• May 2, 2007, Antidepressant drugs: Update to the existing black box warning on the prescribing information on all antidepressant medications to include warnings about the increased risks of suicidal thinking and behavior in young adults ages 18 to 24 years old during the first one to two months of treatment.

• Advise to quit [A]/avoid second-hand smoke.
• Assess patient willingness to attempt to quit [C].
• Assist patients who are ready to quit by:
  • Establishing a quit date
  • Providing self-help materials (e.g., free Quit Kits; see www.michigan.gov/tobacco)
  • Offering nicotine replacement therapy (adults only) and/or withdrawal medications (e.g., sustained release bupropion) [A] (adolescents and adults)
  • Offering referral into smoking cessation program (e.g., MI Quit Line 1-800-480-7848)
  • The combination of nicotine replacement therapy and/or withdrawal medications plus a smoking cessation program is more effective than either alone
• Arrange follow-up contact, either in person or by telephone [D]:
  • First week after quit date
  • First month after quit date

Frequency

• At each periodic health exam, more frequently at the discretion of the physician

Special Circumstances

• Pregnant Smokers: Due to the serious risks to the mother and fetus, pregnant smokers should be offered interventions such as referral to a smoking cessation program.
• Hospitalized Smokers: Clinicians should provide appropriate pharmacotherapy and counseling during hospitalization to reduce nicotine withdrawal symptoms and assist smokers in quitting.
• Smokers with Psychiatric Comorbidity: Nicotine withdrawal symptoms may exacerbate depression among patients with a prior history of affective disorder. Stopping smoking may affect the pharmacokinetics of certain psychiatric agents. Clinicians should monitor closely the actions or side effects of psychiatric medications in smokers/tobacco users who are attempting to quit.

Definitions:

Levels of Evidence for the Most Significant Recommendations

1. Randomized controlled trials
2. Controlled trials, no randomization
3. Observational studies
4. Opinion of expert panel

The guideline is based on several sources including, the Clinical Practice Guideline for the Management of Tobacco Use, Veterans Health Administration/Department of Defense, 2004 (www.oqp.med.va.gov).

The guideline is based on several sources including, the Clinical Practice Guideline for the Management of Tobacco Use, Veterans Health Administration/Department of Defense, 2004 (www.oqp.med.va.gov).

Electronic copies: Available in Portable Document Format (PDF) from the Michigan Quality Improvement Consortium Web site.

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