Evidence-Based Reviews

Beating nicotine: Medication algorithm helps teens quit

Current Psychiatry. 2007 October;6(10):65-74

References

1. Chassin L, Presson CC, Sherman SJ, Edwards DA. The natural history of cigarette smoking: predicting young-adult smoking outcomes from adolescent smoking patterns. Health Psychol 1990;9(6):701-16.

2. Johnston LD, O’Malley PM, Bachman JG, Schulenberg JE. Monitoring the Future national results on adolescent drug use: overview of key findings 2006. Bethesda, MD: National Institute on Drug Abuse; 2007. NIH publication no. 07-6202.

3. DiFranza JR, Rigotti NA, McNeill AD, et al. Initial symptoms of nicotine dependence in adolescence. Tob Control 2000;9(3):313-9.

4. Upadhyaya HP, Deas D, Brady KT, Kruesi M. Cigarette smoking and psychiatric comorbidity in children and adolescents. J Am Acad Child Adolesc Psychiatry 2002;41(11):1294-1305.

5. U.S. Department of Health and Human Services. The health consequences of smoking: a report of the surgeon general. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2004.

6. Himelhoch S, Daumit G. To whom do psychiatrists offer smoking-cessation counseling? Am J Psychiatry 2003;160(12):222-830.

7. Upadhyaya HP, Brady KT, Wharton M, Liao J. Psychiatric disorders and cigarette smoking among child and adolescent psychiatry inpatients. Am J Addict 2003;12(2):144-52.

8. Prokhorov AV, Pallonen UE, Fava JL, et al. Measuring nicotine dependence among high-risk adolescent smokers. Addict Behav 1996;21(1):117-27.

9. Rojas NL, Killen JD, Haydel KF, Robinson TN. Nicotine dependence among adolescent smokers. Arch Pediatr Adolesc Med 1998;152(2):151-6.

10. O’Loughlin J, DiFranza J, Tarasuk J, et al. Assessment of nicotine dependence symptoms in adolescents: a comparison of five indicators. Tob Control 2002;11(4):354-60.

11. Nonnemaker J, Mowery P, Hersey J, et al. Measurement properties of a nicotine dependence scale for adolescents. Nicotine Tob Res 2004;6(2):295-301.

12. Etter JF, LeHouezec J, Perneger TV. A self-administered questionnaire to measure addiction to cigarettes: the Cigarette Dependence Scale. Neuropsychopharmacology 2003;28(2):359-70.

13. Hughes JR, Oliveto AH, Riggs R, et al. Concordance of different measures of nicotine dependence: two pilot studies. Addict Behav 2004;29(8):1527-39.

14. Sobell LC, Sobell MB. Timeline Follow-Back: a technique for assessing self-reported alcohol consumption. In: Litten R, Allen J, eds. Measuring alcohol consumption: psychosocial and biochemical methods. Totowa, NJ: The Humana Press Inc.; 1992.

15. SRNT Subcommittee on Biochemical Verification. Biochemical verification of tobacco use and cessation. Nicotine Tob Res 2002;4(2):149-59.

16. Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence. Quick reference guide for clinicians. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service; 2000.

17. Smith TA, House RF, Croghan IT, et al. Nicotine patch therapy in adolescent smokers. Pediatrics 1996;98(4):659-67.

18. Hurt RD, Croghan GA, Beede SD, et al. Nicotine patch therapy in 101 adolescent smokers: efficacy, withdrawal symptom relief, and carbon monoxide and plasma cotinine levels. Arch Pediatr Adolesc Med 2000;154(1):31-7.

19. Hanson K, Allen S, Jensen S, Hatsukami D. Treatment of adolescent smokers with the nicotine patch. Nicotine Tob Res 2003;5(4):515-26.

20. Moolchan ET, Robinson ML, Ernst M, et al. Safety and efficacy of the nicotine patch and gum for the treatment of adolescent tobacco addiction. Pediatrics 2005;115(4):e407-14.

21. Upadhyaya HP, Brady KT, Wang W. Bupropion SR in adolescents with comorbid ADHD and nicotine dependence: a pilot study. J Am Acad Child Adolesc Psychiatry 2004;43(2):199-205.

22. Killen JD, Robinson TN, Ammerman S, et al. Randomized clinical trial of the efficacy of bupropion combined with nicotine patch in the treatment of adolescent smokers. J Consult Clin Psychol 2004;72(4):729-35.

23. Muramoto ML, Leischow SJ, Sherrill D. A randomized trial of the efficacy of bupropion for adolescent smoking cessation. Paper presented at: Annual Meeting of the Society for Research on Nicotine and Tobacco; March 20-23, 2005; Prague, Czech Republic.

24. Hall SM. Tricyclic antidepressants in the treatment of nicotine dependence. In: George TP, ed. Medication treatments for nicotine dependence. Boca Raton, FL: CRC Press; 2007:95-107.

25. Berlin I. Monoamine oxidase inhibitors for smoking cessation. In: George TP, ed. Medication treatments for nicotine dependence. Boca Raton, FL: CRC Press; 2007:109-21.

26. Weinberger AH, Reutenauer EL, George TP. Other nonapproved agents for smoking cessation. In: George TP, ed. Medication treatments for nicotine dependence. Boca Raton, FL: CRC Press; 2007:137-48.

