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SMOKING CESSATION IN CLINICAL SETTINGS Sponsored by the Medical Society of the State of New York in conjunction with the Medical Educational and Scientific Foundation

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Sponsored by the

Medical Society of the State of New York in conjunction with the Medical Educational and Scientific Foundation

of New York, Inc.

Grant support: NY State Dept. of Health

Modified (with permission) for the Association of Program Directors in Internal Medicine, NY Special Interest Group.

2004 - 2005

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  • At the end of this program, the learner will:

  • Have an understanding of a simple systematic approach to identifying and counseling current and former tobacco users using the Five A’s model.

  • Double cessation rates through brief advice to their patients.

  • Identify the biology of addiction and its pharmacologic treatment.

  • Have a familiarity with the national guidelines on effective tobacco dependence treatment.

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AHRQ 1-800-358-9295

Clinical Practice Guideline

“Treating Tobacco Use and Dependence”


“fax back” program

866-697-8487 866 NY-QUITS

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Tobacco Dependence Outline

  • Why Provide Treatment?

  • What is the Evidence it Works?

    • Public Health Service Guidelines

  • How can you do all this?

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Health effects of tobacco:

  • Cancer: Lung, Head and Neck, Bladder,

    Esophagus, Pancreas, Cervix

  • Coronary Artery Disease, Stroke, PVD, AAA

  • Chronic Lung Disease

  • Ulcer Disease

  • Osteoporosis

  • Low-birth weight, SIDS and URI’s in children

  • Leading cause of fatal home fires

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Actual Causes of Death 2000

Mokdad et al., JAMA 2004; 291:1238-1245

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Smoking in Perspective

  • Kills more than 440,000 Americans each year

  • 23% of adult Americans smoke

  • 3,000 children and adolescents become regular tobacco users every day

  • Causes cancer, heart disease, stroke, pulmonary disease, adverse pregnancy out-comes, and shortens life expectancy 14 years

  • Adds $157 billion in costs per year

  • One-third of all tobacco users in U.S. will die prematurely

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Environmental Tobacco Smoke(Second-hand Smoke)

  • Causes all the diseases that primary smoking causes.

  • Responsible for approximately 40,000 US deaths annually (most from CAD).

  • Leads to 1 million ER visits/yr for asthma.


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Health Benefits of Quitting

  • Cancers:

    Lung - after 10 years, former smokers have 70% lower risk compared to smokers

    Oral & Esophageal - 50% risk after 5 years

  • Cardiovascular disease:

    • CHD - 50% reduction in 12 months

    • Stroke - in 10 years risk is that of nonsmoker

    • PVD - 50% reduction in risk for former

    • smokers

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Clinical Preventive Services Priorities

  • In spite of best intentions, adult patients have an average of 12 risk factors requiring 24 preventive services.

  • Resources are limited, and knowledge that an intervention is effective is not sufficient to set priorities.

  • Therefore, interventions were assessed on two criteria.

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Clinically Preventable Burden (CPB) & Cost Effectiveness (CE)

  • CPB is the product of the burden of disease targeted by the service and its effectiveness and is represented as Quality Adjusted Life Years (QALY)

    • Proportion of disease and injury prevented if delivered to 100% of the target population

  • CE=costs of prevention - costs averted divided by the QALY’s saved expressed in 1995 dollars

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Summary (CE)

  • Screening and brief counseling for behavior change regarding tobacco use, problem drinking, and physical activity are delivered to less than 50% of the eligible US population.

  • Tobacco cessation services are highly cost-effective and can result in a significant reduction in disease burden.

  • Regular counseling is expected to improve patient health substantially.

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Tobacco use presents a rare confluence of circumstances (CE)

  • A highly significant health threat

  • A disinclination among clinicians to intervene consistently

  • The presence of effective interventions

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Tobacco Dependence as a (CE)Chronic Disease

  • Tobacco dependence demonstrates features of a chronic disease:

    • Long-term disorder

    • Periods of relapse and remission

    • Requires ongoing rather than acute care

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Opportunity for Intervention (CE)

  • 70% of smokers have made at least one unsuccessful quit attempt.

  • 46% of smokers try to quit each year.

  • More than 70% of smokers visit a health care setting each year.

  • Effective treatments exist which produce long-term or permanent abstinence.

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Perceived Health Risks Among Cigarette Smokers (CE)

Ayanian & Cleary JAMA 1999;281:1091-1021

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Treatment of Smokers by MDs (CE)

Thorndike et al., JAMA 1998;279:604-608

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It is essential that clinicians and health care delivery systems (including administrators, insurers, and purchasers) institutionalize the consistent identification, documentation, and treatment of every tobacco user seen in a health care setting.

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Brief tobacco dependence treatment is effective, and every patient who uses tobacco should be offered at least brief treatment.

