Smoking Cessation and Tobacco-Related Disease
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Direct answer
Smoking cessation is the single most effective measure against tobacco-related disease, and it remains worth attempting even in patients with established lung, cardiac or cancer disease. First-line pharmacotherapy comprises nicotine replacement therapy, varenicline and bupropion, which all improve quit rates over unaided attempts, and combining counselling with medication gives the best results. In India, smokeless tobacco and areca nut use add substantially to the burden, so cessation advice must cover every form of tobacco.
What you must remember
- Varenicline: a partial nicotinic receptor agonist started about a week before the quit date; nausea is the commonest side effect, and the dose is reduced in renal impairment.
- Bupropion: a noradrenaline and dopamine reuptake inhibitor that is contraindicated in active seizure disorder, eating disorders and abrupt alcohol or benzodiazepine withdrawal.
- Nicotine replacement: patches, gum, lozenges and inhalers; combining a long-acting patch with a short-acting form improves abstinence, and it is usable in stable cardiac disease.
- Burden of disease: smoking accounts for most lung cancer and COPD and a large share of coronary disease, and quitting before about 40 years of age avoids most of the excess mortality.
- Smokeless and areca use: oral submucous fibrosis is strongly linked to betel quid and areca nut chewing, and it carries malignant potential.
- Legal framework: the Cigarettes and Other Tobacco Products Act of 2003 restricts smoking in public places, advertising and sales to minors.
- Brief advice: ask about tobacco use, advise quitting, assess readiness, assist with pharmacotherapy and arrange follow-up.
A cessation plan for a smoker with COPD
A 56-year-old man smoking about 30 pack-years has COPD with an FEV1 of 55 percent predicted, and he also chews tobacco and smokes bidis. He says he wants to quit, so the clinician plans a cessation approach with him.
- Confirm readiness: The clinician confirms his readiness, sets a quit date and chooses between varenicline and combination nicotine replacement based on his preference and any contraindications.
- Start pharmacotherapy: Varenicline is started one week before the quit date, and the first follow-up at one week checks nausea, mood and adherence.
- Follow up and reinforce: Follow-up continues at two and four weeks, with relapse-prevention strategies such as avoiding triggers and planning for cravings.
- Treat all tobacco: The bidi and smokeless habits are treated as tobacco use in their own right, because stopping only cigarettes leaves the same carcinogens in the mouth and airways.
- Use objective feedback: Spirometry at review shows whether the decline in lung function has slowed. Where available, a breath carbon monoxide measurement gives an objective check on recent smoking at each visit.
Where the exam tries to catch you
Cessation questions usually hinge on a contraindication or a misattributed cause.
- Trap: choosing bupropion for a patient with epilepsy. Correct: bupropion lowers the seizure threshold and is contraindicated in active seizure disorder.
- Trap: blaming nicotine for smoking-related cancer. Correct: nicotine drives dependence, while tar, carbon monoxide and other combustion products cause most smoking-related cancers and COPD.
- Trap: giving nicotine replacement in acute myocardial infarction. Correct: it is avoided in the immediate post-infarction period, while stable coronary disease is not a contraindication.
- Trap: a lung-only assessment for an areca nut chewer. Correct: blanched mucosa, fibrous bands or restricted mouth opening needs oral examination, and the stem links oral submucous fibrosis with betel quid rather than cigarettes.
Frequently asked questions
Which smoking cessation drug is contraindicated in seizure disorders?
Bupropion is contraindicated in active seizure disorder because it lowers the seizure threshold, a risk that does not apply to nicotine replacement therapy. Bupropion is also avoided in eating disorders and in abrupt alcohol or benzodiazepine withdrawal.
Why is nicotine replacement safer than smoking?
Nicotine replacement delivers nicotine without the tar, carbon monoxide and other combustion products that cause most smoking-related cancers and COPD. It still raises heart rate and blood pressure, so caution is advised in unstable angina and in the immediate period after myocardial infarction.
Which oral lesion is linked to areca nut and smokeless tobacco use in India?
Oral submucous fibrosis is strongly linked to areca nut and betel quid chewing, with tobacco often increasing the risk. It presents with burning mouth, restricted mouth opening and fibrosis of the oral mucosa, and it has malignant potential.
When should varenicline be preferred over nicotine replacement?
Varenicline is generally more effective than single-agent nicotine replacement in published comparisons, so it is often preferred for motivated patients without contraindications. Its dose is adjusted in renal impairment, and nausea is the commonest adverse effect.