Smoking cessation in primary care

Opening Vignette

Mr Lim, a 60-year-old man, is a chronic cigarette smoker of 40 pack-years. He is on follow-up with his general practitioner for ischaemic heart disease, hypertension, dyslipidaemia and type 2 diabetes mellitus. In the past, he has had the unpleasant experience of being repeatedly admonished to stop smoking when he was not ready to do so. Recently, he suffered a transient ischaemic attack and is now ready to discuss how he can quit smoking. He comes to your clinic to seek your advice on this matter.

WHAT IS SMOKING CESSATION?

Smoking cessation is the discontinuation of tobacco smoking, which encompasses smoking of tobacco-containing products such as cigarettes (self-rolled or manufactured), cigars, beedis, kreteks, hookah and tobacco pipes. Nicotine, which is found in tobacco smoke, is addictive and results in dependence. Although electronic cigarettes (vapourisers) deliver nicotine without the generation of smoke through tobacco burning, they have been deemed to be harmful to health because of the exposure to other toxic chemical substances. Smoking cessation can be unassisted, which includes abrupt quitting (known as ‘cold turkey’) or a gradual reduction in tobacco smoking. It can also be assisted through psychosocial and behavioural therapy or the use of pharmacological agents.

HOW RELEVANT IS THIS TO MY PRACTICE?

Tobacco smoking has many detrimental health and social effects. The leading causes of mortality due to smoking are lung cancer, ischaemic heart disease and chronic obstructive pulmonary disease (COPD).[1] In 2014, it was estimated that the social cost of smoking in Singapore was around 0.2% of the gross domestic product.[2]

The ‘Fletcher–Peto curve’ published in ‘The natural history of chronic airflow obstruction’ in 1977 shows that it is never too late to stop smoking [Figure 1]. It shows that smoking cessation at various ages can slow down the rate of loss of forced expiratory volume in 1 s and resultant disability and death, compared to someone who continues to smoke.

Figure 1.

Graph shows an adaptation of the ‘Fletcher–Peto curve’. (Adapted with permission from Fletcher and Peto).[3] FEV1: forced expiratory volume in 1 s

Smoking cessation efforts in Singapore have long existed. Since the early 1970s, legislations restricting tobacco advertisement and smoking in public places have been in place. In 1986, the National Smoking Control Programme, with an emphasis on education, was introduced.[4] A 14.5-year randomised clinical trial showed an all-cause mortality reduction in smokers who attended a smoking cessation programme (8.83 vs. 10.38 per 1,000 person-years).[5] Ideally, a successful smoking cessation programme should achieve a high quit rate, which represents the proportion of patients who maintain complete abstinence from smoking after a defined period of follow-up. Most studies of smoking cessation programmes use a period of 6 months to 1 year follow-up for comparison. The 1-year quit rate of some programmes is estimated to be around 15%–25%.[6]

According to the National Population Health Survey 2020 by the Ministry of Health, the prevalence of daily smoking among Singapore residents aged 18–74 years is 10.1% (down from 13.1% in 2013). About half (48.3%) of daily smokers had plans to quit smoking and about one-third (27.7%) planned to reduce the number of cigarettes smoked.[7] However, a cross-sectional survey done in 2007 highlighted differences in perception over the roles that physicians play in smoking cessation in terms of discussing and initiation of the topic.[8] This begs the question of how primary care physicians (PCPs) can approach and play a greater role in smoking cessation in day-to-day practice.

The coronavirus disease 2019 (COVID-19) pandemic appears to have affected smokers in different ways. An online survey conducted in the Netherlands in 2020 showed that restrictions in movement and boredom may have stimulated smoking, while concern about becoming severely ill from COVID-19 has motivated others to improve their health by quitting smoking.[9] Although one may leverage the pandemic to encourage more patients to quit smoking, discontinuation of smoking cessation programmes in hospitals and COVID-19 restrictions may mean that patients are not keen to be referred, to avoid unnecessary visits to the hospitals. As a result, more smokers may be willing to seek help from their PCPs on how they can quit smoking and be more open to discuss the topic during their routine follow-up visits for chronic diseases. The advantage of having accessibility, continuity and long-term relationships in primary care practice highlights the need for PCPs to step up and take a more active role to equip themselves with strategies such as counselling skills. A systematic review and metasynthesis published in Nature in June 2021[10] discusses some challenges that PCPs and smokers face, such as patients’ lack of motivation, and PCPs’ lack of sincerity, adequacy, skills and training. Some strategies suggested to induce patients’ motivation include finding the right time to talk about smoking cessation, using familiarity, continuity and trust, as well as taking a patient-centred approach that is based on respect and comprehension.

