Update on the approach to smoking in patients with respiratory diseases

Sales, Maria Penha Uchoa; Araújo, Alberto José de; Chatkin, José Miguel; Godoy, Irma de; Pereira, Luiz Fernando Ferreira; Castellano, Maria Vera Cruz de Oliveira; Tanni, Suzana Erico; Almeida, Adriana Ávila de; Chatkin, Gustavo; Silva, Luiz Carlos Côrrea da; Gonçalves, Cristina Maria Cantarino; Botelho, Clóvis; Santos, Ubiratan Paula; Viegas, Carlos Alberto de Assis; Sestelo, Maristela Rodrigues; Meireles, Ricardo Henrique Sampaio; Correa, Paulo César Rodrigues Pinto; Oliveira, Maria Eunice Moraes de; Reichert, Jonatas; Lima, Mariana Silva; Silva, Celso Antonio Rodrigues da

doi:10.1590/1806-3713/e20180314

Acessibilidade / Reportar erro

Brasil

Jornal Brasileiro de Pneumologia

Español English

Brasil

Español English

sumário « anterior atual seguinte »

Sumário

SPECIAL ARTICLE • J. bras. pneumol. 45 (03) • 2019 • https://doi.org/10.1590/1806-3713/e20180314 copy

Update on the approach to smoking in patients with respiratory diseases

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Smoking is the leading cause of respiratory disease (RD). The harmful effects of smoking on the respiratory system begin in utero and influence immune responses throughout childhood and adult life. In comparison with “healthy” smokers, smokers with RD have peculiarities that can impede smoking cessation, such as a higher level of nicotine dependence; nicotine withdrawal; higher levels of exhaled carbon monoxide; low motivation and low self-efficacy; greater concern about weight gain; and a high prevalence of anxiety and depression. In addition, they require more intensive, prolonged treatment. It is always necessary to educate such individuals about the fact that quitting smoking is the only measure that will reduce the progression of RD and improve their quality of life, regardless of the duration and severity of the disease. Physicians should always offer smoking cessation treatment. Outpatient or inpatient smoking cessation treatment should be multidisciplinary, based on behavioral interventions and pharmacotherapy. It will thus be more effective and cost-effective, doubling the chances of success.

Keywords:
Respiratory tract diseases/therapy; Respiratory tract diseases/drug therapy; Tobacco use disorder/epidemiology; Smoking cessation; Counseling; Lung neoplasms

Smoking history	Information to be collected and tests to be performed
Age at smoking onset and smoking intensity	Age at onset of regular smoking; number of cigarettes/day; frequency of use; and total smoking history, in pack-years
Forms of nicotine use	Conventional cigarettes; hand-rolled cigarettes; clove cigarettes; chewing tobacco; snuff, hookah; e-cigarettes; heat-not-burn tobacco products; cigars; and pipes
Attempts, treatments, abstinence and outcomes	Number of attempts and previous treatments, with or without success; withdrawal symptoms; and relapse and probable causes
Associated factors: smoking triggers	Behavioral (coffee, alcoholic drink, after meals, driving, etc.); emotional (stress, argument, anxiety, depression, etc.); and environmental (living with smokers at home, at work, or during leisure)
Passive smoking	Passive smoking: secondary and tertiary
Level of dependence	Fagerström Test for Nicotine Dependence
Level of motivation	Motivational stage: Prochaska & DiClementi model; and self-efficacy scale: readiness, importance, and trust
Evaluation of anxiety and depression	Hospital Anxiety and Depression Scale; Beck Anxiety Inventory; and Beck Depression Inventory
Clinical comorbidities that alter the course or management of treatment	Oral lesions; peptic ulcer; diabetes; hypertension; heart diseases; lung diseases; nephropathy; liver disease; cancer; history of convulsion; epilepsy; stroke; allergies (cutaneous, respiratory, and drug-related); and skin disorders
Psychiatric comorbidities that alter the course or management of treatment	Anxiety; depression; bipolar disorder; panic disorder; schizophrenia; attention-deficit/hyperactivity disorder; anorexia nervosa; bulimia; and impulse control disorders (food, shopping, pathological gambling)
Consumption of alcohol or other psychoactive substances	CAGE questionnaire; AUDIT; pattern of alcohol use; recent alcohol withdrawal; and pattern of use of marijuana, crack cocaine, and other drugs
Physical activity and body weight	Regular physical activity; sedentary lifestyle; and body mass index
Medications that can affect treatment	Antidepressants; MAO inhibitors; carbamazepine; phenytoin; barbiturates; antipsychotics; cimetidine; pseudoephedrine; oral hypoglycemic agents; insulin; systemic corticosteroids; and theophylline
Individuals/situations that call for caution in the use of drugs	Adolescents; pregnant or breastfeeding women; the elderly; recent cases of acute myocardial infarction or stroke; severe arrhythmia; use of psychotropic drugs; and chronic renal failure (hemodialysis)
Family history	History of smoking in family members; cohabitation with smokers
Physical examination	Complete physical examination, identifying previous or current symptomatology, limited to the therapeutic protocol to be proposed
Ancillary tests	Basic routine: chest X-ray; spirometry; electrocardiogram; complete blood count; and serum/urine biochemistry; and useful tests in the evaluation and follow-up: exhaled carbon monoxide and cotinine level (in serum, saliva, or urine)

