II. Epidemiology

  1. Up to 70% of Tobacco smokers want to quit but only 5% are successful

III. Preparation: Office based Smoking Cessation program

  1. Select an office Smoking Cessation coordinator
  2. Create a smoke free office
  3. Identify all smoking patients: "Do You Smoke"
  4. Review self-help materials with each smoker
  5. Make follow-up visits and call-backs
  6. Consider working with consulting pharmacists to dispense and counsel on Tobacco Cessation products

IV. Protocol: Interview in clinic

  1. "Do You smoke?"
    1. Label Chart "SMOKER" (or sticker)
    2. Make Smoking a Vital Sign
  2. How Much do you smoke?
    1. Greater nicotine dependence if >1 pack per day
  3. How soon after waking do you have first Cigarette?
    1. Greater nicotine dependence if under 30 minutes
  4. Have you tried to quit before?
    1. Successful cessation requires 3-6 attempts (average)
  5. Other assessment tools
    1. CAGE Questions can be applied to Tobacco abuse
    2. Fagerstrom Test for Nicotine Dependence

V. Precautions: Myths regarding quitting smoking - Anxiety will increase

  1. Smokers (n=101) followed for 4 weeks
  2. No increase in anxiety
  3. Anxiety actually decreased after first week
  4. Reference
    1. West (1997) Am J Psych 154:1589-92 [PubMed] (or open in [QxMD Read])

VI. Management: General

  1. See Behavior Modification (Trans-theoretical Model, Five As Technique)
  2. Confirm interest in quitting
  3. Set a quit date
  4. Provide Self-Help materials
    1. See resources below
    2. "Clearing the Air" (National Cancer Institute)
    3. Free NCI Materials: 1-800-4-CANCER
    4. Free telephone quit line: 800-QUIT-NOW
  5. Relapse is common in first 6-12 months after cessation
    1. Reassess interest in quitting after relapse
  6. Tobacco Cessation office-based billing
    1. Medicare covers up to 8 sessions per year
    2. Counseling for >3 minutes: CPT 99406
    3. Counseling for >10 minutes: CPT 99407

VII. Management: Pharmacotherapy

  1. Indications for pharmacotherapy (Nicotine Dependence)
    1. Tobacco use at or exceeding 1 pack per day
    2. First Cigarette smoked within 30 minutes of waking
    3. History of withdrawal symptoms during prior quit attempt
  2. Medications
    1. Bupropion (Zyban, Wellbutrin)
      1. May also help avert the weight gain associated with Tobacco Cessation
    2. Varenicline (Chantix)
      1. Not recommended due to increased cardiovascular event risk
    3. Nortriptyline
      1. Titrate to serum level 50-150 ng/ml (~75 mg/day)
      2. As effective as Bupropion
      3. Da Costa (2002) Chest 122:403-8 [PubMed] (or open in [QxMD Read])
      4. Hall (2002) Arch Gen Psychiatry 59:930-6 [PubMed] (or open in [QxMD Read])
    4. Nicotine Replacement
      1. Base dose on nicotine dependence
      2. See Fagerstrom Test for Nicotine Dependence
      3. Nicotine Patch
      4. Nicotine Gum
        1. Consider an occasional low dose gum (2 mg) as an adjunct to Nicotine Patch to treat breakthrough cravings
      5. Nicotine Nasal Spray
      6. Nicotine Inhaler
  3. Efficacy
    1. Smokers interested in quitting: 70%
    2. Smokers who quit without additional help: 7.9%
    3. Smokers who quit with only advice of physician: 10.2%
    4. Smokers who quit with Nicotine Replacement: 26%
    5. Smokers who quit with combined therapy below: 35%
      1. Behavioral support
      2. Bupropion
      3. Nicotine Replacement
  4. References
    1. Jorenby (1999) N Engl J Med 340:685-91 [PubMed] (or open in [QxMD Read])

VIII. Precautions: Major Depression

  1. Initial risk of Major Depression exacerbation
  2. Higher risk in first 6 months of Tobacco Cessation
  3. Confirm Major Depression control prior to cessation
  4. Consider Bupropion use for cessation
  5. Glassman (2001) Lancet 357:1929-32 [PubMed] (or open in [QxMD Read])

IX. Precautions: Medications with no proven efficacy in Tobacco Cessation (avoid)

  1. Silver acetate (gives Cigarettes bad taste)
  2. Alprazolam (Xanax) or other Benzodiazepine
  3. Clonidine (Catapres)

X. Precautions: Devices with increased risk or unknown safety

  1. Avoid Electronic Cigarette (E-Cigarette)
    1. Inadequate safety available for these devices and the inhaled vapor compared other Nicotine Replacement forms
  2. Avoid Hookah Pipe (Tobacco smoke drawn through water before inhalation)
    1. Water does not filter Tobacco-related toxins
    2. Hookah users tend to smoke for longer and have greater exposure
  3. References
    1. (2013) Presc Lett 20(5): 27
    2. Vardavas (2012) Chest 141(6):1400-6 [PubMed] (or open in [QxMD Read])
    3. Trtchounian (2011) Tob Control 20:47-52 [PubMed] (or open in [QxMD Read])

XI. Resources

  1. AHRQ Smoking Cessation Guidelines
    1. http://www.ahrq.gov/guide
  2. CDC Smoking and Tobacco
    1. http://www.cdc.gov/tobacco
  3. National Cancer Institute
    1. http://www.nci.nih.gov/cancertopics/tobacco
  4. Quitnet
    1. http://www.quitnet.com
  5. Quit Smoking Support
    1. http://www.quitsmokingsupport.com
  6. Nicotine Anonymous
    1. http://www.nicotine-anonymous.org
  7. SmokeFree.gov
    1. http://www.smokefree.gov
  8. Quit Now
    1. Phone: 800-QUIT-NOW

XII. References

  1. (2014) Presc Lett 21(9): 51
  2. Dalack (1995) Am J Psychiatry 152(3):398-403 [PubMed] (or open in [QxMD Read])
    1. Fluoxetine use in Smoking Cessation
  3. Lief (1996) Am J Psychiatry 153(3);442 [PubMed] (or open in [QxMD Read])
    1. Bupropion in Smoking Cessation
  4. Mallin (2002) Am Fam Physician 65(6):1107-17 [PubMed] (or open in [QxMD Read])
    1. Review of Tobacco Cessation measures
  5. Robbins (1993) Am J Prev Med 9(1):31-3 [PubMed] (or open in [QxMD Read])
    1. Review of pharmacotherapy Smoking Cessation
  6. Spring (1995) Am J Clin Nutr 62(6):1181-7 [PubMed] (or open in [QxMD Read])
    1. Weight loss drugs do not stop cessation weight gain

Images: Related links to external sites (from Google)