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Etiology of smoking

The smoking of tobacco products is a widespread phenomenon both worldwide and in The United States. In the U.S. there are estimated to be nearly 47 million active smokers. This prevalence hints at the fact that many find the use of tobacco to be very compelling. Among the various reasons given by people for smoking are pleasure, rebellion, companionship, relaxation, and a variety of others. From this information, it can be seen that tobacco products often represent, in the case of many users, a way to fulfill basic human necessities that might otherwise go unfulfilled.

The Monetary and Health Costs of Tobacco Products

Cigarette smoking is the number one preventable cause of death in The United States of America, and is responsible for approximately five million deaths per year worldwide.20 It is estimated that during the 21st century, tobacco products will be responsible for one billion premature deaths worldwide.25 In addition to a human toll, the economic cost of smoking is tremendous, and it is estimated that a single pack of cigarettes purchased in the United States—and there were 22 billion packs sold in 1999-- costs the community over seven dollars in medical costs and lost productivity.21

Opinion of Healthcare Professionals on Smoking and Tobacco Products

Pharmacist Opinion on Tobacco Products

The sale of a drug known to be detrimental to one’s health when taken in any dose, runs contrary to many of the values of the pharmacy profession and the opinions of the majority of pharmacists. While some patients derive benefits such as weight loss, an increase in ability to concentrate, and decreased stress from tobacco usage, the costs—both economic and health-related--far outweigh the positive effects in the minds of healthcare professionals, and it is not a prescribed substance (12). As a whole, pharmacy profession in The United States is overwhelmingly opposed to the use of tobacco products as evidenced by professed belief, rhetoric, and action.22,21

The American Pharmaceutical Association (APhA) has lobbied since the 1970s to take cigarettes and other tobacco products off of pharmacy shelves, stating that in the interest of public health, pharmacists should discourage the sale of tobacco products in their places of work.21 This belief that tobacco is both detrimental to public welfare and in grave discordance with the spirit of the pharmacy profession is not unique to the APhA, but is echoed in surveys taken of practicing pharmacists, retired pharmacists, and future pharmacists (pharmacy students).

In a 2000 study of pharmacists practicing in Northern California, it was found that only 1.6 percent favored the sale of tobacco in the pharmacy setting.21 Among pharmacy students at several of California’s major schools of pharmacy, the number of students in support of tobacco sales was only two percent.

In a similar study of Kentucky pharmacists, it was discovered that 12.8 percent of pharmacists favored the sale of tobacco products in pharmacies, although the neutral response found on the California survey was not available on the Kentucky survey and may have skewed the results.26 The fact that California has one of the lowest smoking rates in the nation (12.9 percent) while Kentucky has one of the highest (25.6 percent) may explain the differences in pharmacists’ views regarding tobacco sales. The results of these studies indicate that the majority of pharmacists are opposed to the sale of tobacco products in the pharmacy setting.27,28

Treatment

Counseling

Pharmacist-Provided Counseling

In addition to opposing the sale of tobacco products in the pharmacy environment, American pharmacists are strongly in favor of aiding patients in stopping usage of tobacco products. Nearly 87 percent of pharmacists think that the profession should do more to encourage current users of the drug to quit, a belief shared by 97 percent of pharmacy students. 24, 30. One way in which pharmacists demonstrate this willingness to offer assistance is through patient counseling. Counseling for tobacco addiction is available through a number of healthcare professionals in the United States of America, but, as a whole, community pharmacists are the most assessable of these professionals and enjoy widespread trust among the general population 23,24,29.

In contrast to these professed beliefs, however, the majority of pharmacists who deal with patients on a regular basis do not offer counseling concerning tobacco usage over the course of a typical month.

A California study claimed that fewer than four percent of pharmacists in regular contact with patients reported asking their patients about tobacco use on a regular basis.24 In addition, only 21 percent of these pharmacists questioned four or more patients about their smoking habits in the preceding month. A similar study conducted in Texas found that less than 30 percent of pharmacists working in a community setting routinely advise patients to quit smoking even when made aware of their tobacco usage, and 22.5 percent never offer this advice when knowledge of tobacco usage is present. 22

Nearly half of pharmacists who practice in settings where over-the-counter smoking cessation aids are sold estimate that less than 20 percent of patients purchasing these products receive any form of counseling concerning their usage. 24 Of these patients who are counseled, most only receive one to two minutes of individualized attention.24 These findings suggest that a significant portion of pharmacists, roughly 60 percent of those surveyed, believe that pharmacists should do more to help patients reduce their tobacco usage or quit altogether, yet do not actively participate in this initiative themselves. This figure assumes that the pharmacists who do council patients about their tobacco habits believe that more needs to be done within the field to address the tobacco issue. The reasons given by pharmacists for this discrepancy between professed beliefs and practice in The United States were indicated in the previously mentioned studies.

