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Table 8. Providing Counseling—Frequently Asked Questions

Question Answer
My patient doesn't want counseling, only medication. What should I do? Point out that counseling plus medication works better than medication alone. Explain that the goal of counseling (or coaching) is to provide the practical skills that increase the likelihood of quitting successfully. Use the motivational interventions designed for tobacco users who do not want to quit to encourage your patient to accept counseling. Emphasize the inconsistency between not using effective counseling for something as important and difficult as quitting tobacco. If the patient still declines counseling, consider providing medication alone because medication alone has been shown to be effective. During followup, continue to provide the key elements of counseling: problem solving, practical skills, and support.
My patient wants to use a method of quitting not known to be effective such as acupuncture, hypnosis, or laser therapy. What do I do? Ask the patient to consider increasing the success odds of his/her quit attempt by augmenting his/her method of quitting with evidence-based medication and counseling. Do not denigrate any attempt to quit. If the patient declines, support his/her effort, but ask for an agreement that, should it not be successful, the patient will consider evidence-based methods in the future, including medication and counseling.
My patient is concerned about gaining weight. Recommend that the patient start or increase physical activity. For example, take a walk at break time rather than smoke and/or walk at lunch. Also see medication recommendations for such patients.
My patient is concerned about using NRT because he/she believes nicotine to be one of the harmful ingredients in tobacco products. Explain that medicinal nicotine by itself is relatively safe. Emphasize that the 4,000 chemicals in cigarette smoke, including about 40 carcinogens, cause the harm from smoking. Also, medicinal nicotine has been proven to greatly reduce withdrawal symptoms in many people.
My patient does not want to use medication because of:
  • Fear that the medication is addictive.
  • Doubt that the medication will help
  • Doubt that recovery is possible if medication containing nicotine is used, having recovered from another dependency.
 Point out:
  • Medication delivered by mouth or through a patch is not like smoking. Developing a dependency on the medication is uncommon.
  • The probability of successful quitting is much higher when medication is used.
  • Substance abuse counselors routinely use medication to help people quit.
  • The ultimate goal remains neither smoking nor using medication; the use of nicotine-containing medication is a transition step toward that goal.
  • Consider a medication that does not contain nicotine.
My patient says his/her life is too stressful to quit smoking and he/she needs to smoke to relax. Acknowledge that for many people smoking is one way to deal with stress. But it is only one way. Counseling will help him/her develop new ways to cope. It will take some time. At first the new ways may feel less effective but the longer the patient is away from smoking, the easier it will be to handle stress without smoking. Also his/her health will be so much better.
My patient says he/she has been smoking for many (20, 30, or more) years without any health problems, plus his/her grandfather smoked two packs a day and lived to be 105. Consider saying something like, “There are certainly people who smoke for many years without apparent tobacco-related diseases. But about half of people who smoke will die from a tobacco-related illness. The average smoker lives 10 years less than non-smokers. I know it is hard to quit, but is that any reason to gamble with your health when you know that there is a 50-percent chance you will die from a tobacco-related disease?"

Table 9. Suggestions for the clinical use of medication for tobacco dependence treatment a

Medication Cautions/Warnings Side Effects Dosage Use Availability (check insurance)
Bupropion SR 150

Not for use if you:

  • Currently use monoamine oxidase (MAO) inhibitor
  • Use bupropion in any other form
  • Have a history of seizures
  • Have a history of eating disorders
  • See FDA package insert warning regarding suicidality and antidepressant drugs when used in children, adolescents, and young adults.
  • Insomnia
  • Dry mouth
  • Days 1-3: 150 mg each morning
  • Days 4-end: twice daily
 Start 1-2 weeks before quit date; use 2 to 6 months

Prescription only

  • Generic
  • Zyban
  • Wellbutrin SR
Nicotine Gum
(2 mg or 4 mg)
  • Caution with dentures
  • Do not eat or drink 15 minutes before or during use
  • Mouth soreness
  • Stomach ache
  • 1 piece every 1 to 2 hours
  • 6-15 pieces per day
  • If ≤ 24 cigs: 2 mg
  • If ≥ 25 cigs/day or chewing tobacco: 4 mg
 Up to 12 weeks or as needed

OTC only:

