| Supportive treatment component | Examples |
| Train patient in support support solicitation skills. |
|
| Prompt support seeking. |
|
| Clinician arranges outside support. |
|
Assist Component—Pharmacotherapy
The use of pharmacotherapy is a key part of a multicomponent approach to assisting patients with their tobacco dependence. The following tables address the clinical use of pharmacotherapies for tobacco dependence and some of the more common questions and concerns regarding pharmacotherapy.
| Who should receive pharmacotherapy for smoking cessation? | All smokers trying to quit, except in the presence of special circumstances. Special consideration should be given before using pharmacotherapy with selected populations: those with medical contraindications, those smoking fewer than 10 cigarettes/day, pregnant/breastfeeding women, and adolescent smokers. |
| What are the first-line pharmacotherapies recommended? | All five of the FDA-approved pharmacotherapies for smoking cessation are recommended, including bupropion SR, nicotine gum, nicotine inhaler, nicotine nasal spray, and the nicotine patch. |
| What factors should a clinician consider when choosing among the five first-line pharmacotherapies? | Because of the lack of sufficient data to rank-order these five medications, choice of a specific first-line pharmacotherapy must be guided by factors such as clinician familiarity with the medications, contraindications for selected patients, patient preference, previous patient experience with a specific pharmacotherapy (positive or negative), and patient characteristics (e.g., history of depression, concerns about weight gain). |
| Are pharmacotherapeutic treatments appropriate for lighter smokers (e.g., 10-15 cigarettes/day)? | If pharmacotherapy is used with lighter smokers, clinicians should consider reducing the dose of first-line nicotine replacement therapy (NRT) pharmacotherapies. No adjustments are necessary when using bupropion SR. |
| What second-line pharmacotherapies are recommended? | Clonidine and nortriptyline. |
| When should second-line agents be used for treating tobacco dependence? | Consider prescribing second-line agents for patients unable to use first-line medications because of contraindications or for patients for whom first-line medications are not helpful. Monitor patients for the known side effects of second-line agents. |
| Which pharmacotherapies should be considered with patients particularly concerned about weight gain? | Bupropion SR and nicotine replacement therapies, in particular nicotine gum, have been shown to delay, but not prevent, weight gain. |
| Are there pharmacotherapies that should be especially considered in patients with a history of depression? | Bupropion SR and nortriptyline appear to be effective with this population. |
| Should nicotine replacement therapies be avoided in patients with a history of cardiovascular disease? | No. The nicotine patch in particular is safe and has been shown not to cause adverse cardiovascular effects. |
| May tobacco dependence pharmacotherapies be used long-term (e.g., 6 months or more)? | Yes. This approach may be helpful with smokers who report persistent withdrawal symptoms during the course of pharmacotherapy or who desire long-term therapy. A minority of individuals who successfully quit smoking use ad libitum NRT medications (gum, nasal spray, inhaler) long term. The use of these medications long term does not present a known health risk. Additionally, the FDA has approved the use of bupropion SR for a long-term maintenance indication. |
| May pharmacotherapies ever be combined? | Yes. There is evidence that combining the nicotine patch with either nicotine gum or nicotine nasal spray increases long-term abstinence rates over those produced by a single form of NRT. |
| First-line Pharmacotherapies (Approved for use for smoking cessation by the FDA) | ||||||
| Pharmacotherapy | Precautions/
Contraindica- tions |
Side Effects |
Dosage | Duration | Availability | Cost/dayb |
| Bupropion SR |
History of seizure History of eating disorder |
Insomnia Dry mouth |
150 mg every morning for 3 days, then 150 mg twice daily (Begin treatment 1-2 weeks pre-quit) | 7-12 weeks maintenance up to 6 months | Zyban (prescription only) | $3.33 |
| Nicotine Gum |
Mouth soreness Dyspepsia |
1-24 cigs/day-2 mg gum (up to 24 pcs/day) 25+ cigs/day-4 mg gum (up to 24 pcs/day) |
Up to 12 weeks | Nicorette, Nicorette Mint (OTC only) |
$6.25 for 10, 2-mg pieces $6.87 for 10, 4-mg pieces |
|
| Nicotine Inhaler | Local irritation of mouth and throat | 6-16 cartridges/day | Up to 6 months | Nicotrol Inhaler (prescription only) | $10.94 for 10 cartridges | |
