Tobacco Use: Intervention and Cessation

Department of the Navy
Bureau of Medicine and Surgery

Epidemiology

Tobacco use, both smoked and smokeless, continues to be a major health behavior problem in both the Navy and Marine Corps. The most recent available and reliable data indicates an overall smoking rate of 34.9 percent in the Navy and 35 percent in the Marine Corps, and military smokers tend to be heavier smokers.

The use of smokeless tobacco products (chew, dip, spit, and snuff) is at 13.2 percent DoD wide, with the USMC obtaining the highest consumption rates at 24 percent, and the Navy using at a 12 percent rate. Many observers suspect that the reported data of smokeless prevalence rates among Marines are low.

The use of cigars and pipes has been surveyed and revealed overall prevalence rates of 28.4 percent among the Marine Corps and 17.1 percent among the Navy. The 1995 DoD survey data suggests that the Marines and the Navy have higher prevalence tobacco rates of smoking and smokeless usage than the civilian population; and that the prevalence rates have been declining since they have been measured in 1980.

Tobacco Hazards

Tobacco contains over 4,000 chemicals that include carcinogens (nitrosamines), heavy metals (cadmium), poisons (arsenic), and radioactive elements (radium and polonium). The menthol component of cigarettes adds an additional risk since menthol allows deeper lung penetration of tobacco smoke leading to a greater risk of deadly small cell lung cancer.

The nicotine present in tobacco is the addictive component that enhances habit formation. Studies have shown it to be as addictive as opiates. While its link to cancer has been fully established, according to the book Nicotine Safety and Toxicity, the nicotine in tobacco has not been shown to be a carcinogen in any animal based studies. Nicotine acts as a vasoconstrictor, a stimulant, and an appetite suppressant.

Smokeless tobacco is equally as dangerous as smoked tobacco. It has more nicotine by weight than smoked tobacco and is therefore considered more addictive. Smokeless tobacco also produces additional carcinogens when mixed with saliva. Extra care must be taken when working with smokeless tobacco cessation due to the heavier addiction to nicotine.

The current fad with cigars is considered to be extremely dangerous. The average cigar is the diameter of an index finger and has 6 times the nicotine of a cigarette. This increase also pertains to the increase of carbon monoxide, tars, and carcinogens. The risk of lung cancer is equal to smoking cigarettes but the risk of head and neck cancer is greatly increased. Cigar smokers generally do not inhale as with cigarettes but the contents are puffed and held in the oral cavity, thus leading to the increased risk of head and neck cancers.

Second hand smoke (environmental tobacco smoke, passive smoke, side stream smoke) has been labeled as a Class A carcinogen by the Environmental Protection Agency. This action helped lead to the removal of all tobacco use in all Federal facilities. This smoke has been linked to lung cancer, heart and vascular disease, respiratory infections, and asthma in non-smokers. Approximately 4 million children each year are seen in acute care due to middle ear infections, upper respiratory infections, and asthma, linked to parental / caregiver smoking.

The Navy and Marine Corps have encouraged cultural change and cessation efforts by banning tobacco use during recruit training, prohibiting tobacco use in the workspace, making tobacco prevention and cessation an integral part of the Health Promotion and Semper Fit programs, promoting healthy lifestyles, and by offering cessation treatment programs. Despite progress, some researchers have found that up to 10 percent of graduating boot camp recruits begin a tobacco habit upon leaving basic training and up to 80 percent previous users return to their tobacco habit.

Most smokers and smokeless users begin during adolescence. The reasons an individual smokes and or chews/dips are complex and are usually maintained and reinforced by a combination of behavioral, psychological, and physiological factors. Nicotine is an addictive drug and nicotine dependence is listed in the psychiatric nomenclature (DSM-IV) as a substance use disorder.

A one-time message of tobacco use intervention / cessation in a clinical setting has been shown to have a 5 percent success in getting tobacco users to either quit or to decrease their tobacco habit. Although this may be a small percentage, each opportunity needs to be taken to help decrease the use of tobacco. The medical community has a unique opportunity and the means to help tobacco users quit. In keeping with current Navy guidelines, the Agency for Health Care Policy and Research (AHCPR) and the National Cancer Institute (NCI) recommends that the Physician utilize the "Ask, Advise, Assist, and Arrange" Program.

• Tobacco use intervention should occur at each patient visit. The medical officer asks about tobacco use at every contact/visit, identifies users and assesses the patient’s readiness to quit. Initial questions for each patient could include the following: Do you use tobacco? What type(s) of tobacco do you use? How much do you use per day (packs/pouches/cans)? Not every person is ready to change their nicotine habit, and studies have identified a consistent behavior change pattern, which may be helpful in understanding and facilitating change. The transtheortical model emphasizes stages of change: precontemplation, contemplation, preparation, action, maintenance, and termination. The key features of this model are that an individual’s readiness to change can be assessed; and that specific interventions are tailored to the person’s stage of change, in order to increase the likelihood of success.

