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Ask a Pharmacist: Kicking the Smoking Habit

, by Jennifer Cocohoba, PharmD, AAHIVE

CigaretteIMAGEDuring the summer, many people try to commit to a new healthy habit, such as exercising more or eating healthier foods. Adopting one of these healthy new habits can be challenging, just as kicking a habit that is bad for your health—like smoking—can be tough.

Smoking cigarettes is the leading cause of preventable death in the United States, and people living with HIV/AIDS (PLWHA) are more likely to smoke than the average American. Over 40% of PLWHA are current smokers. Smoking when you have HIV increases your risk for cardiovascular disease and lung diseases such as emphysema and asthma, and has been linked to other illnesses such as oral candidiasis, bacterial pneumonia, pneumocystis pneumonia, and tuberculosis. Indeed, researchers in Denmark discovered that in a nationwide cohort of nearly 3,000 people with HIV, 60% of deaths were linked with smoking.

There are not many studies that examine smoking cessation treatments in PLWHA, and there is no one right way to quit. Fortunately, there are many tools you can use to help achieve your goal of stopping smoking. If you’ve been thinking about kicking the smoking habit, here is some information about some of the tools you might use to quit—and a few things to think about before you set that quit date.

Before You Quit

Take time to think. It may seem silly, but it may help if you take time to think about how much, when, and why you smoke. Knowing roughly how many cigarettes you smoke every day will also help you and your treating clinician select the treatments that might be best for you.

Write it down. Plotting the usual times during the day when you smoke may give you some clues about why you smoke. For example, perhaps you typically smoke when you wake up, when you have your coffee, or after meals. Maybe you smoke when you’re feeling stressed, when you’re alone, or when you’re with other smokers. Becoming conscious of these patterns can help you figure out when you might be at the biggest “risk” for reaching for a cigarette.

Find your inspiration. Think about your main reasons for quitting smoking. When you’re feeling tempted to smoke, focusing on these reasons for quitting can sometimes help you get past those difficult moments.

Gather supporters. Think about who might support you in your goal to quit smoking. Friends, family members, co-workers, or members of your health care team such as your doctor or pharmacist can be great advocates.

Use free resources. Take advantage of free “quit lines” such as 1-800-QUIT-NOW. Quit lines are telephone hotlines that provide many free services for people who want to stop smoking. They may provide personalized counseling and advice, can help you create an individual treatment plan, and can refer you to clinics in your area that can help you stop smoking. There are even free programs that can send you text messages to keep you motivated!

Over-the-Counter Tools: Nicotine Replacement

The most common tools that people use to stop smoking are nicotine replacement therapies (NRTs). These treatments replace the use of cigarettes and deliver a specific amount of nicotine to your body. The goal is to gradually reduce the amount of nicotine your body receives and craves. NRTs are generally considered safe, even for those who have heart disease. If you recently had a heart attack, have irregular heart rhythms, or are pregnant, you should speak with your treating clinician before starting any NRT.

NRTs come in many different forms, including patches, gum, lozenges, nasal inhalers, and false cigarettes. Here we discuss patches, gums, and lozenges because they are the most readily available and are used most often.

Nicotine patches. Using a patch to stop smoking typically takes 10 to 12 weeks. Patches usually come in three different strengths, referred to as “steps.” At each step, patches deliver a different amount of nicotine to the body.

Which step you start with and how long you use the patches for each step depends on whether you smoke more than or less than ten cigarettes per day. If you do not usually smoke at night, you are advised to take the patch off before you go to bed and put a new one on each morning. If you usually crave a cigarette during the night, you may wear your patch for 24 hours before changing.

Using the patch may cause similar side effects as smoking cigarettes, such as nausea, headache, and insomnia. Some people are allergic to the tape used in the patch and may get a skin reaction such as swelling or redness around the patch area.

Nicotine gum and lozenges. Nicotine gum and nicotine lozenges come in different brands which have different strengths. Each brand has a different way for you select the appropriate strength to use, based on one of two factors: either what time you have your first cigarette of the day or how much you smoke daily.

As with the patch, you use a certain number of gums or lozenges every day, and you reduce the number of pieces you use over time. Nicotine gum is slowly chewed until you feel a tingling sensation in your mouth, and is then “parked” between your cheek and your gum until the tingling sensation fades. Lozenges are used the same way except they do not need to be chewed. Some people may get a bad taste in the mouth from these products, or feel nausea, headaches, or insomnia.