The California study found the top three reasons that pharmacists did not provide patients tobacco cessation counseling to be unawareness of the purchase of tobacco products (57.3 percent), not enough time for counseling (56.9 percent), and an inadequately staffed pharmacy (52.8 percent).24 A 2007 Montana study listed similar reasons, with the top three being lack of time (52 percent), lack of reimbursement (26 percent) and lack of training (19 percent).28 While pharmacists profess the desire to provide patients with medical advice about the dangers of tobacco products, workplace concerns and a lack of training often interfere and many pharmacists are unable to render this service.

Recording smoking status as a vital sign increases the frequency of brief advice to patients by physicians.[1]

Motivational interviewing may help smoking cessation.[2]

Demonstration of damage to lungs

In general, informing patients of their lung function as measured by spirometry does not increase smoking cession according to a systematic review by the U.S. Preventive Services Task Force (USPSTF).[3] However, in a more recent randomized controlled trial, patients in the group who were informed of their 'lung age' were more likely to stop smoking.[4] However, in this trial, "People with worse spirometric lung age were no more likely to have quit than those with normal lung age in either group".[4]



Medications

Bupropion

Bupropion is both an adrenergic uptake inhibitor and a dopamine uptake inhibitor and can help smoking cessation[5], including adding to the effective of nicotine replacement.[6]

Varenicline

Varenicline, a partial agonist at the α4β2 nicotinic acetylcholine receptor, may be more effective than bupropion[7][8]; however, bupropion is a generic drug. Varenicline is probably better than the nicotine patch; however, the only study was not blinded and was industry sponsored.[9]

The Food and Drug Administration of the United States has issued an advisory for varenicline and psychiatric disease.[10]

Selected medications for abstinence[11][12]
  Eisenberg[11]
(odds ratio)		 Cochrane[12]
(relative risk ratio)
Bupropion 2.07 1.17
Varenicline 2.41 1.18

Nicotine replacement

A systematic reviews of selected medications including nicotine replacement found that the odds ratios for quitting with nicotine are:[11]

  • Spray, 2.37
  • Inhaler, 2.18
  • Patch, 1.88
  • Gum, 1.65

Rimonabant

Rimonabant, a selective type 1 cannabinoid (CB1) receptor antagonist, improves smoking cessation and moderate weight gain associated with smoking cessation according to a meta-analysis of randomized controlled trials by the Cochrane Collaboration.[13] However, "there is current concern (August 2007) over rates of depression and suicidal thoughts in people taking rimonabant for weight control."[13]

Atomoxetine

Addiction is reinforced by the fear of experiencing the adverse effects associated with the cessation of the drug. Smoking withdrawal causes cognitive deficits analogous to attention deficit hyperactivity disorder, an observation which prompted researchers to test the hypothesis that drugs that ameliorate ADHD facilitate smoking cessation. In confirmation of this hypothesis, it was shown that atomoxetine, a norepinephrine reuptake inhibitor that is approved by the FDA to treat the symptoms of ADHD, dose-dependently reversed congnitive deficits in an animal model of nicotine withdrawal.[14] Atomoxetine is not indicated at this time as a medication to treat the ADHD-like symptoms of smoking cessation.

Combinations of medications

Selected trials of combination smoking cessation interventions[15][6]
Study Subjects Intervention Comparison Outcome Results
Intervention group Comparison group
Steinberg[15]
2009		 Community volunteers with predefined medical illnesses Triple therapy of nicotine patch, nicotine oral inhaler, and bupropion ad libitum Nicotine patch alone Abstinence at 26 weeks by 7 days exhaled carbon monoxide testing 35% 19%
Jorenby[6]
1999		 Community volunteers without medical illness Double therapy with bupropion and nicotine patch Nicotine patch alone Abstinence at 52 weeks by single exhaled carbon monoxide testing Both drugs 36%
Bupropion alone 30%		 16%

Incentives

Financial incentives to either smokers or their health care providers may increase rates of smoking cessation.[16][17][18]

Adverse effects

Smoking cessation may lead to weight gain, which may lead to diabetes mellitus type 2.[19]