|
Nicotine Nasal Spray |
Nasal irritation | 8-40 doses/day | 3-6 months | Nicotrol NS (prescription only) | $5.40 for 12 doses | |
| Nicotine Patch |
Local skin reaction Insomnia |
21 mg/24 hours 15 mg/16 hours |
4 weeks 8 weeks |
Nicoderm CQ (OTC only), Generic patches (prescription and OTC), Nicotrol (OTC only) | Brand name patches $4.00-$4.50c | |
| Second-line Pharmacotherapies (Not approved for use for smoking cessation by the FDA) | ||||||
| Pharmacotherapy | Precautions/
Contraindica- tions |
Side Effects |
Dosage | Duration | Availability | Cost/dayb |
|
Clonidine
|
Rebound hypertension |
Dry mouth Drowsiness Dizziness Sedation |
0.15-0.75 mg/day | 3-10 weeks |
Oral Clonidine- generic, Catapres (prescription only) Transdermal Catapres (prescription only) |
Clonidine: $0.24 for 0.2 mg
Catapres |
| Nortriptyline | Risk of arrythmias |
Sedation Dry mouth |
75-100 mg/day | 12 weeks | Nortriptyline HCI-generic (prescription only) | $0.74 for 75 mg |
a The information contained within this table is not comprehensive. Please see package insert for additional information.
b Prices based on retail prices of medication purchased at a national chain pharmacy, located in Madison, WI, April 2000.
c Generic brands of the patch recently became available and may be less expensive.
Note: OTC = Over the Counter.
Assist Component—Intensive Interventions
Intensive interventions are appropriate for any tobacco user who is willing to use them. Evidence shows that intensive interventions are more effective than brief interventions and should be used whenever possible (e.g., available resources, patient is willing). The following table presents the results of guideline analyses that examined different components of intensive treatment programs.
| Assessment | Assessments should ensure that tobacco users are willing to make a quit attempt using an intensive treatment program. Other assessments can provide information useful in counseling (e.g., stress level, presence of comorbidity). |
| Program clinicians | Multiple types of clinicians are effective and should be used. One counseling strategy would be to have a medical/health care clinician deliver messages about health risks and benefits and deliver pharmacotherapy, and nonmedical clinicians deliver additional psychosocial or behavioral interventions. |
| Program intensity | Because of evidence of a strong dose-response relationship,
the intensity of the program should be:
|
| Program format | Either individual or group counseling may be used. Proactive telephone counseling also is effective. Use of adjuvant self-help material is optional. Followup assessment intervention procedures should be used. |
| Type of counseling and behavioral therapies | Counseling and behavioral therapies should involve practical counseling (problem solving/skills training) (see Table 5) and intra-treatment (see Table 6) and extra-treatment social support (see Table 7). |
| Pharmacotherapy | Every smoker should be encouraged to use pharmacotherapies endorsed in the guideline, except in the presence of special circumstances. Special consideration should be given before using pharmacotherapy with selected populations (e.g., pregnancy, adolescents). The clinician should explain how these medications increase smoking cessation success and reduce withdrawal symptoms. The first-line pharmacotherapy agents include: bupropion SR, nicotine gum, nicotine inhaler, nicotine nasal spray, and the nicotine patch. (see Tables 8 and 9). |
| Population | Intensive intervention programs may be used with all tobacco users willing to participate in such efforts. |
Assist Component—Special Populations
Interventions should be culturally, language, and educationally appropriate. In general, the treatments that were found to be effective in the guideline can be used with members of special populations, including hospitalized smokers, members of racial and ethnic minorities, older smokers, and others.
| Action | Strategies for implementation |
| Schedule followup contact, either in person or via telephone. |
|
The "5 R's," Relevance, Risks, Rewards, Roadblocks, and Repetition, are designed to motivate smokers who are unwilling to quit at this time. Smokers may be unwilling to quit due to misinformation, concern about the effects of quitting, or demoralization because of previous unsuccessful quit attempts. Therefore, after asking about tobacco use, advising the smoker to quit, and assessing the willingness of the smoker to quit, it is important to provide the "5 R's" motivational intervention.