SMOKING CESSATION IN PRIMARY CARE

A suggested framework for treating tobacco use and dependence has been described in the Health Promotion Board–Ministry of Health Clinical Practice Guidelines (HPB-MOH CPG) in 2013. It comprises three intervention levels: basic, intermediate and advanced.

Level 1: The ABC approach (basic)

The ABC approach [Box 1] is a simple, quick and effective way to bring up the topic of smoking cessation to the patients during the first few encounters. It brings across the strong message that smoking is harmful to them, but also encourages them that support is available to help them through the quit journey.

Box 1.

The ABC approach.

Ask and document status of tobacco use for every patient	“Do you smoke or use any other forms of tobacco?”
Brief advice to stop tobacco use for every patient who uses tobacco, regardless of the intention to quit	“You may know the risks involved in using tobacco. As your healthcare provider, I want you to know that stopping tobacco use is the most important thing you can do to protect your health, especially since you have this medical condition.”
Cessation support for every patient who expresses the intention to quit	“What are your reasons for not wanting to quit?” “What are some reasons that might make you want to quit?” “Although you have shared reasons for not wanting to quit, there are some reasons that might make you think about quitting. If it’s ok with you, I’d like to give you the list of cessation services available about where you can get help in case you change your mind.”

Level 2: The “5 As” approach (intermediate)

The “5 As” approach has been described in HPB-MOH CPG 2013 and the World Health Organization’s toolkit for tobacco interventions in primary care. The transtheoretical model (stages of change) developed by Prochaska and DiClemente in 1970s states the various stages of health-related behavioural change. Figure 2 shows how the “5 As” approach and the stages of change model can be integrated. This integrated model is a step above the ABC approach, as it assesses the stage of change the patient is currently at, thereby allowing the clinician to employ different strategies to help the patient appropriately and in a timely manner. The first two As — ask and advise — may be skipped if they have already been covered in the ABC approach. The main focus of this model is to assess the various stages of change the patient is in.

Figure 2.

Flowchart integrates both the 5 As approach and the stages of change model.

Level 3: Intensive behavioural support (advanced)

This intervention is an important step for patients in the action and maintenance stages of change. It is done by trained advisors on an individual basis or in a group via in-person sessions or telephone support. This intervention will be elaborated in the next section.

WHAT CAN I DO IN MY PRACTICE?

As PCPs, the main focus of smoking cessation should be counselling and support. Although a combination of behavioural support and pharmacological therapy results in higher quit rates,[11] pharmacotherapy serves as an adjunct to intensive counselling and behavioural support. The components of such support include problem-solving and coping skills, and intra-treatment social support and encouragement. The types of behavioural interventions that can be used include cognitive behavioural therapy and motivational interviewing. Cognitive behavioural therapy strategies include identifying and restructuring maladaptive thoughts and behaviour. For example, patients can be taught to challenge the belief that smoking is the only way to cope with stress, as well as use other activities as a form of distraction to avoid boredom. Motivational interviewing involves the four processes of engaging (establishing the common goal of smoking cessation through a mutually respectful working relationship), focusing (guiding the patient in the right direction), evoking (eliciting the motivations for smoking cessation) and planning (commitment to quit date and treatment plan or follow-up). To provide more intensive counselling, especially in cases of relapse, PCPs can consider formal smoking cessation consultant training by the Health Promotion Board, which includes a basic counselling course (virtual or in-person), certification and workshops for continuing education. Otherwise, referrals can be made to specialised smoking cessation programmes, which will be covered in the later section.

The three main pharmacotherapies are nicotine replacement therapy (NRT), varenicline and bupropion. The choice of pharmacotherapy should be made in a shared clinical decision-making process with the patient. The mode of administration, side effects, contraindications, costs and patient’s preference should be considered. Table 1 shows an overview of these pharmacotherapies.

Table 1.

Overview of pharmacotherapies for smoking cessation.