References

  1. ↑ Rothemich SF, Woolf SH, Johnson RE, et al (2008). "Effect on cessation counseling of documenting smoking status as a routine vital sign: an ACORN study". Ann Fam Med 6 (1): 60-8. DOI:10.1370/afm.750. PMID 18195316. Research Blogging.
  2. ↑ Lai DT, Cahill K, Qin Y, Tang JL (2010). "Motivational interviewing for smoking cessation.". Cochrane Database Syst Rev (1): CD006936. DOI:10.1002/14651858.CD006936.pub2. PMID 20091612. Research Blogging.
  3. ↑ Lin K, Watkins B, Johnson T, Rodriguez JA, Barton MB (2008). "Screening for Chronic Obstructive Pulmonary Disease Using Spirometry: Summary of the Evidence for the U.S. Preventive Services Task Force". Ann. Intern. Med.. PMID 18316746. [e]
  4. ↑ 4.0 4.1 Parkes G, Greenhalgh T, Griffin M, Dent R (2008). "Effect on smoking quit rate of telling patients their lung age: the Step2quit randomised controlled trial". BMJ. DOI:10.1136/bmj.39503.582396.25. PMID 18326503. Research Blogging.
  5. ↑ Hurt RD, Sachs DP, Glover ED, Offord KP, Johnston JA, Dale LC et al. (1997). "A comparison of sustained-release bupropion and placebo for smoking cessation.". N Engl J Med 337 (17): 1195-202. PMID 9337378.
  6. ↑ 6.0 6.1 6.2 Jorenby DE, Leischow SJ, Nides MA, Rennard SI, Johnston JA, Hughes AR et al. (1999). "A controlled trial of sustained-release bupropion, a nicotine patch, or both for smoking cessation.". N Engl J Med 340 (9): 685-91. PMID 10053177. Cite error: Invalid <ref> tag; name "pmid10053177" defined multiple times with different content
  7. ↑ Jorenby DE, Hays JT, Rigotti NA, Azoulay S, Watsky EJ, Williams KE et al. (2006). "Efficacy of varenicline, an alpha4beta2 nicotinic acetylcholine receptor partial agonist, vs placebo or sustained-release bupropion for smoking cessation: a randomized controlled trial.". JAMA 296 (1): 56-63. DOI:10.1001/jama.296.1.56. PMID 16820547. Research Blogging.
  8. ↑ Gonzales D, Rennard SI, Nides M, Oncken C, Azoulay S, Billing CB et al. (2006). "Varenicline, an alpha4beta2 nicotinic acetylcholine receptor partial agonist, vs sustained-release bupropion and placebo for smoking cessation: a randomized controlled trial.". JAMA 296 (1): 47-55. DOI:10.1001/jama.296.1.47. PMID 16820546. Research Blogging.
  9. ↑ Aubin HJ, Bobak A, Britton JR, Oncken C, Billing CB, Gong J et al. (2008). "Varenicline versus transdermal nicotine patch for smoking cessation: results from a randomised open-label trial.". Thorax 63 (8): 717-24. DOI:10.1136/thx.2007.090647. PMID 18263663. PMC PMC2569194. Research Blogging.
  10. ↑ Anonymous (2009). Important Information on Chantix (varenicline) Food and Drug Administration
  11. ↑ 11.0 11.1 11.2 Eisenberg MJ, Filion KB, Yavin D, et al. (July 2008). "Pharmacotherapies for smoking cessation: a meta-analysis of randomized controlled trials". CMAJ 179 (2): 135–44. DOI:10.1503/cmaj.070256. PMID 18625984. PMC 2443223. Research Blogging. Cite error: Invalid <ref> tag; name "pmid18625984" defined multiple times with different content
  12. ↑ 12.0 12.1 Hajek P, Stead LF, West R, Jarvis M, Lancaster T (2009). "Relapse prevention interventions for smoking cessation". Cochrane Database Syst Rev (1): CD003999. DOI:10.1002/14651858.CD003999.pub3. PMID 19160228. Research Blogging.
  13. ↑ 13.0 13.1 Cahill K, Ussher M (2007). "Cannabinoid type 1 receptor antagonists (rimonabant) for smoking cessation". Cochrane Database Syst Rev (4): CD005353. DOI:10.1002/14651858.CD005353.pub3. PMID 17943852. Research Blogging.
  14. ↑ Davis JA, Gould TJ (September 2007). "Atomoxetine reverses nicotine withdrawal-associated deficits in contextual fear conditioning". Neuropsychopharmacology 32 (9): 2011–9. DOI:10.1038/sj.npp.1301315. PMID 17228337. Research Blogging.
  15. ↑ 15.0 15.1 Steinberg MB, Greenhaus S, Schmelzer AC, et al (April 2009). "Triple-combination pharmacotherapy for medically ill smokers: a randomized trial". Ann. Intern. Med. 150 (7): 447–54. PMID 19349630. [e]
  16. ↑ Volpp KG, Troxel AB, Pauly MV, et al (February 2009). "A randomized, controlled trial of financial incentives for smoking cessation". N. Engl. J. Med. 360 (7): 699–709. DOI:10.1056/NEJMsa0806819. PMID 19213683. Research Blogging.
  17. ↑ Reda AA, Kaper J, Fikrelter H, Severens JL, van Schayck CP (2009). "Healthcare financing systems for increasing the use of tobacco dependence treatment". Cochrane Database Syst Rev (2): CD004305. DOI:10.1002/14651858.CD004305.pub3. PMID 19370599. Research Blogging.
  18. ↑ Karlan D; Zinman J. (August 2008) Put your Money where your Butt is: A commitment Savings Account for Smoking Cessation. Workshop on Economics Experiments in Developing Countries at CIRANO
  19. ↑ http://pubmed.gov/20048267
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