CD
Tobacco Cessation
search
Tobacco Cessation
, Smoking Cessation, E-Cigarette Cessation
See also
Tobacco
Five As Technique
Epidemiology
Up to 70% of
Tobacco
smokers want to quit but only 5% are successful
Preparation
Office based Smoking Cessation program
Select an office Smoking Cessation coordinator
Create a smoke free office
Identify all smoking patients: "Do You Smoke"
Review self-help materials with each smoker
Make follow-up visits and call-backs
Consider working with consulting pharmacists to dispense and counsel on Tobacco Cessation products
Tobacco Cessation counseling is billable (CPT 99406 for >3 min and CPT 99407 for >10 min)
Protocol
Interview in clinic
"Do You smoke?"
Label Chart "SMOKER" (or sticker)
Make Smoking a
Vital Sign
How Much do you smoke?
Greater nicotine dependence if >1 pack per day
How soon after waking do you have first
Cigarette
?
Greater nicotine dependence if under 30 minutes
Have you tried to quit before?
Successful cessation requires 3-6 attempts (average)
Other assessment tools
CAGE Questions
can be applied to
Tobacco Abuse
Fagerstrom Test for Nicotine Dependence
Precautions
Myths regarding quitting smoking - Anxiety will increase
Smokers (n=101) followed for 4 weeks
No increase in anxiety
Anxiety actually decreased after first week
Reference
West (1997) Am J Psych 154:1589-92 [PubMed]
Management
Gene
ral
See
Behavior Modification
(
Trans-theoretical Model
,
Five As Technique
)
Use similar methods and medications for E-Cigarette Cessation as for Tobacco Cessation
Confirm interest in quitting
Set a quit date
Provide Self-Help materials
See resources below
"Clearing the Air" (National Cancer Institute)
Free NCI Materials: 1-800-4-CANCER
Free telephone quit line: 800-QUIT-NOW
SmokeFreeTxt: Text 'QUIT' to 47848
Behavioral interventions are effective (with or without pharmacotherapy)
Individual or group counseling
Guaranteed financial incentives
Text message-based counseling
Hartmann-Boyce (2021) Cochrane Database Syst Rev (1):CD013229 [PubMed]
Relapse is common in first 6-12 months after cessation
Reassess interest in quitting after relapse
Tobacco Cessation office-based billing
Medicare covers up to 8 sessions per year
Counseling for >3 minutes: CPT 99406
Counseling for >10 minutes: CPT 99407
Management
Pharmacotherapy
Indications for pharmacotherapy (Nicotine Dependence)
Tobacco
use at or exceeding 1 pack per day
First
Cigarette
smoked within 30 minutes of waking
History of withdrawal symptoms during prior quit attempt
Nicotine Replacement
Eight week course is sufficient with little added benefit to longer use
Schnoll (2015) JAMA Intern Med 175(4): 504-11 [PubMed]
Base dose on nicotine dependence
See
Fagerstrom Test for Nicotine Dependence
Nicotine Patch
Nicotine Gum
Consider an occasional low dose gum (2 mg) as an adjunct to
Nicotine Patch
to treat breakthrough cravings
Nicotine Nasal Spray
Nicotine Inhaler
Adjunctive Medications
Bupropion
(
Zyban
,
Wellbutrin
)
May also help avert the weight gain associated with Tobacco Cessation
Varenicline
(
Chantix
)
Increased cardiovascular event risk
More effective when combined with
Nicotine Replacement
Koegelenberg (2014) JAMA 312(2): 155-61 [PubMed]
Nortriptyline
Titrate to serum level 50-150 ng/ml (~75 mg/day)
As effective as
Bupropion
Da Costa (2002) Chest 122:403-8 [PubMed]
Hall (2002) Arch Gen Psychiatry 59:930-6 [PubMed]
Efficacy
Smokers interested in quitting: 70%
Smokers who quit without additional help: 7.9%
Smokers who quit with only advice of physician: 10.2%
Smokers who quit with
Nicotine Replacement
: 26%
Smokers who quit with combined therapy below: 35%
Behavioral support
Bupropion
Nicotine Replacement
References
Jorenby (1999) N Engl J Med 340:685-91 [PubMed]
Precautions
Major Depression
Initial risk of
Major Depression
exacerbation
Higher risk in first 6 months of Tobacco Cessation
Confirm
Major Depression
control prior to cessation
Consider
Bupropion
use for cessation
Glassman (2001) Lancet 357:1929-32 [PubMed]
Precautions
Medications with no proven efficacy in Tobacco Cessation (avoid)
Silver acetate (gives
Cigarette
s bad taste)
Alprazolam
(
Xanax
) or other
Benzodiazepine
Clonidine
(
Catapres
)
Precautions
Devices with increased risk or unknown safety
Avoid
Electronic Cigarette
(
E-Cigarette
)
Inadequate safety available for these devices and the inhaled vapor compared other
Nicotine Replacement
forms
No good evidence that e-cigs assist patients in quitting nicotine completely (may simply trade one drug for another)
More than half of e-cig users are dual users (use
Tobacco
also)
Emphasize the need to completely quit
Tobacco
Avoid Hookah Pipe (
Tobacco
smoke drawn through water before inhalation)
Water does not filter
Tobacco
-related toxins
Hookah users tend to smoke for longer and have greater exposure
References
(2013) Presc Lett 20(5): 27
Vardavas (2012) Chest 141(6):1400-6 [PubMed]
Trtchounian (2011) Tob Control 20:47-52 [PubMed]
Resources
AHRQ Smoking Cessation Guidelines
http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/index.html
CDC Smoking and
Tobacco
http://www.cdc.gov/tobacco
National Cancer Institute
http://www.cancer.gov/cancertopics/tobacco/smoking
Quitnet
http://www.quitnet.com
Nicotine Anonymous
http://www.nicotine-anonymous.org
SmokeFree.gov (NIH)
http://www.smokefree.gov
References
(2014) Presc Lett 21(9): 51
Dalack (1995) Am J Psychiatry 152(3):398-403 [PubMed]
Fluoxetine
use in Smoking Cessation
Lief (1996) Am J Psychiatry 153(3);442 [PubMed]
Bupropion
in Smoking Cessation
Mallin (2002) Am Fam Physician 65(6):1107-17 [PubMed]
Review of Tobacco Cessation measures
Robbins (1993) Am J Prev Med 9(1):31-3 [PubMed]
Review of pharmacotherapy Smoking Cessation
Spring (1995) Am J Clin Nutr 62(6):1181-7 [PubMed]
Weight loss drugs do not stop cessation weight gain
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