Tobacco product use and smoking cessation

Tobacco use is the leading cause of preventable disease and death in the US. Tobacco products are available in multiple forms (e.g., cigarettes, snuff), including nicotine products that contain no tobacco (e.g., e-cigarettes, gum). Tobacco products are highly addictive, and their use is associated with a multitude of negative health outcomes. All individuals should be screened regularly for tobacco product use; those who screen positive should be offered assistance to quit. Management consists of providing advice on the health risks of continued use and offering both pharmacological and behavioral treatments for smoking cessation. Close follow-up is important, as relapse is common in the first days or weeks after an attempt to quit. For children, adolescents, and pregnant individuals who use tobacco products, behavioral therapy alone is recommended.

• Tobacco: leaves of the plant Nicotiana tabacum, which can be smoked, sniffed, or taken orally
• Nicotine: an addictive alkaloid found in high concentrations in tobacco ^[1]
• Tobacco products: any products containing tobacco or nicotine ^[2][3][4]
  • Forms of tobacco
    • Cigarettes
    • Cigars, little cigars, and cigarillos
    • Bidis ^[5]
    • Pipes
    • Hookahs (water pipes)
    • Chewing tobacco
    • Snuff
    • Snus
    • Dissolvable tobacco
    • Heated tobacco products ^[6]
  • Nicotine products: tobacco-free products containing nicotine that is artificially synthesized or derived from tobacco ^[7]
    • Electronic nicotine delivery systems (also referred to as e-cigarettes, vapes, or tanks) ^[8]
    • Nicotine lozenges, gummies, and gum ^[9]
    • Nicotine pouches ^[3]

• Tobacco use is the leading cause of preventable disease and death in the US. ^[10][11]
• 18.7% of adults currently use tobacco products. ^[2]
• Prevalence of tobacco product use is higher among: ^[12][13]
  • Men
  • Individuals with psychiatric disorders
  • Individuals with disabilities
  • Lesbian, gay, and bisexual individuals
  • Low-income individuals
• 68% of adult cigarette smokers report interest in quitting. ^[14]

Epidemiological data refers to the US, unless otherwise specified.

• Nicotine stimulates nicotinic receptors in the central nervous system and autonomic ganglia, leading to both sympathetic and parasympathetic effects. ^[1]
• Addiction develops from a combination of:
  • Positive neuropsychiatric effects (see “Clinical features of tobacco product use”)
  • Development of nicotine dependence: repeated exposure → substance tolerance → nicotine withdrawal in the absence of nicotine use

Clinical features of tobacco product use

• Neuropsychiatric effects: ↑ release of neurotransmitters, including dopamine, in the brain → activation of the mesolimbic pathway (reward pathway) → euphoria, reduced anxiety, increased alertness ^[15]
• Cardiovascular effects: : stimulation of catecholamine release → tachycardia, ↑ blood pressure ^[16]
• Metabolic effects: ↑ resting metabolic rate, ↓ appetite → weight loss ^[17]
• Signs of long-term use include:
  • Staining of fingers or teeth ^[18][19]
  • Clinical features of complications of tobacco product use

Clinical features of nicotine intoxication ^[20]

• Mild toxicity: nausea, vomiting
• Severe toxicity can lead to cholinergic syndrome.
• See also “Nicotine poisoning.”

Clinical features of nicotine withdrawal ^[13][21]

• Irritability, frustration, anger, restlessness, anxiety
• Cravings
• Dysphoria, depressed mood
• Insomnia
• Impaired concentration
• Increased appetite, weight gain

Indications

• Adults ≥ 18 years and pregnant individuals: Screen regularly at clinical encounters.
  ^[22][23]
• Children > 11 years of age: Screen at least annually. ^[24][25]

Screening modality ^[22]

• Ask all patients about current and past use of nicotine and tobacco products, e.g.:
  • As part of strategies incorporating both screening and intervention:
    • 5 As model of behavior change
    • Ask Advise Refer or Ask Advise Connect ^[26]
  • Via screening tools for substance use, e.g.: ^[27]
    • TAPS tool
    • NIDA quick screen
  • By routinely collecting information about tobacco product use status at every clinical encounter
• See also “Tobacco product use in children and adolescents” for screening recommendations in this age group.

When screening for tobacco product use, ask broad questions that cover smoking, oral ingestion, and use of nicotine products. ^[28]

Further management ^[28]

• Offer assistance with smoking cessation to current smokers.
• Initiate preventive health care for current and former smokers.
• Repeat screening for all patients at recommended intervals.

General principles

• Diagnostic studies are not routinely required for patients with a current or past history of tobacco product use.
• Assessing patients for tobacco use disorder can help determine the severity of dependence but does not affect management.
• Results of tests performed for other indications may be abnormal in smokers, e.g., elevated Hb.
• Further studies (e.g., imaging) may be appropriate as part of lung cancer screening or in patients with symptoms of complications of tobacco product use.

