Ask the Pharmacist

Q) I know it’s not New Year’s, but with all this talk about COVID affecting your lungs, I really would like to try quitting smoking again. What’s the best way to do it?

A) By now, everybody knows at least some of the risks associated with smoking. It is such a blight upon our health that it has been listed as a causal factor in nearly 1 in 5 deaths (which is a holy crap moment for me).

It causes more deaths annually than the combined numbers of deaths from HIV, drug use (although these stats are from a few years ago and the ongoing opioid crisis may have rendered this no longer valid), alcohol use, vehicle accidents and firearms. It has caused more premature deaths, by a factor of 10, than all the wars combined fought in by the United States. There is no way around it, smoking kills.

It also maims as it has been linked to multiple cancers, all kinds of lung diseases (notably COPD), heart disease and stroke, infertility, impotence and erectile dysfunction, poor bone health, poor oral health (i.e. gum disease), eye problems (cataracts and age related macular degeneration which can permanently rob you of your vision), diabetes, rheumatoid arthritis, impaired immune responses to infection and the list goes on and on.

It is the last point that brings us to COVID-19 as one would logically assume that smoking would be detrimental to surviving this infection. That being said, different studies have produced vastly different answers to this theory. When taken collectively (there were 34 peer reviewed studies from around the globe), the evidence suggests that, not surprisingly, smoking is associated with an increase in the severity of the COVID-19 infection and hence a rise in the mortality rate as well. The evidence seems to indicate that the risk of a severe complication is 1.5 times greater in smokers than it is in non or former smokers.

Now all of these studies were conducted on patients who were hospitalized so the results can only be applied to this subset of people. We cannot say for certain that smokers are more likely to be hospitalized or even to get the infection until more studies are conducted.

The odds are the answers will not be kind to smokers, but there is one silver lining. Based upon how the infection attacks our bodies, it has been speculated that nicotine, and by implication nicotine replacement products such as the patch, may in fact be beneficial in the fight against COVID. Nicotine ties up the ACE-2 receptors located in the nose, lungs, kidneys, GI tract and heart thereby, preventing them from binding to COVID-19 virus particles and thereby, hopefully, stopping the resultant inflammatory process before it even begins. Studies have not proven this yet, but if borne out, it would make now as good a time as any to consider quitting.

So, just what is the most effective way to quit? While the answer does depend on the individual, statistically speaking either the prescription drug Champix (varenicline) or what is known as combination nicotine replacement therapy (NRT) are the most efficacious.

The story with varenicline has changed a bit over the years. When it first was released, the drug came with a boxed warning indicating the drug may predispose people to suffering from psychiatric events. This has since been removed based upon the results of a very large trial although health practitioners continue to warn their patients who are quitting smoking to report any changes in mood, thinking or behaviour. These sorts of effects it turns out may not be a side effect of the drug itself but instead may be an unintended consequence resulting from the loss of a major coping strategy for many people (i.e. for a number of smokers, lighting up is a major stress reliever which when taken away causes some people to struggle).

As well, now there is even more data to support that Champix is safe to use in patients with stable cardiovascular diseases including those with heart failure or heart disease. Most will continue to start for one week before their “quit date”, although there is data suggesting that starting even earlier (in some case 3 months before attempting to quit) may improve the odds of success in the long term. The same goes for the treatment duration.

Most will continue Champix for three months after they quit before stopping the drug but there are some who have needed to stay on it for up to a year in order not to return to their addiction and this seems to be a perfectly safe decision. The drugs works by both binding to acetylcholine receptors in the brain while also partially stimulating nicotine receptors at the same time. In doing so, varenicline helps to lessen the pleasure that smoking provides while reducing cravings as well. It is usually taken twice a day (better with food and a full glass of water to minimize stomach upset) at a 1mg dose but there is a lower dose available if side effects are an issue.

The most common complaints about the drug include an upset stomach (which in a few can lead to vomiting), constipation, vivid dreams and a headache. More serious but far less frequent reactions include the potential for depression or seizures. There are some experts who believe its effectiveness is enhanced by using it simultaneously with NRT but while this makes sense in theory, it has yet to be studied enough to make any firm conclusions as of yet.

The other first choice for quitting as I mentioned earlier is combination NRT. This means combining the daily use of a long acting form of nicotine such as the patches with an “as needed” form such as the nicotine gums, lozenges, sprays or inhaler which are used only if and when the urge to smoke becomes too much. I’m not a massive fan of the gum as it tastes pretty crappy and is rather unnatural to use in that it is meant to be chewed only twice a minute which goes against our normal gum impulses.

I do really like the inhaler due to its rapid onset of action and fantastic flexibility. Each cartridge is “good” for 20 minutes, but it does not have to be used all at once. In other words, if you just get off work and walk by the smoker’s door, you can take your inhaler out, drag on it for a couple of minutes until the cravings fade, and put it back in your pocket until next time.

The major advantage of varenicline over NRT is cost. A prescription for varenicline costs about $60 a month whereas NRT can cost about $100 a month depending on how many nicotine gums, spray, patches… one uses. These are however, not the only options available.

There is another prescription drug indicated for smoking cessation known as Zyban (bupropion) which has been used for an even longer period of time then has Champix, as well as several other drugs that appear to help but have never gone through the formal approval process for this use. These include clonidine (which is used in ADD therapy, hot flashes and high blood pressure), nortriptyline (frequently used to help with nerve pain or insomnia) and topiramate (epilepsy and mood disorders).

E-cigarettes can also be helpful and while their long-term effects are still unknown and they too have addictive properties, not even their worst critics would say they are even close to being as harmful as the real things.

Lastly, (at least as products go as some find strategies such as acupuncture, hypnosis, behavioural therapy and others helpful) there the natural solutions such as Cravv (cysteine) which is believed to work by a mechanism similar to varenicline and has been used for many years in Europe, although it is relatively new to this side of the ocean. Preliminary evidence for Cravv seems very promising when compared to quitting cold turkey or even against standard NRT.

Listen, your doctor and loved ones aren’t really going to care how you quit, just pick a choice that you think works for you (your pharmacist would be happy to go through all of the options in much greater detail I am sure) and do it. Your health is too important to waste. For more information about this or any other health related questions, contact your pharmacist.