  • Generic
  • Nicorette
Nicotine Inhaler May irritate mouth/ throat at first (but improved with use) Local irritation of mouth and throat
  • 6-16 cartridges/day
  • Inhale 80 times/cartridge
  • May save partially-used cartridge for next day
Up to 6 months; taper at end Prescription only:
Nicotrol inhaler
Nicotine Lozenge
(2 mg or 4 mg)
  • Do not eat or drink 15 minutes before or during use
  • One lozenge at a time
  • Limit 20 in 24 hours
  • Hiccups
  • Cough
  • Heartburn
  • If smoke/chew ≥ 30 minutes after waking: 2 mg
  • If smoke chew ≤ 30 minutes after waking: 4 mg
  • Weeks 1-6: 1 every 1-2 hrs
  • Wks 7-9: 1 every 2-4 hrs
  • Wks 10-12: 1 every 4-8 hrs
3-6 months

OTC only:

  • Generic
  • Commit

Nicotine Nasal Spray
  • Not for patients with asthma
  • May irritate nose (improves over time)
  • May cause dependence
Nasal irritation
  • 1 "dose" = 1 squirt per nostril 1 to 2 doses per hour
  • 8 to 40 doses per day
  • Do not inhale
3-6 months; taper at end Prescription only:
Nicotrol NS
Nicotine Patch Do not use if you have severe eczema or psoriasis
  • Local skin reaction
  • Insomnia
  • One patch per day
  • If ≥ 10 cigs/day; 21 mg 4 wks, 14 mg 2-4 wks, 7 mg 2-4 wks
  • If <10/day: 14 mg 4 wks, then 7 mg 4 wks

8-12 weeks

OTC or prescription:

  • Generic
  • Nicoderm CQ
  • Nicotrol
Varenicline

Use with caution in patients:

  • With significant renal impairment
  • With serious psychiatric illness
  • Undergoing dialysis
  • FDA Warning: Varenicline patients have reported depressed mood, agitation, changes in behavior,
    suicidal ideation, and suicide.
  • Go to www.fda.gov for further updates regarding recommended safe use of Varenicline.
  • Nausea
  • Insomnia
  • Abnormal, vivid, or strange dreams
  • Days 1-3: 0.5 mg every morning
  • Days 4-7: 0.5 mg twice daily
  • Day 8-end: 1 mg twice daily
Start 1 week before quit date; use 3-6 months Prescription only:
Chantix

Combinations:

  1. Patch + bupropion
  2. Patch + gum
  3. Patch + lozenge + inhaler
  • Only patch + bupropion is currently FDA approved
  • Follow instructions for individual medications
Refer to individual medications above. Refer to individual medications above. Refer to information provided above. Refer to information provided above.

a Based on the 2008 Clinical Practice Guideline: Treating Tobacco Use and Dependence, U.S. Public Health Service, May 2008. Refer to the FDA Web site for additional dosing and safety information, including safety protocols.