Drug & formulation	Dose	Administration	Side effects	Advantages	Disadvantages	Contraindications/precautions
Nicotine patch 7 mg, 14 mg, 21 mg (24-hour) 10 mg, 15 mg, 25 mg (16-hour)	• 21 mg for ≥10 cigarettes per day • 14 mg for <10 cigarettes per day • After 6 weeks, can taper or continue the original dose.	• Apply a new patch every morning to dry skin. • Rotate application site to reduce skin irritation. • Remove patch before sleep if insomnia or vivid dreams.	• Skin irritation • Insomnia • Vivid dreams	• Easy to use • Provides steady nicotine level • Combination NRT can be used with gum and lozenges as necessary for cravings	• Cannot change dose according to cravings	Contraindication • Hypersensitivity to nicotine Precautions • Avoid using other tobacco products while on NRT • Recent myocardial infarction • Severe cardiac arrhythmias/angina • Severe renal/hepatic impairment • Pregnancy/breastfeeding • Adolescents (aged <18 years)
Nicotine gum 2 mg, 4 mg	• If 1st cigarette is ≤30 min of waking: 4 mg • If 1st cigarette is >30 min of waking: 2 mg • Use ≥12 weeks	• Chew briefly tingling sensation occurs, then ‘park’ gum between cheek and gum until tingle fades. • Repeat until the tingle fades (around 30 min of use). • Use up to 1 piece per hour. • Max 12–24 per day (depending on dose and brand).	• Throat/mouth irritation • Jaw soreness (gum) • GI symptoms (nausea, vomiting, heartburn, hiccups) • Dizziness	• Oral substitute for cigarettes • Can be added on top of patch use for cravings so patient can control dose	• No food/coffee/juices/acidic and fizzy drinks 15 min before or during use • Difficult to use for patients with dentures, may damage dental work
Nicotine lozenges 1 mg, 2 mg, 4 mg		• Place between gum and cheek to let it melt. • Use 1 piece every 1–2 h. • Max 20 per day (depending on dose and brand).
Varenicline 0.5 mg, 1 mg	Step-dose regime: 0.5 mg OM × 3 days, then 0.5 mg BD × 4 days, then 1 mg BD × 11 weeks Total duration: 12 weeks	• Start 1–4 weeks before quit date. • Take with food to minimise GI side effects.	• GI symptoms (flatulence, constipation, nausea, taste alteration) • Insomnia • Vivid dreams • Headache	• Quit date can be flexible after starting drug	• Patients may be apprehensive of psychiatric adverse events (previous FDA boxed warning has now been removed)	Contraindication • Hypersensitivity to varenicline Precautions • History of psychiatric illness or neuropsychiatric symptoms • Severe renal impairment • Pregnancy/breastfeeding • Adolescents (aged <18 years)
Bupropion SR (sustained release) 150 mg	Step-dose regime 150 mg OM × 3 days, then 150 mg BD Total duration: 12 weeks	• Start 1–2 weeks before quit date.	• Insomnia • Agitation • GI symptoms (nausea, dry mouth) • Headache, dizziness	• May reduce post- cessation weight gain while on drug	• Not for use if there is seizure disorder or binge drinking in view of increased seizure risk	• Contraindications • History of seizure disorder • Hypersensitivity to bupropion • Simultaneous abrupt discontinuation of ethanol, sedatives or anti-epileptics • Use of MAO-inhibitors • Precautions History of psychiatric illness Pregnancy/breastfeeding • Adolescents (aged <18 years)

[Adapted from Barua RS et al][12] BD: twice a day, FDA: Food and Drug Administration, GI: gastrointestinal, MAO: monoamine oxidase, NRT: nicotine replacement therapy, OM: omni mane (every morning)

In Singapore, NRT mainly comprises patches, gums and lozenges. Each NRT product has about the same efficacy, increasing the quit rates as compared to placebo (risk ratio about 1.6).[13] Although there was an increase in cardiovascular symptoms such as tachycardia and arrhythmia due to the sympathomimetic effects of nicotine, a meta-analysis of NRT studies showed no increase in major cardiovascular events (death, myocardial infarction, stroke).[14]

