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Physicians and other health care providers are in an excellent
position to influence smokers' desire to quit as well as their
ability to succeed. In 2000, the U.S. Public Health Service released
a set of evidence-based guidelines, Treating Tobacco Use and
Dependence. The purpose of these guidelines is to help clinicians
understand tobacco dependence and to provide appropriate treatment
for all smokers.
View the
Tobacco Use and Dependence: Quick Reference Guide for Clinicians,
which summarizes the key strategies from the guidelines. The full
text of the guidelines is also available online at the Virtual
Office of the Surgeon General.
There are two ways that have been scientifically documented
to most help your patient quit. These are counseling support
and medication support. The "Five-A" guidelines
are a great way to engage your patient in a discussion about stopping
smoking .
- Ask about tobacco use
- Advise to quit through
clear personalized messages
- Assess willingness to quit
- Assist to quit
- Arrange follow-up
In addition, some useful recommendations for providers
are listed below:
1. The smoking status of every patient should
be assessed, as if a vital sign, at every visit. This information
should be displayed prominently in the medical record. Assessment
of smoking status can be done efficiently by non-physician staff
who can communicate the information to the physician with a chart
note or label.
2. Smoking cessation counseling by a clinician
is recommended on a regular basis for all patients who smoke.
Because repeated messages over time produce better success, counseling
should ideally be done at each patient visit. At a minimum, it
should occur once per year (e.g., at an annual health examination)
and at any problem visit for a potentially smoking-related condition.
All smokers should receive clear, strongly- worded and personalized
advice from physicians and nurses to quit smoking. Pregnant women
and parents with children at home should be counseled on the effects
of smoking on fetal and child health. Advice to avoid tobacco
use should be included in health promotion counseling for all
adolescents and young adults, even those who do not use tobacco.
3. Each smoker should be asked whether he/she
is willing to attempt cessation. Physicians should attempt to
motivate those who are not willing to quit. For smokers who are
willing to attempt quitting, physicians should provide specific
help including:
- Advice to set a quit date within 4 weeks.
- Written self-help materials on quitting (e.g. the Massachusetts Tobacco Control Program's "Life
After Cigarettes."
- Consideration of referral to a formal smoking cessation program
(see (four) below) or to a free telephone counseling service
like the Massachusetts Quitline:1-800-Try-To-Stop. Outside MA:
1-800-QUITNOW
- Recommendation for therapy with nicotine replacement, bupropion
SR [Zyban], or varenicline [Chantix] unless medically contraindicated
(see (five) below).
- A plan for in-person or telephone follow-up soon after the
quit date.
4. Referral to a formal smoking cessation program
is appropriate for all smokers, but especially for those who have
a high level of nicotine dependence (e.g., smoke > 1 pack per
day, smoke within 30 minutes of awakening or have had severe nicotine
withdrawal symptoms on prior quit attempts), psychiatric co morbidity,
other substance abuse, little social support for nonsmoking, or
low level of confidence in their ability to quit.
5. Drug therapy is appropriate for all smokers
except those with a medical contraindication. The U.S. FDA has approved
seven products as cessation aids; five of these are forms of nicotine
replacement therapy (gum, patch, nasal spray, lozenge, and vapor
inhaler). Contraindications include myocardial infarction within
the past two weeks, severe or worsening angina, life-threatening
cardiac arrhythmia, and pregnancy. Even in these situations, nicotine
replacement may be preferable to continued smoking, if cessation
is not otherwise possible. Pharmacotherapy should be used for at
least eight weeks. Patches are generally easier to use than gum.
Nicotine nasal spray and nicotine inhaler are available by prescription.
They might best be used in combination with the nicotine patch.
Pharmacotherapy is effective alone, but cessation rates are higher
when it is combined with a formal smoking cessation program and
this should be recommended.
6.
Bupropion SR (sustained-release) is also FDA-approved for smoking
cessation. The dose is 150 mg qd for three days, then 150 BID, starting
one week before the quit date and continuing for 8-12 weeks. Combinations
of bupropion and nicotine replacement are safe and clinically appropriate,
especially in heavily nicotine-addicted smokers.
Varenicline (Chantix), a partial agonist of the α4β2
nicotinic acetylcholine receptor, is also FDA-approved for smoking
cessation. The dose is 1 mg BID for a total of 12 weeks,
with an initial one-week dose titration to avoid nausea (Day 1-3:
0.5 mg qd; Day 4-7: 0.5 BID; then 1 mg BID) The quit date
should be one week after start of treatment. Patients who
have stopped smoking at end of treatment benefit from an additional
12 weeks of treatment to maintain long-term abstinence.
The safety and efficacy of combining varenicline with nicotine
replacement or bupropion has not been tested.
7. Nortriptyline and clonidine are two second-line
therapies that may be considered if nicotine replacement therapy,
bupropion SR, and varenicline are ineffective. These treatments,
however, are not FDA-approved for smoking cessation and have more
side effects than the other treatments.
(Source http://www.massgeneral.org/tts/)
Support is the best thing you can offer your patient.
Also, there are a number of resources you can inform your patient
about to help them stay quit including support groups, complementary
therapies, and other techniques. This website contains information
on many of these resources and others.
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