27. Lancaster T, Stead LF. Mecamylamine (a nicotine antagonist) for smoking cessation. Cochrane Database Syst Rev 2005;2:CD001009.-

28. Nicoderm CQ [package insert]. Bridgewater, NJ: Sanofi Aventis; 2006.

29. Zyban [package insert]. Research Triangle Park, NC: GlaxoSmithKline; 2007.

30. Sussman S, Sun P, Dent CW. A meta-analysis of teen cigarette smoking cessation. Health Psychol 2006;25(5):549-57.

31. Upadhyaya H, Deas D, Brady K. A practical clinical approach to the treatment of nicotine dependence in adolescents. J Am Acad Child Adolesc Psychiatry 2005;44(9):942-6.

Behavioral therapy. Specialized treatments developed specifically for teen smoking cessation—such as Not On Tobacco (see Related Resources)—often are delivered in schools or other group settings. The most successful consist of ≥5 sessions and include motivational enhancement, cognitive-behavioral, and social influence-oriented approaches.³⁰

Other behavioral treatments. Most psychiatrists are not equipped to deliver these specialized behavioral treatments. Instead, you can use simple yet effective behavioral treatments during routine office visits as adjuncts to pharmacotherapy. At the very least, we recommend the U.S. Public Health Service’s “5 As” strategy (Box 2).¹⁶

Educate patients about what to expect during withdrawal, how long withdrawal will last, and medication side effects. To help adolescents develop appropriate treatment expectations:

discuss the difference between a “slip” (having 1 cigarette) and a “relapse” (returning to daily smoking)
explain that many individuals need multiple attempts before they quit.

Encourage adolescent smokers to contact the National Network of Tobacco Cessation Quitlines (1-800-784-8669; www.smokefree.gov), which provides free access to telephone-based counseling services.

Box 2

Behavioral therapy: ‘5 As’ of smoking cessation

Ask every patient about tobacco use during every visit, and have a system for recording and tracking tobacco use in the chart

Advise patients clearly and unambiguously to stop smoking, and tailor that advice to each patient’s needs

Assess every patient’s readiness to quit

Assist patients who are ready to quit through self-help materials, referral, and/or smoking cessation treatment

Arrange follow-up visits for relapse prevention or to reassess readiness to quit

Source: Reference 16

Choosing treatment

Evidence guiding treatment choice for teen smoking cessation is limited but growing. Most studies examined daily cigarette smoking, with significantly less evidence to support treatment decisions for light (non-daily) smokers and teens who use other tobacco products.

Clinical Point

We suggest NRT in combination with smoking cessation counseling as a first-line treatment for young smokers

Recommendations.We have developed a strategy to guide treatment of adolescent smokers (Algorithm). We recommend using pharmacologic interventions only for teens who smoke daily because:

most studies have focused on daily smoking
efficacy data are limited
pharmacologic interventions carry potential risks.

Because of bupropion SR’s contraindications and potential side effect profile, we suggest NRT in combination with smoking cessation counseling as a first-line treatment for young smokers. We recommend beginning with transdermal NRT because of the low likelihood of underdosing with the patch’s once-daily application.²⁰ With either NRT or bupropion SR, schedule follow-up appointments to target relapse prevention and solve any issues that arise.

Help your patient choose a “quit date,” preferably 1 to 2 weeks after your initial assessment. We recommend encouraging young smokers to reduce their smoking by 1 cigarette per day to help minimize withdrawal symptoms from “cold turkey” cessation.³¹

Clinical Point

We strongly recommend using transdermal NRT on adolescent inpatient units, especially for daily smokers

Some physicians have found it helpful to see the patient on the quit day—or 2 days after when withdrawal symptoms tend to be most robust—to provide support and encouragement. Ask the adolescent to bring and discard during the visit all smoking paraphernalia as a symbol of his or her new smoke-free status.

Step 1: NRT. Initiate smoking cessation counseling plus transdermal NRT using the dosing guidelines in Table 3,^28,31 and adjust the dose depending on severity of withdrawal symptoms. Ideally, the patch delivery will be used for 12 weeks, with at least 3 and ideally 6 weeks on the initial dose, followed by a gradual taper.²⁸ We strongly recommend using transdermal NRT on adolescent inpatient units, especially for daily smokers and those who exhibit nicotine withdrawal symptoms.

Step 2: Bupropion SR. If NRT fails, the next step is bupropion SR plus smoking cessation counseling, assuming the adolescent does not have contraindications to bupropion SR. Start the medication based on the dosing guidelines in Table 3,^28,31 and set a quit date for 2 weeks after starting bupropion SR.

Clinical Point

Encourage teens to reduce by 1 cigarette per day over the 2 weeks before their quit date to minimize withdrawal symptoms

Again, encourage adolescents to reduce by 1 cigarette per day over the 2 weeks before the quit day to minimize withdrawal symptoms.³¹ Continue bupropion SR for at least 8 and optimally 12 weeks.³¹

Combination therapy? If teens are unable to successfully quit smoking with NRT or bupropion SR alone, experience with adults suggests combining the 2 therapies might be beneficial. However, no evidence supports combination therapy in adolescents. Instead, consider referring adolescents who can’t quit to a smoking cessation specialist.

AlgorithmA strategy to initiate smoking cessation in adolescents

CDC: Centers for Disease Control and Prevention; CM: contingency management; NIDA: National Institute of Drug Abuse; NRT: nicotine replacement therapy
Source: Adapted from Upadhyaya H, Deas D, Brady K. A practical clinical approach to the treatment of nicotine dependence in adolescents. J Am Acad Child Adolesc Psychiatry 2005;44(9):942-6 with permission of Lippincott Williams & Wilkins.Table 3