Exhaled carbon monoxide tests and cotinine (a nicotine metabolite) urine and saliva tests can detect smoking but are more often used in research than in clinical practice. ^[29]

Diagnostic criteria for tobacco use disorder ^[13][28]

Common abnormal values in smokers

• Blood gas: ↑ carbon monoxide levels ^[31]
• CBC: ↑ hemoglobin (smoker's polycythemia), ↑ hematocrit ^[32]
• CEA: Slight elevations are common. ^[33]

This section is focused on management of tobacco smoking cessation. Guidelines on treatment of patients who use other tobacco and nicotine products (e.g., chewing tobacco, e-cigarettes) are lacking, and treatment plans should be individualized through shared decision-making.

Approach ^[22][26]

• Initiate preventive health care for current and former smokers.
• Advise patients on the health benefits of smoking cessation and harms of continued use.
• Offer a combination of pharmacological and behavioral treatments for cessation to all patients.

A combination of behavioral and pharmacological therapies to stop smoking increases the likelihood of treatment success. ^[28][34]

Patients not currently interested in quitting

• Offer varenicline to reduce nicotine dependence. ^[34]
• Advise patients that they can return at any point for support with smoking cessation.
• There is no consensus on harm reduction strategies for tobacco smoking. ^[35]

Patients interested in quitting

• Inquire about past attempts to quit, including their duration and any tools used.
• Assess the degree of nicotine dependence (e.g., number of cigarettes per day, timing of first cigarette). ^[13]
• Encourage the selection of a specific quit date and help formulate a treatment plan. ^[34][36]
• Educate patients on expected withdrawal symptoms and duration. ^[37]
• Discuss how to manage cravings. ^[38]
• Arrange follow-up within 2–4 weeks to evaluate for barriers to quitting or problems with the treatment plan. ^[28]

Patients may either quit by gradually reducing smoking or by immediately stopping use. Regardless of the strategy, the goal should be complete cessation.

Approach ^[8][13][34]

• Initiate a first-line smoking cessation medication through shared decision-making. ^[34][39]
  • Varenicline is associated with higher success rates than bupropion and nicotine replacement therapy (NRT).
  • A combination of NRT products is more effective than a single form of NRT alone.
• For patients starting varenicline or bupropion, begin medication ≥ 1 week before the planned quit date.
• Follow up closely with patients to assess for side effects and efficacy.
  • For patients experiencing side effects: Consider reducing the dose or changing to another first-line smoking cessation medication. ^[40]
  • For patients with a poor response, see “Managing relapse during smoking cessation.”
• Recommended treatment duration is usually 12–24 weeks to reduce the risk of relapse. ^[8][34]

E-cigarettes are not FDA-approved for smoking cessation and are not currently recommended. Although studies show they are effective for quitting tobacco use, most patients continue to use e-cigarettes, and their long-term health consequences are unknown.^[22][41][42]

First-line pharmacotherapy

Bupropion decreases the seizure threshold and is contraindicated in patients with seizure disorders. ^[8]

Combining the nicotine patch with a short-acting form of NRT (i.e., gum, lozenge, inhaler, or nasal spray) is more effective for smoking cessation than using only one form of NRT. ^[45]

Alternative pharmacotherapies ^[13][46]

• Second-line treatments: Nortriptyline and clonidine can be used off-label for smoking cessation.
• Cytisine is a partial nicotine agonist that is used for smoking cessation in some countries, but it is not currently available for use in the US. ^[39]

The following interventions can improve smoking cessation success. ^[8][22][26]

• Advice to quit from a health care professional
• Individual or group counseling (e.g., CBT, behavioral therapy)
• State tobacco quitlines (1-800-QUIT-NOW) : interactions (phone or text) with trained tobacco cessation counselors
• Support via smartphone apps, internet, or text messaging ^[47][48]
• Individualized self-help materials (written, audio, or video)
• Patient incentives (vouchers or cash payments)

There is insufficient evidence to support the use of acupuncture, hypnotherapy, or biomedical feedback (e.g., spirometry or carbon monoxide monitoring) for smoking cessation. ^[26]

• Encourage patients to see relapses as learning opportunities rather than failures.
• Explore the reasons for relapse (e.g., triggers, poor adherence to pharmacotherapy).
• To reduce the risk of relapse for their next quit attempt:
  • Discuss avoidance of triggers, and create a plan for responding to triggers that cannot be avoided.
  • Increase the frequency of counseling or try a different method of counseling.
  • Provide more frequent follow-up.
  • Encourage patients to seek support from family and friends.
  • For patients with poor response to pharmacotherapy, consider: ^[28]
    • Addition of behavioral therapy, if not already using
    • Combination therapy (e.g., varenicline PLUS NRT)