Prescription Medications to Stop Smoking

There are two prescription medications approved by the U.S. Food and Drug Administration to help people stop smoking: bupropion (brand name Zyban) and varenicline (Chantix, Champix).

Bupropion. This medication was first approved to treat depression, before researchers discovered that at higher doses it helps people stop smoking. Researchers do not completely understand the mechanism by which bupropion works to help people quit smoking; however, it is known that the drug allows several brain chemicals, including norepinephrine, dopamine, and serotonin, to remain at their active sites for longer, and it also works to block nicotine receptors in the body.

Bupropion is taken for 12 weeks to help stop smoking. Treatment begins one week before your scheduled quit date. Sometimes people stay on bupropion for up to six months after they complete treatment to help prevent relapse. Some people may experience rapid heartbeat, headache, insomnia, dizziness, dry mouth, weight loss, and nausea with bupropion.

Anti-HIV medications such as protease inhibitors, efavirenz, or nevirapine may lower the effect of bupropion. That does not mean you cannot use bupropion to stop smoking, but you may not feel the full effects or may need to use a combination of products, such as bupropion plus a nicotine replacement therapy to have the most successful quit attempt.

Varenicline. Varenicline works by partially activating nicotine receptors in the body. Like bupropion, it takes at least 12 weeks to quit smoking while using varenicline. You may start taking the medication one week before your scheduled quit date, or you can begin taking it and select a quit date that is up to 35 days after you started. Like bupropion, some people may continue taking varenicline after the 12 weeks is complete, to help prevent relapse.

Varenicline is a newer medication and researchers are still learning more about its side effects. If you have depression, other psychologic conditions, or cardiovascular disease, you should talk about these health conditions with your doctor before beginning varenicline. Some people have experienced changes in mood such as feeling agitated, hostile, or depressed. In rare cases, some persons experienced psychosis or the desire to commit suicide.

A large meta-analysis of studies found that more patients who received varenicline had cardiovascular events such as heart attack or stroke. However, these cardiovascular events did not occur very often overall and the rate with which they happened was not statistically significantly different between varenicline users and placebo users.

There are no known drug-drug interactions with anti-HIV medicines. Unlike bupropion, there are no studies looking at combining varenicline with nicotine replacement therapies.

Getting Your Medicines

You may want to talk to your insurance company to see which therapies, if any, they might cover. Sometimes you need a prescription or a written letter from your treating clinician before the insurance company will provide coverage.

Remember that your pharmacist can also be a great resource. Your pharmacist may be familiar with the items your insurance needs to help pay for your smoking cessation treatments. They can answer your questions about the different options for smoking cessation and can work with you to individualize your treatment plan.

Quitting smoking may not be easy, but it is one of the best ways to keep your heart and lungs healthy for the long haul. Good luck!

Jennifer Cocohoba, PharmD, is an associate clinical professor in the School of Pharmacy at the University of California, San Francisco (UCSF). Since 2004, she has worked as the clinical pharmacist for the UCSF Women’s HIV Program, where she provides adherence support and medication information to patients and providers.

Selected Sources

Carson, K. and others. Current and emerging pharmacotherapeutic options for smoking cessation. Substance Abuse 23(7):85–105. May 2013.

Cui, Q. and others. Safety and tolerability of varenicline tartrate (Champix/Chantix) for smoking cessation in HIV-infected subjects: a pilot open-label study. AIDS Patient Care and STDS 26(1):12–19. January 2012.

Helleberg, M. Mortality attributable to smoking among HIV-1–infected individuals: a nationwide, population-based cohort study. Clinical Infectious Diseases 56(5):727–34. March 1, 2013.

Larzelere, M. and D. Williams. Promoting smoking cessation. American Family Physician. 85(6):591–98. March 15, 2012. http://www.aafp.org/afp/2012/0315/p591.html

Lifson, A. and H. Lando. Smoking and HIV: prevalence, health risks, and cessation strategies. Current HIV/AIDS Reports 9(3):223–30. September 2012.

Niaura, R. and others. Interventions to address chronic disease and HIV: strategies to promote smoking cessation among HIV-infected individuals. Current HIV/AIDS Reports 9(4):375–84. December 2012.

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