department. After that day, 29% of the New York City firefighters who smoked indicated that they had increased their tobacco use, and 23% of those who had quit smoking reported starting up again.

Those numbers are particularly troubling, given that many firefighters have had to contend with persistent respiratory problems resulting from exposure to toxic dust after the collapse of the twin towers. “We realized that we had to institute a tobacco cessation program,” Dr. Prezant remarked.

He and his colleagues designed a 12-week program aimed specifically at New York City firefighters, emergency medical workers, and their spouses. Treatment was based on the extent of tobacco dependency:
• Participants who smoked about one to five cigarettes daily were given a nicotine inhaler to be used as needed.
• Those who usually smoked six to 20 cigarettes daily initially received either the patch or the inhaler, but if they were still smoking at the second visit, they were given both agents and told that they could combine them, if necessary.
• Smoking 20 to 30 cigarettes daily qualified a participant immediately for the patch/inhaler combination.
• Participants who smoked more than 30 cigarettes daily were treated with two nicotine patches and an inhaler.
• That regimen plus bupropion was prescribed for participants who smoked more than 40 cigarettes daily.

In addition, any participant could use the nicotine nasal spray as needed. The program also included counseling about tobacco use and access to a specially designed interactive Web site. Furthermore, participants were allowed to continue pharmacotherapy after the end of the 12-week program if it was deemed necessary.

Of the approximately 2,000 New York City firefighters who smoked at the time, about 600 entered the 12-week program. Its results were impressive: Almost two thirds of the participants reported that they had stopped smoking three months after the program started; the smoking cessation rate at six months was a respectable 40%. The participants’ self-reports were confirmed with exhaled carbon monoxide (CO) tests, which showed that the mean exhaled carbon monoxide level among the participants had dropped to 3 parts per million (ppm), from 19 ppm at baseline.

Dr. Prezant believes that even greater success could be achieved if all smoking cessation programs were permitted to last longer than 12 weeks when necessary. He noted that no one would think of confining treatment for diabetes, osteoarthritis, or asthma to 12 weeks. High rates of permanent smoking cessation will only be achieved, Dr. Prezant suggested, when tobacco dependence is thought of as a chronic condition akin to these other diseases.

Tool Kit Helps Physicians Help Patients

The American College of Chest Physicians (ACCP) has created a tool kit that enables physicians and their staffs to provide aggressive smoking cessation treatment. The tool kit covers all aspects of smoking cessation, including the biology of nicotine addiction, the use of chest imaging to motivate smokers to quit, and pharmacologic treatment. It also includes patient education brochures, as well as stickers that can be attached to patient’s charts. The tool kit emphasizes that smoking is a chronic disease in which relapse is common. Despite the relapse rate, smokers deserve treatment, as do patients with any other chronic disease. The tool kit can be obtained from the ACCP’s store (www.chestnet.org/store).

—Timothy Begany

Reference
1. Successful outcomes in tobacco cessation: practical applications. Presented at: annual meeting of the American College of Chest Physicians; October 28, 2003; Orlando, Fla.

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