Table 10. Providing Medication—Frequently Asked Questions

Question Answer
Who should receive medication for tobacco use? Are there groups of smokers for whom medication has not been shown to be effective? All smokers trying to quit should be offered medication, 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).
What are the recommended first-line medications? All seven of the FDA-approved medications for treating tobacco use are recommended: bupropion SR, nicotine gum, nicotine inhaler, nicotine lozenge, nicotine nasal spray, the nicotine patch, and varenicline. The clinician should consider the first-line medications shown to be more effective than the nicotine patch alone: 2 mg/day varenicline or the combination of long-term nicotine patch use + ad libitum NRT. Unfortunately, there are no well-accepted algorithms to guide optimal selection among the first-line medications.
Are there contraindications, warnings, precautions, other concerns, and side effects regarding the first-line medications recommended in this Guideline Update? All seven FDA-approved medications have specific contraindications, warnings, precautions, other concerns, and side effects. Please refer to FDA package inserts and updates for complete information on how to use the medication safely.
What other factors may influence medication selection? Pragmatic factors may also influence selection such as insurance coverage or out-of-pocket patient costs, likelihood of adherence, dentures when considering the gum, or dermatitis when considering the patch.
Is a patient's prior experience with a medication relevant? Prior successful experience (sustained abstinence with the medication) suggests that the medication may be helpful to the patient in a subsequent quit attempt, especially if the patient found the medication to be tolerable and/or easy to use. However, it is difficult to draw firm conclusion from prior failure with a medication. Some evidence suggests that retreating relapsed smokers with the same medication produces small or no benefit while other evidence suggests that it may be of substantial benefit.
What medications should a clinician use with a patient who is highly nicotine dependent? The higher dose preparations of nicotine gum, patch, and lozenge have been shown to be effective in highly dependent smokers. Also, there is evidence that combination NRT therapy may be particularly effective in suppressing tobacco withdrawal symptoms. Thus, it may be that NRT combinations are especially helpful to highly dependent smokers or those with a history of severe withdrawal.
Is gender a consideration in selecting a medication? There is evidence that NRT can be effective with both sexes; however, evidence is mixed as to whether NRT is less effective in women than men. This may encourage the clinician to consider use of another type of medication with women such as bupropion SR or varenicline.
Are cessation medications appropriate for light smokers (i.e., <10 cigarettes/day)? As noted above, cessation medications have not been shown to be beneficial to light smokers. However, if NRT is used with light smokers, clinicians may consider reducing the dose of the medication. No adjustments are necessary when using bupropion SR or varenicline.
When should second-line agents be used for treating tobacco dependence? Consider prescribing second-line agents (clonidine and nortriptyline) for patients unable to use first-line medications because of contraindications or for patients for whom the group of first-line medications has not been helpful. Assess patients for the specific contraindications, precautions, other concerns, and side effects of the second-line agents. Please refer to FDA package inserts for this information.
Which medications should be considered with patients particularly concerned about weight gain? Data show that bupropion SR and nicotine replacement therapies, in particular 4 mg nicotine gum and 4 mg nicotine lozenge, delay, but do not prevent, weight gain.
Are there medications that should be especially considered in patients with a past history of depression? Bupropion SR and nortriptyline appear to be effective with this population, but nicotine replacement medications also appear to help individuals with a past history of depression.
Should nicotine replacement therapies be avoided in patients with a history of cardiovascular disease? No. The nicotine patch in particular has been demonstrated as safe for cardiovascular patients.
May tobacco dependence medications be used long-term (e.g., up to 6 months)? Yes. This approach may be helpful with smokers who report persistent withdrawal symptoms during the course of medications, who have relapsed in the past after stopping, 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 for up to 6 months does not present a known health risk and developing dependence on medications is uncommon. Additionally, the FDA has approved the use of bupropion SR, varenicline, and some NRT medications for 6-month use.
Is medication adherence important? Yes. Patients frequently do not use cessation medications as recommended (e.g., they don't use them at recommended doses or for recommended durations); this may reduce their effectiveness.
May medications ever be combined? Yes. Among first-line medications, evidence exists that combining the nicotine patch long term (> 14 weeks) with nicotine gum or nicotine nasal spray, the nicotine patch with the nicotine inhaler, or the nicotine patch with bupropion SR, increases long-term abstinence rates relative to placebo treatments.
My patient can't afford medications and doesn't have insurance to cover it. What can I do?
  • Instruct the patient to set aside all the money they would have spent on tobacco once they quit. After initial use of medication they will be able to afford medication going forward.
  • Many clinics that serve people with no health insurance will provide treatment for tobacco dependence, including medication. Check for ones in your area and have them available for staff and patients as a referral source.
  • As a clinician, you can call the tobacco quitline and ask about any sources of free or reduced cost medication for your patients. Try 1-800-QUIT-NOW, which works nationwide and seamlessly routes you to the quitline in the State you are calling from.
  • If your patient qualifies for Medicaid or Medicare, these programs cover some tobacco dependence treatment medications. Get this information for your State and have available for staff and patients.
  • Most pharmaceutical companies have programs to provide medications to those who cannot afford them. Contact the pharmaceutical companies directly or check with Partnership for Prescription Assistance at www.pparx.org or 1-888-4PPA-NOW.

Arrange

Tobacco dependence is an addiction. Quitting is very difficult for most tobacco users. It is essential that the patient trying to quit has scheduled followup. This is especially important when the treatment is shared by a team of clinicians and includes treatment extenders such as quitline counseling.

