Despite a significant drop in cigarette use in the US in the past 50 years—from about half of all adults to 11.5% in 2021—tobacco products continue to be a significant contributor to morbidity and mortality. 

During CHEST 2024, experts reviewed the latest approaches and statistical trends in tobacco and nicotine cessation during the session, New Paradigms in Treating Nicotine Dependence.

Pharmacotherapy and harm reduction

Jackie Hayes, MD, FCCP, Clinical Professor of Medicine, Director of the Tobacco Cessation Program, and Director of the Pulmonary Function Laboratory at Brooke Army Medical Center, discussed pharmacotherapy and harm reduction strategies.

The rise in popularity of noncombustible tobacco products, like e-cigarettes, has added to the controversy surrounding harm reduction, as the patient is replacing a very harmful product with a less harmful, but still harmful, product.

“We have to balance whether it might be reasonable for some of our patients who have comorbidities and are not able to completely stop smoking, or they don’t want to completely stop smoking—would the electronic cigarette be a safer option for those patients?”  Dr. Hayes said. “We also have to balance that against the fact that we don’t want to addict a new generation of people to electronic cigarettes and therefore be delivering nicotine to them in another manner.”

Pharmacologic options with approval from the US Food and Drug Administration for nicotine cessation therapy include nicotine replacement via patches, gum, or lozenges to reduce withdrawal symptoms and cravings; bupropion, a dopamine/norepinephrine uptake inhibitor; and varenicline, an α4β2 nicotinic receptor agonist that reduces withdrawal symptoms as well as produces receptor antagonism that prevents the user from experiencing the full effect of nicotine. Although not available in the US, cytosine is gaining more evidence as a treatment option.

Nicotine dependence treatment primarily involves pharmacotherapy and counseling interactions or therapy, Dr. Hayes noted.

“I think it’s best delivered when it’s multidisciplinary, and, in most cases, a combination of both pharmacotherapy and counseling is the best option,” he said. “The combined therapy improves outcomes by about 2.5 times that of a single therapy.”

The compounded effects of behavioral health interventions and pharmacotherapy show increased benefits compared with either on its own, but which combination of behavioral modification and medication is most effective remains inconclusive, said Michael Chatterton, PysD, a clinical health psychologist at the Pulmonary Clinic at Brooke Army Medical Center.

Behavioral health interventions

Dr. Chatterton outlined a variety of behavioral approaches to treating nicotine dependence, including motivational interviewing, cognitive behavioral therapy (CBT), acceptance commitment therapy, and mindfulness meditation.

Motivational interviewing has been shown to be more than five times more likely to result in abstinence from nicotine use after 12 months than dispensing anti-smoking advice to the patient, he reported.

CBT also has been proven to significantly reduce smoking. The self-help program relies on identifying dysfunctional thinking or behavior and changing thinking patterns. The thought, “I need a cigarette,” might become, “I am stressed, but I don’t need a cigarette,” Dr. Chatterton explained.

The majority of behavioral-based nicotine cessation programs, including CBT, focus on avoidance of cues and substitute behaviors, but mindfulness meditation shifts the focus to acknowledging the craving for nicotine in a nonjudgemental way to make it less intimidating over time. 

“This is really helpful for folks who are trying to quit smoking because it makes them pay attention to cravings,” Dr. Chatterton said. “So often the response to having a craving for a cigarette is to smoke immediately, and they delay as little as possible in doing that, and so they don’t get to learn what that craving actually feels like. Sometimes when you sit with it, it takes some of that fear out of it. It’s less stressful. It’s less anxiety provoking.”

The relationship between mental health and smoking is strong. Data from the Centers for Disease Control and Prevention show smoking rates increase among individuals with depression.

“All the minority groups doubled their rates of smoking when depression was factored in, so we really have to focus on both psychological health in addition to health overall,” said Andrew Salomon, MD, Assistant Professor of Medicine at the William Beaumont Army Medical Center.

Health disparities

Dr. Salomon addressed cultural and racial inequities in tobacco use and cessation statistics.

Smoking is tied to 30% of cancer deaths overall and 80% of lung cancer deaths, but the statistics are more stark for individuals who fall into one of these groups: young people who start smoking early; racial and ethnic minorities; sexual minorities; individuals with lower socioeconomic status, physical illness or disability, psychiatric disorder, or substance use disorder; and people with a criminal record.

“There are specific demographic groups that are having higher proclivity to nicotine dependence, and we really need to focus on that in terms of tobacco cessation,” Dr. Salomon said.

This can be done at the individual level or the population level.

“You need to acknowledge the social contextual factors—you know, culture, class—as well as the individual biology, including race and psychology, in factoring in how you are going to address health disparities,” Dr. Salomon said.

In a review of almost 95,000 patient encounters published in 2023, only 1% of patients were billed for smoking cessation, 3% were provided prescriptions for smoking cessation, and 13% had CT scans ordered for lung cancer screening.

“With smoking rates approaching 20%, you can see that there’s a big gap in what we’re actually doing in practice and what the numbers actually show,” Dr. Salomon said.

Novel approaches to nicotine dependence therapy being studied include the use of psychedelics, new pharmacological agents, vaccines, and magnetic brain stimulation.

Addressing smoking as a socioeconomic problem and using strategic taxation has seen some success. As the price of cigarettes increases, cigarette use decreases, Dr. Salomon explained. Missouri has the lowest tax rate on tobacco products in the US and one of the highest rates of smoking at 20% of the state’s population. By comparison, in New York and Connecticut, states with some of the highest tax rates on tobacco, the smoking rate is around 12%, among the lowest in the country.

“We just need to be more aware and vigilant that any impetus that we can provide as health care providers will lead to reduced smoking rates,” Dr. Salomon said.