Stage	Description of the stage and motivational counseling strategies
Precontemplation	There is no intention to stop in the foreseeable future (next 6 months); nor is there even the realization that the smoking behavior is undesirable. Counseling strategy: patients should be educated about the risks of smoking.
Contemplation	Although there is awareness that smoking is a problem, there is ambivalence about the perspective of changing; the patient plans to quit within the next 6 months. Counseling strategy: patients are receptive to information about how to change their behavior.
Preparation (determination)	There is a readiness to stop smoking, often within the next month, and the patient is determined to do so. Counseling strategy: patients should actively plan a cessation date as a strategy to change the behavior.
Action	Smoking cessation: the patient takes the action that leads to the desired change in behavior. Counseling strategy: patients should change their behavior and quit smoking.
Maintenance (prevention of relapse)	The patient finalizes the change process or relapses. Counseling strategy: patients should learn strategies to resist triggers and prevent relapse.

Medication	Characteristic
Nicotine replacement therapy	Mechanism of action	Acts on the nicotinic receptors in the nucleus accumbens, in the ventral tegmental area of the central nervous system
	Absorption	Slow: transdermal patch (75% of the dose is absorbed over 24 h), peak plasma concentration in 40 min, serum levels stable after 8-10 h Rapid: gum and lozenges (50% of the dose is absorbed), peak plasma concentration in 20 min
	Metabolism	Nicotine is metabolized into cotinine in the liver; minimal renal elimination in an unaltered form. Only 5% binds to plasma proteins.
	Formulations	Patch^a: 21, 14, and 7 mg, boxes of 7
		Gum^a: 2 and 4 mg, boxes of 30
		Lozenges^a: 2 and 4 mg, blister packs of 4 or boxes of 36
	Standard dosing schedule	Patch: For moderate-to-high dependence (15-20 cigarettes/day): 21 mg/day for 4 weeks, followed by 14 mg/day for 4 weeks and 7 mg/day for 2-4 weeks Gum and lozenges: 2 mg every 1-2 h for 4 weeks, followed by 2 mg every 2-4 h for 4 weeks and 2 mg every 4-8 h for 2-4 weeks. Maximum: 20 per day. Dose can be increased to 4 mg in the first 4 weeks in subjects with high-to-very high dependence
Bupropion	Mechanism of action	Inhibition of reuptake of dopamine, norepinephrine, and serotonin
	Absorption	Rapid by the digestive system, reaching peak plasma concentration in 3 h, remaining high in patients with renal failure
	Metabolism	Half-life of 21 h; metabolized in the liver, mainly by isoenzyme CYP2B6, which can be affected by several drugs; slow release by the kidneys (87%); many drug interactions (see Table 5)
	Formulations	Bupropion hydrochloride tablets, 150 mg; boxes of 30 or 60
	Standard dosing schedule	1 tablet (150 mg) in the morning, after breakfast, for the first 3 days, followed by 1 tablet (150 mg) in the morning and in the afternoon for 12 weeks
Varenicline	Mechanism of action	Partial agonist of α4β2 nicotinic receptors (competes with nicotine for the receptors and releases dopamine) and dopamine reuptake inhibitor
	Absorption	Almost total absorption after oral administration and with high systemic availability; peak at 3 h and steady state at 4 days
	Metabolism	Minimal; renal elimination (92%), excreted in an unaltered form
	Formulations	Varenicline tartrate tablets, 0.5 mg and 1 mg, boxes containing 11 0.5-mg tablets + 154 1-mg tablets
	Standard dosing schedule	1st week: 1 tablet (0.5 mg) per day for 3 days, followed by 1 tablet (0.5 mg) twice daily for 4 days 2nd to 12th week: 1 tablet (1 mg) twice daily

