Combination of two images - woman smoking in a café and yellow dahlia flower

Non-adherence to smoking cessation treatment regimens can play a significant role in limiting their effectiveness

Only 50% or less of NRT users adhere to the recommended length of treatment21-23

It’s important to discuss the issues that your patients may face in remaining adherent to NRT and help them overcome them to increase their chances of quitting success

Potential issues limiting adherence to NRT

Issue
Solution
Perception that efficacy decreases with longer use

Counsel patients that proper duration of use increases the chances of quitting success. Studies show:21,24

  • The amount of NICORETTE® Lozenge use 1-2 weeks after the quit date predicted abstinence at 6 weeks (OR: 1.25 for ‘high’ [10.2 ± 2.5] vs. ‘low’ [5.1 ± 1.9] lozenge use, p<0.02)
  • A significant impact of oral nicotine consumption during the first week on abstinence at 4 weeks (adjusted OR per additional mg/day = 1.05); the amount of NRT consumed (a mix of patch and short-acting oral formats) predicted future abstinence
  • Patients using NRT for >5 weeks were significantly more likely to report continuous abstinence at 6 months than those using it <5 weeks (p<0.001)*
Concerns about long-term safety

Provide accurate safety information to help increase your patients’ willingness to use NRT:25

  • Nicotine has not been shown to cause cancer26
  • Toxins in cigarette smoke, rather than nicotine, cause chronic lung disease, heart disease and other disorders26
  • NRT safety profiles have been established in over 30 years of worldwide clinical use27
Practical issues (e.g., cost; run out of medication)

Offer strategies to help patients overcome their hurdles:

Lack of confidence and/or motivation in quitting

Use every visit to identify barriers and offer solutions:

  • Talking to patients about the serious health consequences of smoking can help motivate some smokers to quit
  • Use counselling tools to help patients manage triggers and cravings
  • Be persistent: even less than 3 minutes of counselling can help a smoker quit.4 Learn more

*Data from the 2010-2011 US Current Population Survey, Tobacco Use Supplement. Analysis was limited to current daily smokers who made a quit attempt in the past year and former smokers who were daily smoker 1 year prior to the survey (n=8263). Respondents were asked about duration of use of prescription medication (varenicline, bupropion, other) and NRT (nicotine patch, gum/lozenges, nasal spray, inhaler). Primary outcome was successful smoking cessation.

Other pharmacotherapy

If you are prescribing varenicline or bupropion, it is important that your patient knows what to expect. Discussing possible side effects upfront can help improve adherence.

Varenicline

It is important to explain to your patients that even though varenicline is designed to help relieve cravings and withdrawal symptoms, quitting smoking still requires motivation and commitment. When quitting smoking, with or without varenicline, patients might experience:28

  • Urge to smoke
  • Depressed mood
  • Trouble sleeping
  • Irritability, frustration, anger
  • Anxiety
  • Difficulty concentrating
  • Restlessness
  • Decreased heart rate
  • Increased appetite or weight gain

To minimize nausea as a side effect, patients can take varenicline after eating and with a full glass of water. Patients should be encouraged to continue in their quit attempt even if they have early lapses after their quit date.28

Adherence data:

  • Catz S et al. (2011): Smokers were randomized to receive different modes of cessation counselling and varenicline. Good adherence (≥80% of days taken) was associated with a 2X increase in 6-month quit rates vs. poor adherence (52% vs. 25%).29
  • Hays et al. (2010): Three factors were shown to predict adherence: higher age, abstinence at week 2 and smoking 20 fewer cigarettes/day in the last month. Adverse events in the first 30 days did not significantly predict adherence.30

Bupropion

As with all forms of pharmacotherapy, beliefs about medication may be associated with treatment adherence and outcomes.

Adherence data:

  • Fucito et al.: Beliefs and attitudes about bupropion were shown to predict outcomes.31
  • World Health Organization: Studies suggest that adherence to smoking cessation therapies is a logarithmic function of the number of weeks of treatment and shows a rapid decrease during the first 6 weeks of treatment, followed by a slower decline after 24 weeks.32
  • Gifford et al. 2002 showed a similar decline with buproprion SR: adherence was 75% at week 3, decreasing to 40% at week 7 and 28% at week 10.33

Distraction techniques

Healthy distraction techniques can help patients fight the urge to smoke. Many help to satisfy the ‘hand-to-mouth’ ritual of smoking. Here are a few strategies to offer your patients:34

Keep your hands and mouth busy with other things:

  • Drink a glass of cold water
  • Brush your teeth; use mouthwash/breath strips
  • Chew gum
  • Do chores, such as vacuuming, filing papers or washing the dishes
  • Enjoy a low-calorie snack (e.g., raw carrots, sunflower seeds, nuts) – something crunchy and satisfying
  • Engage in a fun activity, like doing a crossword or playing a game on your phone or tablet

If you’re feeling bored or irritable (and crave a cigarette), do something relaxing:

  • Stretch
  • Go for a walk or work-out
  • Call up a friend
  • Listen to relaxing music
  • Practice relaxation breathing: breathe in through your nose expanding your stomach (rather than your chest) and then exhale slowly through your mouth

What factors may predict relapse?

In a U.S. survey, the strongest baseline predictors for relapse of self-initiated quitters were:35*

  • Shorter period of abstinence during the longest prior quit attempt (p=0.001)
  • Lower motivation for quitting (p=0.006)
  • Lower short-term confidence (p=0.009)
  • Having a significant other or >50% of friends who were smokers (p=0.020)
  • Greater alcohol consumption (p=0.023)

*A study of 235 smokers who initiated quit attempts a median of 4 days after baseline interviews. Relapse was defined as >7 consecutive days or episodes of smoking. Subjects were interviewed by telephone or in-person. Changes in psychological stress were determined using a 5-point Likert scale.

Longer duration of use of pharmacotherapy was shown to be associated with a greater chance of abstinence (p<0.001):24*

Adjusted cessation rates at 6 months:†

  • 5+ weeks of use: 27.8%, NRT; 28.8%, prescription medications vs.
  • <5 weeks of use: 14.5%, NRT; 6.2%, prescription medications

*Data from the 2010-2011 US Current Population Survey, Tobacco Use Supplement. Analysis was limited to current daily smokers who made a quit attempt in the past year and former smokers who were daily smoker 1 year prior to the survey (n=8263). Respondents were asked about duration of use of prescription medication (varenicline, bupropion, other) and NRT (nicotine patch, gum/lozenges, nasal spray, inhaler). Primary outcome was successful smoking cessation.

†Adjusted for the effect of number of cigarettes smoked per day, sex, age, race/ethnicity, education, occupation and family income.

Longer duration of use of pharmacotherapy was shown to be associated with a greater chance of abstinence (p24*

 

Adjusted cessation rates at 6 months:†

 

5+ weeks of use:

27.8%, NRT;

28.8%, prescription medications

<5 weeks of use:

14.5%, NRT;

6.2%, prescription medications

*Data from the 2010-2011 US Current Population Survey, Tobacco Use Supplement. Analysis was limited to current daily smokers who made a quit attempt in the past year and former smokers who were daily smokers 1 year prior to the survey (n=8263). Respondents were asked about duration of use of prescription medication (varenicline, bupropion, other) and NRT (nicotine patch, gum/lozenges, nasal spray, inhaler). Primary outcome was successful smoking cessation.

† Adjusted for the effect of number of cigarettes smoked per day, sex, age, race/ethnicity, education, occupation and family income.

NEXT: Readiness to Quit