Varenicline is a partial agonist at the α4β2 nicotinic cholinergic receptor, which reduces withdrawal symptoms. The EAGLES trial, a double-blind, randomised, placebo-controlled clinical trial, showed that varenicline is more efficacious in achieving higher abstinence rates compared to bupropion (odds ratio [OR] 1.75), nicotine patch (OR 1.68) and placebo (OR 3.61).[15] Contrary to many concerns, the study did not show a significant increase in neuropsychiatric adverse events attributable to varenicline or bupropion compared to nicotine patch or placebo. Unfortunately, in July 2021, Pfizer issued a voluntary recall for Chantix (varenicline) due to a higher-than-acceptable level of an impurity, N-nitrosovarenicline. Subsequently, the Singapore Health Sciences Authority announced a local retail-level recall of all batches of Champix (varenicline) in November 2021. However, patients who were already on Champix were advised to continue with the course prescribed. For now, physicians will need to rely on NRT or bupropion for alternative pharmacotherapy options. Bupropion is a norepinephrine/dopamine-reuptake inhibitor that reduces reward and withdrawal symptoms. It can be useful in patients with concomitant depression but is contraindicated in patients with seizure disorders as it can precipitate seizures.

WHAT IS AVAILABLE OUTSIDE OF MY PRACTICE?

The I Quit Programme is an initiative of the Health Promotion Board that allows smokers to register online to receive a customised quit journey. The programme includes counselling by trained advisors through SMS, phone calls or face-to-face sessions. Patients are incentivised with shopping vouchers of up to SGD 50 when they remain smoke-free for 28 days, 3 months and 6 months. They can also enroll in a Start to S.T.O.P (Speak To Our Pharmacist) programme at participating retail pharmacies, where the pharmacists can provide pharmacotherapy without a doctor’s prescription.

Smoking cessation clinics are available at various polyclinics and restructured hospitals in Singapore. One example is the pharmacist-managed smoking cessation clinic at Changi General Hospital. Firstly, the patient’s nicotine dependence is assessed and a quit plan is devised. Behavioural modification is recommended with initiation of pharmacotherapy (NRT and non-NRT) if necessary. Lastly, there is follow-up and documentation of the patient’s progress. It costs SGD 30 for the first visit and SGD 19 for follow-up visits (or a package of three sessions for SGD 55) regardless of payment class. Patients can be self-referred or referred by any healthcare professional (physician, nurse, pharmacist) or by their self-referral. Table 2 shows a list of outpatient services available in Singapore.

Table 2.

Outpatient smoking cessation services in Singapore.

Organisation/service	Contact information/details
QuitLine (a hotline managed by trained nurse counsellors)	1800-438-2000
Health Promotion Board — I Quit Programme Register online: https://www.healthhub.sg/programmes/iquit List of participating pharmacies (Guardian, Watsons, Unity): https://www.pss.org.sg/start-stop	Three types of quit journeys 1. SMS • First 28 days: Daily text messages and optional QuitLine call • Over 12 months: Two text messages monthly, one QuitLine call at end of the 1st, 3rd, 6th and 12th month 2. QuitLine • First 28 days: Three text messages and one QuitLine call weekly • Over 12 months: Two text messages monthly, one QuitLine call at the end of the 1st, 3rd, 6th and 12th month 3. Face-to-face counselling • First 28 days: Two text messages weekly, three face-to-face counselling sessions at pharmacies and three telephone follow-ups over 6 weeks • Over 12 months: Two text messages monthly, one call from counsellor at the end of the 1st, 3rd, 6th and 12th month
Polyclinics
National Healthcare Group Polyclinics	6340 2300
National University Polyclinics	6908 2222
SingHealth Polyclinics	6643 6969
Hospitals
Admiralty Medical Centre	6602 2220
Changi General Hospital	6850 3333
Khoo Teck Puat Hospital	6602 2220
Singapore General Hospital	6326 5361
National University Hospital	6908 2222
Ng Teng Fong General Hospital	6716 2222
Tan Tock Seng Hospital	6889 4343/6357 7000

Note: The list of outpatient smoking cessation services is correct at the time of writing.

In this digital age with wide usage of mobile devices and applications, mobile health (mHealth) is a useful platform to aid our smoking cessation efforts. There are many free applications available providing useful motivational interviewing tips, customised plans and logs, health and financial statistics, and even distraction games. Table 3 summarises some applications available.

Table 3.

List of mobile applications available for smoking cessation (at the time of writing).