• The physician has the influence, as a credible expert in a position of authority, to suggest and advise patients to quit tobacco use. The medical officer may state, in a kind, warm, serious and direct manner, for the patient to quit. One often used phrase is- "As your physician, I must advise you to quit", or another is "I need you to know that quitting smoking/smokeless tobacco is the most important thing you can do to protect your current and future health".

• Each tobacco user should be informed of the hazards of tobacco use, the benefits of quitting, and where to get help in quitting. Additionally, if the patient is pregnant, the expecting mother must be informed that her tobacco use is harming both herself and her fetus. This harm could include low birthweight / preterm birth, spontaneous abortion, or miscarriage. The nicotine of the tobacco product is concentrated in the fetal tissues and acts as a fetal neurotoxin. Studies also show that the baby born of a tobacco-using mother will undergo nicotine withdrawal upon birth.

• The physician assists the patient by discussing various quitting strategies (cold turkey, tapering, nicotine fading), and by reviewing common and specific problem areas (withdrawal symptoms, tension, cravings, weight gain, psychosocial stressors, and relapse prevention). The physician also assists by listening to concerns and issues, by providing self-help materials, and if possible, by establishing a quit date.

• The final and critical step is to arrange follow up supportive care and or other more intensive interventions such as a referral to a formal tobacco cessation program. Scheduling follow up supportive appointments or phone calls assists with fostering a therapeutic relationship, helps with the commitment to quit, offers support and surveillance, and increases the number of quit attempts and quitters. Each user should receive a prepared wallet-sized card or paper-slip at each visit with the phone number and location of the tobacco cessation program.

Any counseling given to patients must be given in an encouraging, empowering manner. Current studies show that 48 percent of 18 to 24 year old Marines use smokeless tobacco. This fact coupled with an alarming increase in teen / young adult smoking (1.5 million start each year), leads to a more difficult group to encourage to quit. Although young tobacco users have an advantage in that they have spent fewer years forming their tobacco habit, their young age suggests that they will have greater risk taking behaviors and less fear of the fatal effects of tobacco use. These youthful tobacco users would best be reached by appealing to their sense of esthetics and monetary budgeting.

The aging effects of tobacco (wrinkling), yellowing teeth, stained hands, offensive breath odor, and the monetary costs ($1,100 per year for 1 pack / day) of tobacco use should be strongly used to effect a decrease or cessation of their tobacco habit. Current research shows gradual reduction in tobacco use demonstrates to the user that they have control of their habit and that they can indeed quit. People who have successfully kicked their tobacco habit have made, on the average, at least 6 serious attempts.

Regardless of the message content, the key is to empower the tobacco user in their attempt to quit by providing brief, uplifting advice and motivational counseling. The medical officer may use the patient’s medical history, presenting complaints, physical exam, results of the lab tests and non-health reasons (cost, inconvenience, role model, self esteem) to help personalize the message to quit. The expression of confidence in the patient’s ability to quit and accentuating the positives of quitting seem to be beneficial.

Cessation Medications and Counseling

The benefits of nicotine replacement therapy (NRT), medicinal adjuncts (Bupropion), herbal replacements (non-tobacco / mint snuff products) and behavior modification should be considered in any cessation counseling. Numerous studies have established the effectiveness of NRT, and the AHCPR Clinical Practice Guidelines recommend that NRT should be offered to every smoker, except when medically contraindicated. Each patient should be informed that nicotine has not been shown to be a carcinogen. Nicotine is simply the addictive component of tobacco.

The list of NRT and adjunctive medications / materials is growing daily. Since no one single product is appropriate or suitable for all patients, the cessation counseling should include a brief description of materials available to allow patients the opportunity to select a program that fits their specific needs. Some of the tested, efficacious medications / adjuncts available include:

Nicotine Replacement Therapy (NRT)

• Transdermal Patch- Nicoderm, Habitrol, Prostep, Nicotrol

• Nicotine Gum- Nicorette 2 and 4 mg. (mint and regular flavor)

• Inhaler: Nicotrol Inhaler

• Nasal Spray: Nicotrol N/S

• Sublingual Tablet: 2 mg Nicotine Sublingual Tablet (awaiting FDA approval)

• Bupropion- Wellbutrin SR, Zyban 150 mg daily, for 3 days then 150 mg BID

• Snuff Replacement- Mint Snuff

The GMO does not have to be the only medical provider involved in the tobacco cessation process. Studies have found that by use of a systematic, coordinated office plan or a prevention team approach, such as the national PPIP (Put Prevention Into Practice) program, increases success, is effective, and is time efficient. This team approach can be accomplished by screening for tobacco use as a fifth vital sign; asking about tobacco at every work station; documenting tobacco use; and by encouraging Sailors and Marines to quit by every member of the health care team. Also helpful is selecting a tobacco cessation coordinator who trains the team, and sets up, implements, and evaluates the tobacco clinic program.

The gender differences in nicotine dependence treatment are also very important to note. Women have been shown to be biologically less sensitive to nicotine levels, more sensitive to the method of nicotine delivery, more sensitive to non-pharmacological effects, and less receptive to psychoactive effects. Studies indicate that female hormones may account for some of these differences. Men have been shown to be more sensitive to nicotine levels than women. Additionally, women are much more sensitive to issues regarding weight gain and social factors associated with tobacco use. These differences have strong implications in the delivery of cessation programs and should be addressed on an individual basis.