Most smokers relapse within days or weeks after an attempt to quit, but relapse can also occur years after successful cessation. ^[8]

Primary prevention

• Advise all individuals to abstain from tobacco product use.
• To help protect children and adolescents:
  • Ask about tobacco product use among household members of children and adolescents. ^[49]
    • Encourage household members who smoke to quit, referring for smoking cessation as indicated.
    • For household members who do not wish to quit, recommend they stop smoking in their homes and cars.
  • Educate children on the harms of tobacco products. ^[49][50]

Preventive health care for current and former smokers

• To facilitate early detection and management of complications of tobacco product use, educate patients on the importance of attending adult health maintenance visits and undergoing cancer screening.
• Additional screening may be recommended.
  • AAA screening: a one-time screening in men 65–75 years of age who have ever smoked ^[51][52]
  • Patients may require lung cancer screening depending on lifetime cigarette consumption in pack years. ^[53]
    • Pack years: the number of cigarette packs (1 pack = 20 cigarettes) that an individual smokes or has smoked per day multiplied by the number of years of cigarette consumption
    • Lung cancer screening is recommended annually for patients aged 50–80 years with a ≥ 20 pack-year smoking history. ^{[53][54][55] [53]}
• Advise patients to remain up-to-date with routine vaccinations; catch-up pneumococcal vaccination is recommended if the primary series is incomplete (see “Immunization schedule by medical indication”).

The USPSTF recommends against screening asymptomatic adults for COPD. The GOLD guideline recommends screening with spirometry in patients undergoing annual lung cancer screening with low-dose CT scans and patients with incidental imaging findings consistent with COPD. ^[56][57]

Tobacco product use is a chronic condition requiring long-term management even after cessation. ^[13]

Tobacco product use in children and adolescents ^[58]

• Most nicotine dependence starts in childhood and adolescence; e-cigarettes are the most commonly used product. ^[3][20]
• Nicotine use impairs adolescent brain development. ^[58]

Screening tools

Validated screening tools for tobacco product use in this population include: ^[49]

• Screening to Brief Intervention (S2BI)
• Brief Screener for Tobacco, Alcohol, and other Drugs (BSTAD)

Management

Evidence for smoking cessation treatment in children and adolescents is limited. ^[49][50]

• Offer behavioral treatment for smoking cessation for all patients. ^[49]
• Pharmacotherapy may be considered for adolescents with moderate to severe nicotine dependence. ^[49]

Tobacco product use in pregnancy and postpartum

• Tobacco products are teratogenic (see “Risks of tobacco product use during pregnancy”).
• All patients should undergo screening for tobacco product use during preconception care, prenatal care, and the postpartum visit. ^[22]
• Smoking cessation before 15 weeks' gestation is recommended to reduce the risk of perinatal complications. ^[23]

Smoking during pregnancy is associated with an increased risk of obstetric complications and complications for the fetus and birthing parent. ^[23]

Management ^[22][23]

• Educate patients and household members on the risks of:
  • Tobacco product use during pregnancy (including through secondhand smoke)
  • Secondhand smoke exposure in the neonatal period ^[59]
• Offer behavioral interventions for smoking cessation to all pregnant individuals who smoke. ^[22][23]
• Continue behavioral and psychosocial support in the postpartum period. ^[23]
• In breastfeeding individuals, NRT may be considered after shared decision-making. ^[60][61][62]

Because of the risk of secondhand smoke to the fetus and neonate, recommend smoking cessation for all household members. ^[49]

Relapse to smoking is common in the first year postpartum. Continue to assess and manage tobacco use disorder after delivery. ^[23]

• Cancer (e.g., lung cancer, esophageal cancer, cervical cancer, oral cancer) ^[28]
• Cardiovascular disease (including coronary heart disease and stroke) ^[28]
• Respiratory disease (e.g., COPD)
• Diabetes
• Periodontal disease
• Early death
• Erectile dysfunction
• Age-related macular degeneration
• Postoperative complications (e.g., delayed wound healing, postoperative pulmonary complications)
• Delayed and nonunion of fractures ^[63]
• E-cigarette or vaping product use associated lung injury (EVALI) ^[64]
• Perinatal complications: See “Risks of tobacco product use during pregnancy.”

Tobacco smoke contains > 7000 chemicals, including carcinogens, respiratory irritants, and other toxins. ^[1]

The development of smoking-related complications can be a motivator for behavioral change and an opportunity to engage patients in smoking cessation treatment. ^[8]

We list the most important complications. The selection is not exhaustive.

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