Table 11. Arrange—Ensure followup contact

Action Strategies for implementation
Arrange for followup contacts, either in person or via telephone.
  • Timing: Followup contact should begin soon after the quit date, preferably during the first week. A second followup contact is recommended within the first month. Schedule further followup contacts as indicated.
  • Actions during followup contact: For all patients, identify problems already encountered and anticipate challenges in the immediate future. Assess medication use and problems.
    Remind patients of quitline support (1-800-QUIT-NOW).
    Address tobacco use at next clinical visit (treat tobacco use as a chronic disease).
    For patients who are abstinent, congratulate them on their success.

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Tobacco Users Unwilling to Quit at This Time

Ask, Advise, and Assess every tobacco user following the suggestions in Tables 2-4. If the patient is unwilling to make a quit attempt at this time, use the motivational strategies that follow to increase the likelihood of quitting in the future.

Assist

Tobacco users who do not want to quit now should be provided with specific interventions designed to increase the likelihood that they will decide to quit. This goal can be achieved through strategies designed to enhance motivation to quit.

Such interventions could incorporate the "5 R's": Relevance, Risk, Rewards, Roadblocks, and Repetition. In these interventions, the clinician can introduce the topic of quitting but it is important that the tobacco users address each topic in their own words. The clinician can then help refine the patient's responses and add to them as needed.

Table 12. Enhancing motivation to quit tobacco—the "5 R's"

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:

  • Acute risks: Shortness of breath, exacerbation of asthma or bronchitis, increased risk of respiratory infections, harm to pregnancy, impotence, infertility.
  • Long-term risks: Heart attacks and strokes, lung and other cancers (e.g., larynx, oral cavity, pharynx, esophagus, pancreas, stomach, kidney, bladder, cervix, and acute myelocytic leukemia), chronic obstructive pulmonary diseases (chronic bronchitis and emphysema), osteoporosis, long-term disability, and need for extended care.
  • Environmental risks: Increased risk of lung cancer and heart disease in spouses; increased risk for low birth weight, sudden infant death syndrome (SIDS), asthma, middle ear disease, and respiratory infections in children of smokers.
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:

  • Improved health.
  • Food will taste better.
  • Improved sense of smell.
  • Saving money.
  • Feeling better about yourself.
  • Home, car, clothing, breath will smell better.
  • Setting a good example for children and decreasing the likelihood that they will smoke.
  • Have healthier babies and children.
  • Feeling better physically.
  • Performing better in physical activities.
  • Improved appearance including reduced wrinkling/aging of skin and whiter teeth.
Roadblocks

The clinician should ask the patient to identify barriers or impediments to quitting and provide treatment (problem-solving counseling, medication) that could address barriers. Typical barriers might include:

  • Withdrawal symptoms.
  • Fear of failure.
  • Weight gain.
  • Lack of support.
  • Depression.
  • Enjoyment of tobacco.
  • Being around other tobacco users
  • Limited knowledge of effective treatment options.
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 and that you will continue to raise their tobacco use with them.

Interventions to increase the likelihood that a tobacco user who does not want to quit will decide to quit can draw upon the principles of motivational interviewing:

Table 13. Motivational interviewing strategies

Express Empathy
  • Use open-ended questions to explore:
    • The importance of addressing smoking or other tobacco use (e.g., "How important do you think it is for you to quit?").
  • Concerns and benefits of quitting (e.g., "What might happen if you quit?").
  • Use reflective listening to seek shared understanding:
    • Reflect words or meaning (e.g., "So you think smoking helps you to maintain your weight?").
    • Summarize (e.g., "What I have heard so far is that smoking is something you enjoy. On the other hand, your boyfriend hates your smoking and you are worried you might develop a serious disease.")
  • Normalize feelings and concerns (e.g., "Many people worry about managing without cigarettes.")
  • Support the patient's autonomy and right to choose or reject change (e.g., "I hear you saying you are not ready to quit smoking right now. I'm here to help you when you are ready.")
Develop Discrepancy
  • Highlight the discrepancy between the patient's present behavior and expressed priorities, values, and goals (e.g., “It sounds like you are very devoted to your family. How do you think your smoking is affecting your children and spouse/partner?”).
  • Reinforce and support “change talk” and “commitment” language.
    • “So, you realize how smoking is affecting your breathing and making it hard to keep up with your kids.”
    • “It's great that you are going to quit when you get through this busy time at work.”
  • Build and deepen commitment to change:
    • “There are effective treatments that will ease the pain of quitting, including counseling and many medication options.
    • “We would like to help you avoid a stroke like the one your father had.”
Roll with Resistance
  • Back off and use reflection when the patient expresses resistance.
    • “Sounds like you are feeling pressured about your tobacco use.”
  • Express empathy.
    • “You are worried about how you would manage withdrawal symptoms.”
  • Ask permission to provide information.
    • “Would you like to hear about some strategies that can help you address that concern when you quit?”
Support Self-Efficacy
  • Help the patient to identify and build on past successes.
    • “So you were fairly successful the last time you tried to quit.”
  • Offer options for achievable, small steps toward change.
    • Call the quitline (1-800-QUIT-NOW) for advice and information.
    • Read about quitting benefits and strategies.
    • Change smoking patterns (e.g., no smoking in the home).
    • Ask the patient to share his or her ideas about quitting strategies.