Relevance
Encourage the patient to indicate why quitting is personally relevant, being as specific as possible. Motivational information has the greatest impact if it is relevant to a patient's disease status or risk, family or social situation (e.g., having children in the home), health concerns, age, gender, and other important patient characteristics (e.g., prior quitting experience, personal barriers to cessation).
Risks
The clinician should ask the patient to identify potential negative consequences of tobacco use. The clinician may suggest and highlight those that seem most relevant to the patient. The clinician should emphasize that smoking low-tar/low-nicotine cigarettes or use of other forms of tobacco (e.g., smokeless tobacco, cigars, and pipes) will not eliminate these risks.
Examples of risks are:
Rewards
The clinician should ask the patient to identify potential benefits of stopping tobacco use. The clinician may suggest and highlight those that seem most relevant to the patient.
Examples of rewards follow:
Roadblocks
The clinician should ask the patient to identify barriers or impediments to quitting and note elements of treatment (problemsolving, pharmacotherapy) that could address barriers.
Typical barriers might include:
Repetition
The motivational intervention should be repeated every time an unmotivated patient visits the clinic setting. Tobacco users who have failed in previous quit attempts should be told that most people make repeated quit attempts before they are successful.
Most relapses occur soon after a person quits smoking, yet some people relapse months or even years after the quit date. All clinicians should work to prevent relapse. Relapse prevention programs can take the form of either minimal (brief) or prescription (more intensive) programs.
Components of Minimal Practice Relapse Prevention
These interventions should be part of every encounter with a patient who has quit recently. Every ex-tobacco user undergoing relapse prevention should receive congratulations on any success and strong encouragement to remain abstinent. When encountering a recent quitter, use open-ended questions designed to initiate patient problemsolving (e.g., How has stopping tobacco use helped you?). The clinician should encourage the patient's active discussion of the topics below:
Components of Prescriptive Relapse Prevention
During prescriptive relapse prevention, a patient might identify a problem that threatens his or her abstinence. Specific problems likely to be reported by patients and potential responses follow:
Lack of support for cessation
Negative mood or depression
Weight gain
Flagging motivation/feeling deprived
Tobacco dependence is a chronic disease that deserves treatment. Effective treatments have now been identified and should be used with every current and former smoker. This Quick Reference Guide for Clinicians provides clinicians with the tools necessary to effectively identify and assess tobacco use, treat tobacco users willing to quit, treat tobacco users who are unwilling to quit at this time, and treat former tobacco users. There is no clinical intervention available today that can reduce illness, prevent death, and increase quality of life more than effective tobacco treatment interventions.
This guideline is available in several formats suitable for health care practitioners, the scientific community, educators, and consumers.
The Clinical Practice Guideline presents recommendations for health care providers with brief supporting information, tables and figures, and pertinent references.
The Quick Reference Guide is a distilled version of the clinical practice guideline, with summary points for ready reference on a day-to-day basis.
The Consumer Version is an information booklet for the general public to increase consumer knowledge and involvement in health care decisionmaking.
The full text of the guideline documents and the meta-analyses references for online retrieval are available on the Surgeon General's Web site (http://www.surgeongeneral.gov/tobacco/default.htm).
Single copies of these guideline products and further information on the availability of other derivative products can be obtained by calling any of the following Public Health Service clearinghouse's toll-free numbers:
Agency for Healthcare
Research and Quality (AHRQ)
800-358-9295
Centers for Disease Control and Prevention
(CDC)
800-CDC-1311
National Cancer Institute (NCI)
800-4-CANCER
U.S. Department of Health and Human Services
Public Health Service
Current as of October 2000
ISSN-1530-6402
Internet Citation:
Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians, October 2000. U.S. Public Health Service. http://www.surgeongeneral.gov/tobacco/tobaqrg.htm
Tobacco Cessation Guideline Index
Department of Health and Human
Services