Medication	Characteristic	Points to consider
Nicotine replacement therapy	Prescription	Standard prescription
	Mode of use	Initiation: recommended to start on the scheduled cessation date; can be used as pre-cessation therapy on a case-by-case basis Patch: apply to the trunk every morning, in hairless areas that are not exposed to the sun; leave in place for 24 h; no need to remove for bathing; rotate sites Gum: chew until tasting the flavor or feeling a tingling sensation; then leave between the gingiva and the cheek; chew again for 20-30 min Lozenge: slowly move it around in the mouth, without sucking, chewing or swallowing; dissolves in the oral cavity after 20-30 min
	Precautions	Avoid citrus drinks and food for 15-30 min after using nicotine gum or lozenges.
	Adverse effects	Patch: erythema and infiltration of the dermis at the site of application, sialorrhea, nausea, vomiting, diarrhea, and insomnia Gum: gingival lesions, sialorrhea, unpleasant taste, dental softening, nausea, vomiting, dyspepsia, hiccups, and pain in the TMJ Lozenges: hiccups, sialorrhea, unpleasant taste, and dyspepsia
	Contraindications	In the presence of cerebrovascular disease or cardiovascular disease that is severe or acute (< 15 days), discuss with the specialist and assess the risk-benefit ratio. Avoid the use of nicotine gum or lozenges in patients with active peptic ulcer or TMJ pain. In patients who are pregnant or breastfeeding, weigh the risk-benefit ratio of a dose lower than that of smoking and opt for gum or lozenges over the patch.
	Efficacy	Relative risk of success = 2.60 (95% CI: 1.29-5.24)
	Combinations	Patch used in combination with nicotine lozenges or gum Addition of bupropion or varenicline in cases that are more difficult
Bupropion	Prescription	Restricted prescription, in duplicate
	Mode of use	Start 7 days before the scheduled cessation date. Take the second tablet in the afternoon, at least 8 h after the first.
	Precautions	If possible, avoid taking the 2nd dose after 5:00 p.m., to reduce the risk of insomnia. Patients with gastritis should use an antacid and take bupropion with food. Patients with uncontrolled hypertension should not take bupropion.
	Adverse effects	Reduced reflexes (poor performance on tasks that require motor skills), dry mouth, insomnia, dizziness, headache, agitation, anxiety, tremors
	Contraindications and drug interactions	Numerous drug interactions Relative: harmful use of alcohol; and the use of carbamazepine, barbiturates, phenytoin, antipsychotics, antidepressants, cimetidine, theophylline, systemic corticosteroids, oral hypoglycemic agents, and insulin Absolute: epilepsy and seizures (including febrile seizures), recent alcohol withdrawal, cerebrovascular disease, bulimia, anorexia nervosa, panic attacks, use of MAO inhibitors in the last 14 days, < 16 years of age, pregnancy, and breastfeeding
	Efficacy	Relative risk of success = 2.03 (95% CI: 1.26-3.28)
	Combinations	Addition of nicotine replacement therapy or varenicline in cases that are more difficult
Varenicline	Prescription	Standard prescription
	Mode of use	Start 7 days before the scheduled cessation date 0.5-mg tablets only for the 1st week, then 1-mg tablets twice daily for 11 weeks
	Precautions	The bioavailability is not affected by eating or by the schedule of administration; it can be taken after meals.
	Adverse effects	Most common: nausea (in 33%, rarely requiring discontinuation); and vivid dreaming Some patients report dizziness, dry mouth, drowsiness, and flatulence. It can be associated with depressive mood, suicidal ideation, and lack of control of psychiatric disorders, although such symptoms can also occur due to withdrawal syndrome.
	Contraindications and drug interactions	Few drug interactions Use with caution in smokers with severe psychiatric disorders (psychotic outbreak, suicidal ideation/attempt, etc.): discuss with the psychiatrist.
	Efficacy	Relative risk of success = 3.35 (95% CI: 1.89-5.92)
	Combinations	Addition of nicotine replacement therapy or bupropion in cases that are more difficult

