What are the recommendations for smoking cessation in patients with Chronic Kidney Disease (CKD)?

Smoking and Chronic Kidney Disease

All patients with CKD who smoke must be advised to quit at every healthcare visit, with combined behavioral interventions and pharmacotherapy (varenicline, bupropion, or combination nicotine replacement therapy) to maximize cessation rates and reduce cardiovascular mortality and CKD progression. 1

Assessment and Screening

• Screen tobacco use at every healthcare visit to identify patients who may benefit from cessation interventions, as routine screening increases clinician intervention rates and allows reinforcement of abstinence or identification of relapse 1
• Document smoking status in the electronic health record with clinician prompts to improve referral to cessation programs 1
• Assess e-cigarette use in addition to traditional tobacco products, as many patients have become "dual users" 1

Evidence for Smoking Cessation in CKD

Smoking dramatically accelerates CKD progression and cardiovascular events. Current smokers with CKD face a 2.14-fold higher risk of cardiovascular events or death compared to never smokers, while former smokers have a 1.30-fold increased risk 2. The magnitude of risk is dose-dependent: former smokers with ≥20 pack-years have a 2.14-fold higher risk compared to never smokers, while those with <20 pack-years have only a 1.05-fold increased risk 2.

The benefits of cessation are substantial but require prolonged abstinence in CKD patients. Among former smokers with CKD, the hazard ratios decrease progressively with longer cessation duration: 1.75 for <10 years, 1.43 for 10-20 years, and 1.11 for ≥20 years of cessation 2. Notably, CKD patients require longer cessation periods than the general population to achieve risk comparable to never smokers—approximately ≥20 years versus shorter durations in those without CKD 2.

Pharmacotherapy for Smoking Cessation

Combine behavioral interventions with pharmacotherapy for maximum efficacy. 1

First-Line Pharmacologic Options:

• Varenicline may be preferred over bupropion or nicotine replacement therapy (NRT) to increase cessation rates, though this is a weaker recommendation 1
• Bupropion is effective and not associated with increased cardiovascular events 1
• Combination long- and short-acting nicotine replacement therapy is recommended as an alternative 1

Dose Adjustments for CKD:

Consider kidney function when dosing medications cleared by the kidneys, using validated eGFR equations for drug dosing 3, 4. Specific dose adjustments for varenicline and bupropion should account for reduced GFR 5.

E-Cigarettes:

Short-term use of nicotine-containing e-cigarettes may be considered only to aid smoking cessation alongside a formal tobacco cessation program, but the risk of sustained use and unknown long-term safety may outweigh benefits 1. E-cigarettes should generally be avoided as they are not harm-free and can cause negative changes in vascular endothelial function 1.

Behavioral Interventions

• Provide brief advice and counseling at every visit, as this increases quit rates 1
• Refer to formal smoking cessation programs where available 1
• Utilize psychologists and pharmacists as part of a comprehensive cessation strategy 1
• Electronic health record-based interventions with clinician prompts improve documentation and referral rates 1

Integration with Comprehensive CKD Management

Smoking cessation must be part of a holistic CKD treatment strategy that includes: 1

• SGLT2 inhibitors as first-line therapy for most CKD patients 3
• RAS inhibition (ACE inhibitor or ARB) at maximum tolerated dose when hypertension or albuminuria is present 1, 3
• Blood pressure target <120 mmHg systolic for most patients, or <130/80 mmHg if albuminuria ≥30 mg/24h 1, 3
• Statin therapy for all adults ≥50 years with CKD 3, 4
• Physical activity of at least 150 minutes per week of moderate intensity 1, 3
• Dietary modifications with higher plant-based food consumption and protein intake of 0.8 g/kg/day 1, 3

Secondhand Smoke Exposure

Patients with CKD must avoid secondhand smoke exposure to reduce cardiovascular event risk 1. Counsel patients on the importance of avoiding passive smoking in their home and work environments 1.

Special Populations

Dialysis Patients:

All dialysis patients should be counseled and regularly encouraged to stop smoking, as continued tobacco use is associated with increased cardiovascular events and mortality 1. The evidence for cardiovascular benefit of cessation is particularly strong in this population 6.

Kidney Transplant Recipients:

Smoking accelerates graft loss and worsens survival in kidney transplant recipients, making cessation critical in this population 7.

Common Pitfalls

• Underestimating the time required for risk reduction: CKD patients need ≥20 years of smoking cessation to achieve cardiovascular risk comparable to never smokers, longer than the general population 2
• Failing to screen at every visit: Most clinicians do not routinely screen for tobacco use despite its critical importance 1
• Not addressing e-cigarette use: Many patients are dual users of traditional cigarettes and e-cigarettes, requiring assessment of both 1
• Inadequate follow-up: Less than 10% of adults who want to quit succeed, typically requiring multiple attempts and ongoing support 8