Arrange Followup

More than one motivational intervention may be required before the tobacco user who is unwilling to quit commits to a quit attempt. It is essential that the patient trying to quit has scheduled followup. Provide followup at the next visit and additional interventions to motivate and support the decisionmaking process of the patient who is unwilling to quit now.

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Tobacco Users Who Recently Quit

Ask every patient at every visit if they use tobacco and his or her status documented clearly in the clinical record (e.g., as part of the vital signs, displayed prominently in the electronic medical record). (Go to Table 2 for more details)

Table 14. Assess former tobacco user relapse potential

Action Strategies for Implementation
How long has it been since you quit? Most relapse occurs within the first 2 weeks after the quit date and the risk decreases over time. Tobacco users who have quit very recently should be provided assistance. But the risk for relapse can persist for a long time for many tobacco users. Therefore, assess all former tobacco users, regardless of how long ago they quit, about challenges by asking the question below:
Do you still have any urges to use tobacco or any challenges to remaining tobacco free? Any recent quitter or former tobacco users still experiencing challenges should receive assistance.

Table 15. Assist former tobacco users with encouragement to stay abstinent

Action Strategies for Implementation
The former tobacco user should receive congratulations on any success and strong encouragement to remain abstinent

When encountering a recent quitter, use open-ended questions relevant to the topics below to discover if the patient wishes to discuss issues related to quitting:

  • The benefits, including potential health benefits, the patient may derive from cessation.
  • Any success the patient has had in quitting (duration of abstinence, reduction in withdrawal, and so on).
  • The problems encountered or anticipated threats to maintaining abstinence (e.g., depression, weight gain, alcohol, other tobacco users in the household, significant stressors).
  • A medication check-in, including effectiveness and adherence.

Table 16. Specific challenges and potential responses to the tobacco user who recently quit

Challenges Responses
Lack of support for cessation
  • Schedule followup visits or telephone calls with the patient.
  • Urge the patient to call the quitline (1-800-QUIT-NOW).
  • Help the patient identify sources of support within his or her environment.
Negative mood or depression
  • Refer the patient to an appropriate organization that offers counseling or evidence-based support.
  • If significant, provide counseling, prescribe appropriate medication, or refer the patient to a specialist.
Strong or prolonged withdrawal symptoms
  • If the patient reports prolonged craving or other withdrawal symptoms, consider extending the use of an approved medication or adding/combining medications to reduce strong withdrawal symptoms.
Weight gain
  • Recommend starting or increasing physical activity.
  • Reassure the patient that some weight gain after quitting is common and is usually self-limiting.
  • Emphasize the health benefits of quitting relative to the health risks of modest weight gain.
  • Emphasize the importance of a healthy diet and active lifestyle.
  • Suggest low-calorie substitutes such as sugarless chewing gum, vegetables, or mints.
  • Maintain the patient on medication known to delay weight gain (e.g., bupropion SR, NRTs, particularly 4 mg nicotine gum, and lozenge).
  • Refer the patient to a nutritional counselor or program.
Smoking slips
  • Suggest low-calorie substitutes such as sugarless chewing gum, vegetables, or mints.
  • Maintain the patient on medication known to delay weight gain (e.g., bupropion SR, NRTs, particularly 4 mg nicotine gum, and lozenge).
  • Refer the patient to a nutritional counselor or program.

Arrange Followup

All patients that have recently quit or still face challenges should receive followup for continued assistance and support.

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