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Evidence-Based Strategies for Common Clinical Questions

September, 2018

What’s the best way to help parents quit smoking?

Primary Author: Kristin Streiler, MD | Chief Pediatric Resident, Children's Mercy 

Column Editor: Rupal Gupta, MD | Medical Director, Operation Breakthrough Clinic | General Academic Pediatrics | Assistant Professor, UMKC School of Medicine

As was discussed in last month’s LINK column on evidence-based practice, children are disproportionately affected by secondhand smoke, and this exposure is detrimental to children’s health. The Surgeon General warns that children’s exposure to secondhand smoke has been associated with SIDS, lung problems, ear infections and severe asthma.1 It also substantially impacts cardiovascular health.2 Parental smoking is a common source of cigarette exposure for children.3 Thus, an intuitive way to decrease children’s exposure to secondhand smoke is for their parents to quit smoking. Pediatricians can effectively advocate for children’s health by assisting parents with smoking cessation. 

According to a 2018 Cochrane review involving 78 studies, parent/caregiver interventions including any combination of counseling, motivational interviewing with brief interventions, and educational materials were not consistently shown to reduce children’s exposure to environmental tobacco smoke or improve children’s health.3While many pediatricians feel comfortable performing brief efforts such as these, evidence shows these practices do not reliably decrease children’s exposure to tobacco smoke.

Nicotine replacement therapy (NRT), on the other hand, is a safe, effective, inexpensive, well-tolerated, over-the-counter method to increase the likelihood that a motivated adult will successfully quit. Quitting is defined as continued abstinence from tobacco at a six-month follow-up. A 2013 Cochrane review involving 101,000 adults found that combination NRT (e.g., both transdermal patch and gum) is as effective as varenicline, a nicotine receptor partial agonist available by prescription only.4 When compared to placebo, NRT increases the likelihood of successfully quitting by about 60%.4 Interestingly, another Cochrane review from 2018 studying 64,000 adults found that NRT carried a 50-60% likelihood of success regardless of the amount of additional support provided.5Thus, if the pediatrician’s primary objective is to assist parents with their attempts to successfully quit, a convincing body of high-quality evidence supports the use of NRT, particularly combination NRT.

Developing a treatment plan for NRT is straightforward. First, it is important to recognize that a cigarette contains about 1 mg of nicotine, and a pack contains 20 cigarettes. Transdermal patches deliver slow, but consistent doses of nicotine. Other products (such as gum or lozenges) are available for breakthrough cravings. Gum and lozenges are available in 2 mg or 4 mg doses per piece. Typical combination NRT regimens involve using a daily transdermal patch to provide a steady dose of nicotine, and as-needed dosing of other products (such as gum) for breakthrough cravings. Transdermal patches are available in doses of 7 mg, 14 mg, or 21 mg per patch, and are typically supplied in 14-patch boxes that cost about $40/box at retail pharmacies. One patch, roughly equivalent to the total daily cigarette use, is applied daily. This daily dose of nicotine is then slowly weaned over about 10 weeks. 

One popular suggested dosing regimen for an adult who smokes approximately one pack per day and weighs >45kg is as follows:

  • Apply 21 mg patch once daily for six weeks;

  • Then apply 14 mg patch once daily for two weeks;

  • Then apply 7 mg patch once daily for two weeks;

  • Then stop using patches.6

Throughout this 10-week course, the individual should chew nicotine gum as needed. Gum is the most frequently used product for breakthrough cravings because it is typically the most palatable and least expensive option. A generic box of nicotine gum contains 110-170 pieces, costs about $50/box at retail pharmacies, and should last two weeks. Physicians, including pediatricians, can prescribe nicotine replacement therapy, which substantially reduces the out-of-pocket cost, often eliminating it entirely. In fact, Missouri Medicaid will completely cover the cost of 24 weeks of any nicotine replacement products for its beneficiaries.7

Pediatricians have a tremendous opportunity to positively influence their patients’ lives by assisting their parents in their attempts to quit smoking. Based on a large body of high-quality evidence, physicians should prescribe combination nicotine replacement therapy to provide patients with the highest likelihood of sustained abstinence from tobacco. Most insurance programs, including Missouri Medicaid, will cover the cost of these safe, effective, over-the-counter products. Pediatricians can be powerful advocates for healthy families by prescribing nicotine replacement therapy for parents.

Editor’s Note: This column is the first in a series of four from Dr. Streiler that will focus on practical, evidence-based recommendations to empower community pediatricians to advocate for their patients and families.


References:

  1. Office on Smoking and Health (US). The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Atlanta (GA): Centers for Disease Control and Prevention (US); 2006. Available from: https://www.ncbi.nlm.nih.gov/books/NBK44324/

  2. Cardiovascular Consequences of Childhood Secondhand Smoke Exposure: Prevailing Evidence, Burden, and Racial and Socioeconomic Disparities: A Scientific Statement from the American Heart Association. Raghuveer G et al. Circulation 2016:134:e336-359. DOI: 10.1161/CIR00000000000000443.

  3. Family and Carer Smoking Control Programmes for Reducing Children’s Exposure to Environmental Tobacco Smoke. Behbod B, Sharma M, Baxi R, Roseby R, Webster P. Cochrane Database of Systematic Reviews 2018, Issue 1. Art. No: CD0001746. DOI: 10.1002/14651858.CD001746.pub4.

  4. Pharmacological Interventions for Smoking Cessation: An Overview and Network Meta-analysis. Cahill K, Stevens S, Perera R, Lancaster T. Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD009329. DOI: 10.1002/14651858.CD009329.pub2.

  5. Nicotine Replacement Therapy Versus Control for Smoking Cessation. Hartmann-Boyce J, Chepkin SC, Ye W, Bullen C, Lancaster T. Cochrane Database of Systematic Reviews 2018, Issue 5. Art. No.: CD000146. DOI: 10.1002/14651858.CD000146.pub5.

  6. You Can Reduce Secondhand Smoke Exposure! Prescribing Nicotine Replacement in the Pediatrician’s Office. Fernandez S. Pediatric Annals 2017, Vol 46, No. 9.

  7. MO HealthNet Division. Explanation of Benefits: MO HealthNet Nicotine Replacement Therapy (NRT) and Behavioral Smoking Cessation Benefits in Missouri: A Summary. https://dmh.mo.gov/docs/mentalillness/nrtdetails.pdf. Accessed 8 August 2018.