Smoking Cessation

1. Smoking Cessation

2. Opportunity for Physicians • 70 percent of smokers want to quit. • Without assistance only 5 percent are able to quit. • Most try to quit do so on their own, without evidence-based programs; more than 95 percent relapse. • Using evidence-based programs can more than double success rates.

3. Brief interventions • Minimal interventions lasting less than 3 minutes increase overall tobacco abstinence rates. • Every tobacco user should be offered at least a minimal intervention, whether or not he or she is referred to an intensive intervention. • Even when patients are not willing to make a quit attempt, clinician-delivered brief interventions enhance motivation and increase the likelihood of future quit attempts. STRENGTH OF EVIDENCE: A

4. Ask and Act Ask every patient about tobacco use. Act to help them quit.

5. Patients unwilling to quit • Use brief intervention to promote motivation (motivational interviewing) • Patients unwilling to quit may: • Lack information about harmful effects or benefits of quitting • Lack financial resources • Have fears or concerns about quitting • Think they can’t quit PHS Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update

6. Counseling

7. What will constitute smoking cessation counseling in your setting? • Ask (identify smoking/tobacco use status) • Advise (advise patient to quit) • Assess (determine interest/readiness to quit) • Assist (in developing quit plan if ready to quit) • Arrange (follow-up contact) • Motivate (if patient not ready to quit) • Prevent Relapse (if quit within past year) Training Staff in Smoking Cessation Counseling

8. Principles for Motivational Interviewing • Express empathy • Develop discrepancy • Roll with resistance • Support self-efficacy Motivational interviewing is effective in increasing future quit attempts.

9. Express empathy • Open ended questions • Reflective listening • Normalize feelings and concerns • Support right to choose whether or not to quit PHS Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update

10. Nicotine Withdrawal Symptoms Withdrawal symptoms appear as soon as within 4 hours of taking last one. More symptoms remain in between three and five days and start to disappear within 2 weeks, though some may experience few symptoms even for months.

12. Pharmacotherapy

13. Who should receive it? All smokers trying to quit, except where contraindicated or for specific populations for which there is insufficient evidence of effectiveness (i.e., pregnant women, smokeless tobacco users, light smokers, and adolescents) STRENGTH OF EVIDENCE = A

14. First-line Pharmacotherapy • Buproprion slow release • Nicotine gum • Nicotine inhaler • Nicotine nasal spray • Nicotine patch • Nicotine lozenge • Varenicline

15. Factors To Consider When Prescribing • Clinician’s familiarity with medications • Contraindications • Patient preference • Previous patient experience • Patient characteristics (history of depression, weight gain concerns, etc.)

16. Nicotine Lozenge • 12.15- 18.6375 SR ($3.24 - $4.95) per day • Available in 2mg or 4mg • Weeks 1-6: one every 1-2 hoursWeeks 7-9: one every 2-4 hoursWeeks 10-12: one every 4-8 hours • Common side effects are mouth soreness, dyspepsia and nausea.

17. Nicotine gum • 8.1- 17.55 SR ($2.16 - $4.68) per day • Available in 2mg or 4mg • Weeks 1-6: one every 1-2 hoursWeeks 7-9: one every 2-4 hoursWeeks 10-12: one every 4-8 hours • Common side effects are jaw pain and mouth soreness.

18. Nicotine patch • 7.12- 14.58 SR ($1.90 - $3.89) per day • >25 cigarettes per day: 21mg every 24hrs for four weeks, then 14mg for two weeks, then 7 mg for two weeks • Common side effects are skin irritation or sleep issues if worn at night.

19. Nicotine inhaler • 27.45 SR ($7.32) per day (6 cartridges) • 6-16 cartridges per day, initially one every 1-2 hours • Common side effects are mouth and throat irritation and cough.

20. Nicotine Nasal Spray • 14.7 SR ($3.92) per day • 1-2 doses (2-4 sprays) per hour • Common side effects are nose and throat irritation, sneezing and cough.

21. Bupropion Slow Release • Start 150mg once daily for 6 days, • then twice per day for seven to twelve weeks. • Plan quit date 1-2 weeks after start of treatment. • Approved for up to 6 months • Common side effects include Insomnia and dry mouth.

22. Varenicline • Start 0.5mg daily for 1-3 days, then increase to twice daily for 1-4 days. Increase to 1 mg twice daily on quit date. • Take after eating and with a full glass of water. • Consider dosage reduction in patients unable to tolerate the adverse reactions. • Treat for 12 wk. For patients who have successfully stopped smoking after 12 wk, an additional 12-wk course may increase the likelihood of long-term abstinence. • Most common side effects are nausea and vivid dreams. • Monitor for psychiatric symptoms.

23. Medication Recommendation Certain combinations of first-line medications have been shown to be effective smoking cessation treatments. Therefore, consider using these combinations of medications for patients who are willing to quit. Effective combination medications are: * Long-term (> 14 weeks) nicotine patch + other NRT (gum and spray) * The nicotine patch + the nicotine inhaler * The nicotine patch + bupropion SR. (Strength of Evidence = A)