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Impact of Physician’s Advice to Quit ( (CE)n = 7 studies)

Odds Ratio

(95%) CI


Abstinence Rate


No advice to quit

(reference group)






Physician advice

to quit

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Efficacy of Interventions Delivered by Various Types of Clinicians (n = 29 studies)

Odds Ratio

(95%) CI


Abstinence Rate

Type of Clinician

No clinician

(reference group)














Physician clinician


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Efficacy of Various Intensity Levels of Person-to-Person Contact (n = 43 studies)

Odds Ratio

(95%) CI


Abstinence Rate

Level of Contact

No contact

(reference group)





Minimal counseling

(< 3 minutes)




Low intensity counseling

(3-10 minutes)


Higher intensity counseling

(> 10 minutes)




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There is a strong dose-response relation between the intensity of tobacco dependence counseling and its effectiveness. Treatments involving person-to-person contact (via individual, group, or proactive telephone counseling) are consistently effective, and their effectiveness increases with treatment intensity (e.g., minutes of contact).

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Numerous effective pharmacotherapies for smoking cessation now exist. Except in the presence of contraindications, these should be used with all patients attempting to quit smoking.

  • Six first-line pharmacotherapies reliably increase long-term smoking abstinence rates:

    • Bupropion SR • Nicotine Nasal Spray

    • Nicotine Gum • Nicotine Patch

    • Nicotine Inhaler • Nicotine Lozenge

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Pharmacotherapeutic Interventions Contact (

  • All patients attempting to quit smoking should be encouraged to use pharmacotherapy except under special circumstances such as:

    • Medical contraindications

    • Smoking fewer than 10 cigarettes/day

    • Pregnant/breastfeeding women

    • Adolescents

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Effects of Nicotine Contact (

  • Release of dopamine & norepinephrine

  • Boost of energy and euphoria

  • Improved concentration, hand-eye coord.

  • Anorexia

  • Regular use creates physiologic dependence withdrawal, and cravings

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Nicotine Addiction Contact (

  • Per milligram dose, nicotine is the most addictive substance known to man.

  • Nicotine acts in the locus ceruleus which controls arousal, concentration, stress reduction, and appetite.

  • Nicotine is a stimulant in the reward pathway causing dopamine release creating dependency.

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Assessing nicotine addiction: Contact (

  • How soon after you wake up do you smoke your first cigarette?

  • How many cigarettes do you smoke in a day?

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Nicotine withdrawal syndrome has 5 of these sx in 24 hrs. Contact (

  • Depression or dysphoric mood

  • Insomnia

  • Irritability, frustration, or anger

  • Anxiety, restlessness, or impatience

  • Difficulty concentrating

  • Decreased heart rate

  • Increased appetite or weight gain

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Efficacy of Nicotine Gum Contact ((n = 13 studies)


Abstinence Rate

Odds Ratio

(95%) CI



(reference group)




(1.3 - 1.8)


Nicotine Gum

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Efficacy of Nicotine Inhaler Contact ((n = 4 studies)


Abstinence Rate

Odds Ratio

(95%) CI



(reference group)




(1.7 - 3.6)


Nicotine Inhaler

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Efficacy of Nicotine Nasal Spray Contact ((n = 3 studies)


Abstinence Rate

Odds Ratio

(95%) CI



(reference group)




(1.8 - 4.1)


Nicotine Nasal


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Efficacy of Nicotine Patch Contact ((n = 27 studies)


Abstinence Rate

Odds Ratio

(95%) CI



(reference group)




(1.7 - 2.2)


Nicotine Patch

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Efficacy of Over-the-Counter NRT Contact ((n = 3 studies)


Abstinence Rate

Odds Ratio

(95%) CI


Placebo (reference group)




Nicotine Patch


1.8 (1.2 - 2.8)

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Efficacy of Combination NRT Contact ((n = 3 studies)

Odds Ratio

(95%) CI


Abstinence Rate


One NRT (reference group)



Two NRTs

1.9 (1.3 - 2.6)


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Nicotine Replacement Therapy (NRT) Contact (

  • Nicotine is active ingredient

  • Supplied as steady dose (patch) or self-administered (gum, inhaler, nasal spray, or lozenge)

  • Self-administered products should be used on scheduled basis initially before tapered to ad lib use and eventual discontinuation

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Nicotine Replacement Therapy Contact (

  • No evidence of increased cardiovascular risk with NRT except with acute disease

  • Should abstain from smoking from the time you begin using these products

  • Medical contraindications:

    • immediate myocardial infarction (< 2 weeks)

    • serious arrhythmia

    • serious or worsening angina pectoris

    • accelerated hypertension

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Nicotine Gum Contact (

  • Transmucosal absorption

  • 2 mg (< 24 cigs/day) & 4 mg (> 24 cigs/day)