The issue of weight gain is a very important in light of the current military, physical readiness standards. Studies indicate that quitting tobacco can result in up to a 7 percent decrease in the metabolism of some patients. Nicotine is both a stimulant and an appetite suppressant. Patients quitting tobacco must be counseled to increase their exercise routine and to watch their dietary intake. Patients concerned about weight gain should be referred for dietary / nutritional counseling.

Tobacco cessation programs are offered through the Health Promotion Program at the MTF or at the Wellness/Semper Fit Center. The program usually offers a variety of self help materials, as well as a formal behavior modification program, such as the American Cancer Society Fresh Start Program, or a local program tailored to promote cessation for the beneficiary population. All Navy/Marine Corps tobacco cessation programs offer some type of pharmacotherapy (NRT patches/ gum or Zyban/Wellbutrin) along with the behavior change class. Additional resources may be obtained from the American Lung Association, the Center for Disease Control and Prevention, the American Heart Association, as well as the American Cancer Society.

Relapse is a frequent occurrence with nicotine cessation and is a natural part of the change process. Most smokers make four to seven serious attempts to quit before they succeed. Early relapsers tend to resume tobacco use due to withdrawal symptoms, weight gain, cravings and habit within 48 hours to one week. Psychosocial factors, such as interpersonal problems, stress, emotional difficulties, and/or crisis; or due to stimulus control- such as tobacco with coffee, food or alcohol, are the primary reasons for later relapse. Most studies have found that relapse occurs within 30 to 60 days.

Former tobacco users should be counseled that relapse is a very real possibility if their "non-tobacco use guard" is let down. Former users benefit from learning that a quit is only one day at a time and that one slip does not mean a full return to tobacco use. Patients returning to tobacco use should be questioned about recent life changes that may require further evaluation for stress management, relaxation, and / or coping strategy counseling.

Additional information on tobacco intervention and cessation can be obtained from the following sources via the Internet:

• http://www.ahcpr.gov/clinic/smokepcc.htm (Current Agency for Health Care Policy and Research, Clinical guidelines for tobacco cessation)

• http://nmimc-web1.med.navy.mil/MED-06/tobacco\tobacco.htm (Link to various tobacco hazard and Nicotine Replacement Therapy presentations)

• http://www-nehc.med.navy.mil/hp/tobacco/index.htm (Navy Health Promotion Tobacco Cessation website, with presentations and information)

• http://www.srnt.org (Society for Research on Nicotine and Tobacco website with links to worldwide resources)

• http://www.cancer.org/gasp/index.html (Great American Smokeout website, updated each year)

• http://www.zyban.com/aol2/Pages/zap.htm

• http://www.nicorette.com/

• http://www.nicodermcq.com/

• A Review of the New Strategies from the Agency for Health Care Policy and Research, American Pharmaceutical Association, 1996.

• Fiore, M, et al., The Effectiveness of the Nicotine Patch for Smoking Cessation, A Meta-analysis, JAMA, 1994.

• National Institute of Health, Internet Source

• NicNet, Internet Source.

• Pomerleau, C. Smoking and Nicotine Replacement Treatment Issues Specific to Women, American Journal of Health Behavior, 1996; 20(5): 291-299.

• Prochaska, J. In Search of the Structure of Change, NIH Grant CA 27821.

• Society for Research on Nicotine and Tobacco, Internet Source.

• U.S. Navy Manual of the Medical Department, chapter 6.

• Bray, R, et al 1995 Department of Defense Survey of Health Related Behaviors Among Military Personnel, Research Triangle Institute, December 1995.

• Prochaska, J, Norcross, J, DiClemente, C. Changing For Good. New York: Avon Books, 1994.

• Glynn, T, Manley, M, Solberg, L, Slade, J. Creating and Maintaining an Optimal Medical Practice Environment for the Treatment of Nicotine Addiction. In Nicotine Addiction

• Principles and Management. Eds. Orleans T, Slade J. New York: Oxford Press, 1993.

• Counseling to Prevent Tobacco Use. In Guide to Clinical Preventive Services, 2^nd ed., Report of the U.S. Preventive Services Task Force. Baltimore: Williams & Wilkins,1996.

• Glynn,T, Manley, M. How To Help Your Patients Stop Smoking. National Cancer Institute, U. S. Department of Health and Human Services. NIH PubNo. 97-3064, September, 1997.

• Benowitz, N. Nicotine Safety and Toxicity, New York: Oxford University Press, 1998.

• AHCPR. Smoking Cessation. Clinical Guideline Number 18. AHCPR Publication No. 96- 0692,

• April 1996.

• Hurt, R. et al. A Comparison of Sustained Release Bupropion and Placebo for Smoking Cessation. NEJM, 1997;337:1195-1202.

• Hughes,J. et al. Recent Advances in the Pharmacotherapy of Smoking. JAMA, 1999; 281:72-76.