What is the best approach to help a dialysis patient with impaired renal function quit smoking?

Smoking Cessation Approach for Dialysis Patients

For dialysis patients who smoke, the most effective approach is a combination of behavioral counseling and pharmacotherapy with appropriate dose adjustments for renal impairment, particularly using varenicline at reduced dosages for those with severe renal dysfunction.

Understanding the Challenge

• Smoking cessation in dialysis patients is difficult to achieve, similar to the general population, but is critically important for reducing cardiovascular risk 1
• There are limited comprehensive studies specifically examining smoking cessation pharmacotherapies in dialysis patients 1
• Smoking increases the risk of cardiovascular disease, which is already elevated in dialysis patients 1, 2

Recommended Approach

Assessment and Initial Counseling

• Use the 5 As approach: Ask about tobacco use, Advise to quit, Assess willingness, Assist with quitting, and Arrange follow-up 1
• Incorporate smoking cessation counseling as a routine component of dialysis care 1
• Ask two key questions during a brief (3-minute) counseling session:
  1. "Are you willing to make a quit attempt now?"
  2. "What worked or did not work when you tried to quit before?" 1

Pharmacotherapy Options

Varenicline (First-line option for dialysis patients)

• For patients with severe renal impairment (CrCl <30 mL/min) or on dialysis:
  • Begin with 0.5 mg once daily and titrate to 0.5 mg twice daily 3
  • For end-stage renal disease patients on hemodialysis, maximum dose is 0.5 mg daily if tolerated 3
• Standard dosing schedule (with renal adjustments):
  • Starting week: 0.5 mg once daily on days 1-3, then 0.5 mg twice daily on days 4-7 3
  • Continuing weeks: Adjusted dose (as above) for a total of 12 weeks 3
• Consider an additional 12 weeks of treatment for successful quitters to increase long-term abstinence 3

Bupropion and Nicotine Replacement Therapy (NRT)

• There are no comprehensive studies of these therapies specifically in dialysis patients 1
• When using these alternatives, careful dose adjustment and monitoring is necessary 4, 2

Behavioral Support

• Combine pharmacotherapy with behavioral counseling for maximum effectiveness 5
• Behavioral interventions should include:
  • Problem-solving strategies (e.g., removing tobacco products from home and work) 1
  • Coping skills development (e.g., deep breathing techniques, changing routines associated with smoking) 1
  • Telephone quit lines and mobile phone-based interventions 1

Special Considerations for Dialysis Patients

• Assess and address psychological factors that may impact smoking cessation success, as depression and anxiety are common in dialysis patients 1
• Consider referral to a psychologist for psychometric testing if needed 1
• Evaluate adequate dialysis and anemia control as these contribute to overall well-being and may impact cessation success 1
• Involve the dialysis facility social worker in the smoking cessation plan 1
• Medicare will cover 50% of outpatient mental health treatment charges (after deductible) if provided by an approved Medicare provider 1

Effectiveness and Follow-up

• Combined pharmacotherapy and behavioral interventions increase smoking cessation success compared to minimal intervention or usual care 5
• Success rates at 1 year range from:
  • 3-5% with unassisted quitting
  • 7-16% with behavioral intervention
  • Up to 24% with combined pharmacological treatment and behavioral support 6
• Arrange regular follow-up to provide continued support and adjust treatment plans as needed 1

Pitfalls to Avoid

• Don't underestimate the importance of smoking cessation in dialysis patients - it's a modifiable cardiovascular risk factor 4
• Don't overlook psychological assessment as part of the smoking cessation plan 1
• Don't use standard doses of smoking cessation medications in patients with severe renal impairment - dose adjustment is essential 3
• Don't recommend e-cigarettes as a smoking cessation aid as there is insufficient evidence for their effectiveness and safety 1