  • Scheduled dosing: every 1-2 hrs, >9/day, up to 24/day

  • Technique: chew and park

  • Do not use with acidic foods

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Nicotine Patch Contact (

  • Transdermal delivery 24 hr, 16 hr

  • >10 cig/day: 21mg or 15mg

  • Apply on Quit Date: trunk, hair-free, waist to neck or upper arm

  • New Patch daily, different spot

  • Careful disposal

  • S.E.’s: rash, insomnia

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Nicotine Nasal Spray Contact (

  • Trans nasal mucosa, fastest acting NRT

  • Dose: 1 spray each nostril = 1mg nicotine

  • Use: 1-2 doses/hr; total > 7 to <40/day

  • Technique: clear nose, tilt head, 1 spray each side, NO INHALING

  • S.E.’s: nasal, eye, throat irritation: tolerance develops

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Nicotine Inhaler Contact (

  • Transmucosal absorption, like gum

  • 10 mg cartridge delivers 4 mg nicotine with rapid inhalations (80/20 minutes)

  • Use: 6-16 cartridges/day

  • Technique: puncture cartridge, place in mouthpiece, use over 20 minutes

  • S.E.’s: throat, nasal, eye irritation: tolerance develops

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Nicotine Lozenge Contact (

  • Efficacy: Doubles to triples 12 mo cessation

  • Dosage:

    --2mg: smokes > 30 min after waking

    --4mg: smokes < 30 min after waking

  • First 6 weeks: 1 lozenge every 1-2 hrs, then taper

  • Technique: dissolve slowly, move around mouth

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Combination Nicotine Replacement Therapy Contact (

  • Combining the nicotine patch and a self-administered NRT (either nicotine gum or nicotine nasal spray) is more efficacious than a single form of NRT.

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Summary of NRT’s Contact (

  • PATCH: a no-brainer

  • GUM: “mouth thing”

  • NASAL SPRAY: fast acting for overwhelming urges

  • INHALER: ritual and handling

  • LOZENGE: “candy”

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Efficacy of Bupropion SR Contact ((n = 2 studies)


Abstinence Rate

Odds Ratio

(95%) CI



(reference group)




(1.5 - 3.0)


Bupropion SR

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Bupropion SR Contact (

  • Doubles abstinence rates vs. placebo

  • Only non-nicotine medication approved by US FDA for smoking cessation treatment

  • Marketed as Zyban for smoking cessation or Wellbutrin SR for depression

  • Mechanism: presumably blocks neural reuptake of dopamine and/or norepinephrine

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Bupropion SR Contact (

Side Effects: insomnia, dry mouth,

Treatment emergent: hypersensitivity, BP


  • Seizure disorder, or risk

  • Anorexia (eating disorder)

  • MAO Inhibitor within 14 days

  • Same medication (Wellbutrin, Zyban)

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Bupropion and Seizures Contact (

  • Immediate release formulation: 0.01-0.04%

    mostly with dose of 450mg or greater

  • SR formulation: 0.01%

    no seizures in smoking cessation trials

    reported seizures in patients with predisposition

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Bupropion: Screening for Seizure Risk Contact (

  • Known seizure disorder: epilepsy, febrile childhood seizures, alcohol withdrawal

  • History of brain injury: closed head trauma, stroke, brain surgery

  • Eating disorders: anorexia nervosa, bulimia

  • Drugs that lower seizure threshold: phenothiazines, theophylline, sudden alcohol or benzodiazepine withdrawal

    Hays JT. Mayo Clin Proc;2003

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Bupropion SR Contact (

  • Available by prescription only (USA)

  • Dosing:

    start 1-2 weeks before quit date

    — 150 mg orally once daily x 3 days

    — 150 mg orally twice daily x 7-12 weeks

    — no taper necessary at end of treatment

  • Maintenance - efficacious as maintenance medication for < 6 months post-cessation

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Bupropion SR Summary Contact (

  • Neurotransmitter effects that address addiction and withdrawal

  • Antidepressant and anorectogenic

  • Must screen for contraindications

  • Can be used with NRT

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Extended Use of Pharmacotherapy Contact (

  • First-line tobacco dependence medications may be considered for extended use, especially in patients with persistent withdrawal symptoms.

  • Evidence demonstrates that a minority of patients continue ad libitum NRT agents.

  • Does not present known health risks.

  • US FDA has approved bupropion SR for a long-term maintenance indication.

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Systems Interventions Contact (

  • Health care administrators, insurers, and purchasers should implement systems interventions to promote the consistent identification and treatment of tobacco users:

    • Implement a tobacco-user identification system in every clinic

    • Provide education, resources, and feedback to promote provider intervention

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Systems Interventions (con’t) Contact (

  • Dedicate staff to provide tobacco dependence treatments

  • Promote hospital policies that provide inpatient services

  • Include tobacco dependence treatments as a paid or covered service

  • Reimburse clinicians for providing treatment

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Psychosocial Contact (Interventions

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Two Questions, Three Minutes Contact (Very Brief Counseling

  • Do you smoke?