Application	Platform	Price	Functions
QuitSTART	iPhone, Android	Free	Includes healthy lifestyle habits and motivational quotes
QuitGuide	iPhone, Android		Ability to share quit date with friends on social media, track cravings and slip ups, distraction games
Quit Now: My QuitBuddy	iPhone, Android		Tracks financial and health benefits, distraction games
Smoking Log - Stop Smoking	Android		Set personal goals, track progress and smoking habits
QuitNow	iPhone, Android	Free with in-app purchases	Includes ex-smokers’ achievements, browse frequently-asked questions and provides a platform to ask questions
Smoke Free	iPhone, Android		Includes evidence-based techniques to quit, log craving patterns
Quit Tracker: Stop Smoking	Android		Tracks financial and health benefits
Flamy	Android		Offers 14-day quit challenge, distraction games
Quit Smoking - Stop Smoking Counter	Android		Includes stories and tips from others who successfully quit smoking

TAKE HOME MESSAGES

1. Smoking cessation is relevant in primary care due to the harmful health and social effects of smoking and its cessation benefits.

2. The COVID-19 pandemic emphasised the importance of PCPs in smoking cessation. Some advantages of PCPs include accessibility, continuity of care and long-term relationships with patients.

3. The three levels of interventions for tobacco use and dependence can help guide PCPs’ approach to smoking cessation in primary care.

4. The integrated flowchart uses the “5 As” approach and the stages of change model to offer appropriate strategies to our patients.

5. As PCPs, the main focus of smoking cessation should be counselling and behavioural support. Pharmacotherapy serves as an adjunct to non-pharmacological measures.

Closing Vignette

After speaking to Mr Lim using the “5 As” model, you realise that he is in the contemplation stage and assess his nicotine dependence to be high. You educate him on the negative effects of smoking and benefits of quitting, and discuss the barriers, misconceptions and the pros and cons of smoking cessation. You then make a follow-up appointment in 2 weeks to set a quit date and discuss NRT as a pharmacotherapy. After 12 weeks of regular follow-up, behavioural support and NRT use, Mr Lim successfully quits smoking.

Financial support and sponsorship

Nil.

Conflicts of interest

How CH is a member of the SMJ Editorial Board.

SMC CATEGORY 3B CME PROGRAMME

Online Quiz: https://www.sma.org.sg/cme-programme

Deadline for submission: 6 pm, 09 February 2024

Question	True	False
1. The major causes of mortality caused by smoking are lung cancer, ischaemic heart disease and chronic obstructive pulmonary disease.
2. Smoking not only has negative health effects, but also has negative social and economic effects.
3. Based on the ‘Fletcher–Peto’ curve, as a person gets older, there are no more health benefits in quitting smoking.
4. Primary care is a good setting to encourage smoking cessation, in view of the opportunity to provide accessible, continuous and long-term care.
5. The ABC approach (basic intervention) for smoking cessation stands for Ask, Brief and Counsel.
6. The use of the ABC approach is a time-consuming process that requires multiple follow-up visits.
7. The “5 As” approach allows doctors to assess and give appropriate smoking cessation advice according to the stage of change of the patient.
8. For patients in the pre-contemplative stage, we should discuss about the quit date and provide coping skills for smoking cessation.
9. Pharmacotherapy alone is more superior and effective for smoking cessation than both behavioural support and counselling.
10. Cognitive behavioural therapy and motivational interviewing are strategies to help counsel patients on smoking cessation.
11. Nicotine replacement therapy is generally safe for use even in patients with cardiovascular risk factors.
12. Patients who are still smoking can use nicotine replacement therapy concurrently to reduce cravings to smoke.
13. Trials have shown that varenicline is more efficacious than nicotine replacement therapy or bupropion.
14. Varenicline is absolutely contraindicated in patients with psychiatric disorders.
15. Bupropion works in smoking cessation by reducing reward and withdrawal symptoms.
16. Bupropion is safe for use in patients with concomitant depression and seizure disorders.
17. The various pharmacotherapies for smoking cessation can only be prescribed by a licensed medical doctor.
18. Patients can self-register online to participate in a smoking cessation programme such as the I Quit Programme by the Health Promotion Board.
19. Outpatient smoking cessation programmes are available only in all restructured hospitals through referrals by doctors.
20. We can recommend many free and easily accessible mobile applications for patients to use to aid them in their smoking cessation journey.