Description	Recommendations
Consultation	All patients with COPD should be asked if they smoke and, if so, should be encouraged to stop smoking and referred to a smoking cessation program.
Start of treatment	Smoking cessation treatment alters the natural course of COPD.
Start of treatment	Begin smoking cessation treatment as part of COPD treatment.
Treatment strategy	Combining behavioral counseling with first-line drugs (nicotine replacement therapy, bupropion, and varenicline) is the most effective approach.
Treatment strategy	Patients who have more difficulty in quitting smoking can benefit from the use of more than one drug or high-dose nicotine patches.
Benefits of smoking cessation	In patients with COPD, the benefits vary depending on age, severity, and comorbidities. Main benefits: Slows the progressive decline in FEV₁ Reduces exacerbation and hospitalization rates Minimizes respiratory symptoms and improves quality of life Reduces the limitations in activities of daily living Improves the ability to perform activities of daily living Improves the control of comorbidities Improves the response to bronchodilators and inhaled corticosteroids

Description	Recommendation
Consultation	All patients should be asked if they smoke.
Chart	Insert a category for smoking status in the patient chart, as one more vital sign.^a
Start of treatment	Initiating treatment in the preoperative period increases cessation rates. Smoking cessation treatment should be integrated into the cancer treatment strategy.
Treatment strategy	Counseling alone is indicated only when pharmacotherapy is contraindicated or refused by the patient.
	Pharmacotherapy is usually similar to that used in the general population.
	First-line pharmacotherapy, in combination with counseling, is cost-effective and should be offered to all patients who smoke, including those in follow-up treatment.
	Patients undergoing chemotherapy or radiotherapy should receive counseling and pharmacotherapy.
Nicotine replacement therapy	Pre-cessation nicotine replacement therapy and counseling provide the best results. Consider using combined therapy, extended therapy, and higher doses of nicotine replacement therapy. Patch: its use is inadvisable in patients with graft-versus-host disease. Gum/lozenges: can accentuate mucositis after chemotherapy.
Bupropion	Its use is indicated in patients with depressive symptoms. It can inactivate tamoxifen and is contraindicated in patients with metastases in the central nervous system.
Varenicline	It can exacerbate the nausea caused by chemotherapy.
Benefits of smoking cessation	Greater chances of survival; a lower risk of relapse; a lower incidence of a second smoking-related primary tumor Better treatment efficacy and response; improved quality of life and pain control; and higher self-esteem Lower risk of surgical complications (pulmonary embolism, suture dehiscence, and infections), as well as of complications of radiotherapy and chemotherapy Lower risk of developing or worsening of other smoking-related diseases

Description	Recommendation
Consultation	Patients should be encouraged to stop smoking and should be referred to a smoking cessation program.
Risks of active smoking	High risk of varicella-zoster virus pneumonitis Two times higher risk of influenza, with worse clinical evolution Four times higher risk of pneumonia in patients with COPD Higher risk of pneumonia in HIV-infected patients Two times higher risk of community-acquired pneumonia Smoking is an aggravating factor for other respiratory infections
Risks of passive smoking	Exposure to environmental tobacco smoke is associated with Mycobacterium tuberculosis infection and active pulmonary tuberculosis
Treatment strategy	Combine behavioral counseling with first-line medications
Benefits of smoking cessation	Reduces the risk of respiratory infections in active and passive smokers, especially children

Sociedade Brasileira de Pneumologia e Tisiologia SCS Quadra 1, Bl. K salas 203/204, 70398-900 - Brasília - DF - Brasil, Fone/Fax: 0800 61 6218 ramal 211, (55 61)3245-1030/6218 ramal 211 - São Paulo - SP - Brazil
E-mail: jbp@sbpt.org.br

Acompanhe os números deste periódico no seu leitor de RSS

[1] Correspondence to:
Maria da Penha Uchoa Sales. Rua Gothardo Moraes, 155/1002A, CEP 60177-340, Fortaleza, CE, Brasil. Tel.: 55 85 99909-8728. E-mail: puchoasales152@gmail.com