  • Do you want to quit?

    • If yes-

      • provide advice

      • set quit date

      • prescribe meds

      • set follow-up

    • If no-

      • provide advice provide advice and move on

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Remember to … Contact (

Ask about other forms of tobacco use:

  • Cigars

  • Pipes

  • Smokeless forms (chew and snuff)

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The “5 R’s” to Enhance Motivation for Patients Unwilling To Quit

  • RELEVANCE: Tailor advice and discussion to each patient.

  • RISKS: Discuss risks of continued smoking.

  • REWARDS: Discuss benefits of quitting.

  • ROADBLOCKS: Identify barriers to quitting.

  • REPETITION: Reinforce the motivational message at every visit.

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The “5 A’s” Unwilling To QuitFor Patients Willing to Quit

  • ASKabout tobacco use

  • ADVISEto quit

  • ASSESS willingness to make a quit attempt

    • willingness to go for intensive treatment

    • gather data regarding their habit

  • ASSISTin quit attempt

  • ARRANGE for follow-up

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Predictive Factors For Cessation Unwilling To Quit

  • Validated predictors of cessation (Farkas, 1996; Dale, 2001)

    • smoking <15 cigs/day and after 30 minutes of waking

    • not smoking daily

    • quit for 6 or more days in 12 months

    • quit for >1 year anytime

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Elements of a Counseling Intervention Unwilling To Quit

  • Quit Date. Set a stop date, preferably within two weeks. Starting on the quit date, total abstinence is essential.

  • Past quit experience. Identify what helped and what hurt in previous quit attempts.

  • Anticipate triggers or challenges in upcoming attempt. Discuss challenges/triggers and how patient will successfully overcome them.

  • Alcohol. Since alcohol can cause relapse, the patient should consider limiting/abstaining from alcohol while quitting.

  • Other smokers in the household. Quitting is more difficult when there is another smoker in the household. Patients should encourage housemates to quit with them or not smoke in their presence.

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Weight Gain Unwilling To Quit

  • Clinicians should openly address post-cessation weight gain concerns:

    • Acknowledge weight gain is likely but typically limited.

    • Encourage concentration on smoking cessation now, weight control later.

    • Recommend healthy diet and physical activity.

    • Consider pharmacotherapy, particularly bupropion SR and nicotine gum, shown to delay (but not prevent) weight gain.

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Who is likely to gain the most weight? Unwilling To Quit

  • “Heavier” smokers

    (number of cigarettes)

  • Age <55

  • Underweight women

  • Women who report little physical activity

  • African-Americans

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Preventing Relapse Unwilling To Quit

  • Relapse prevention interventions should be provided with every smoker who has recently quit.

  • Crucial to address relapse the first 3 months after quitting

  • Strategies to use with recent quitters:

    • Encourage continued abstinence.

    • Invite discussion of benefits, success milestones, problems encountered or anticipated.

    • Use or refer to an intensive intervention as appropriate.

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In Summary Unwilling To Quit

  • Brief tobacco dependence treatment is effective and every patient who uses tobacco should be identified, urged to quit, and offered at least one of these treatments:

    • Patients willing to quit should be provided treatments identified as effective.

    • Patients unwilling to quit should be provided an intervention to increase their motivation to quit.

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AHRQ 1-800-358-9295 Unwilling To Quit

Clinical Practice Guideline

“Treating Tobacco Use and Dependence”


“fax back” program

866-697-8487 866 NY-QUITS

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Conclusion Unwilling To Quit

  • Research regarding the treatment of tobacco use and dependence continues to grow exponentially.

  • The challenge is translation--ensuring that the practice of treating tobacco use and dependence keeps pace with the research.

  • Support material at

    • Medicaid now covers pharmacotherapy: New York State Smokers Quit Line 888-609-6784

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Diagnostic Codes Unwilling To Quit


Tobacco Use Disorder 305.1

Tobacco Dependence (V15.82)


Initial preventive medicine evaluation

•(Age 5-11 99383; 12-17 99384; 18-39 99385; 40-64 99386,

over 65 99387)

PHS Guideline 2000 pages 167-172

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Billing Codes Unwilling To Quit


Established Patient

•(Age 5-11 99393; 12-17 99394; 18-39 99395; 40-64 99396,

over 65 99397)


99401 15 minutes; 99402 30 minutes

99403 45 minutes; 99404 60 minutes

PHS Guideline 2000 pages 167-172

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Billing Codes Unwilling To Quit


99411 30 minutes

99412 60 minutes



PHS Guideline 2000 pages 167-172

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In accordance with ACCME’s policy, please complete the program evaluation.

Thank you.