Exam 3 Self-Care (Bach)

Harmful Components

• Nicotine (addiction)

• Tar (lung damage, cancer)

• Carbon monoxide (↓ oxygen delivery)

• Nitrosamines (carcinogens)

• Benzene (leukemia risk)

• Formaldehyde (toxic irritant)

• Absorption: buccal (gum/lozenge), dermal (patch), pulmonary (smoking, fastest).

• Distribution: rapid CNS penetration; crosses placenta.

• Metabolism: hepatic CYP2A6 → cotinine (half‑life ≈ 20 h).

• Excretion: renal.

• Dopamine reward pathway: nicotine stimulates mesolimbic dopamine release → reinforcement of smoking behavior → addiction

List four clinically significant drug interactions associated with tobacco smoking.

• CYP 1A2 substrates

  • ↓ levels of:

    • Theophylline

    • Clozapine

    • Olanzapine

  • When patient quits → levels increase → toxicity risk

• Oral contraceptives 

  • ↑ thromboembolism risk

  • ↓ effectiveness

• Caffeine 

  • Smoking ↑ metabolism → quitting causes jitteriness

  • May need caffeine reduction

• Warfarin (and other vitamin K antagonists) 

  • Smoking ↑ metabolism → ↓ INR

  • Monitor INR closely when quitting.

• Withdrawal effects (≈ 6‑8 days peak)

  • Irritability

  • Anxiety

  • Poor concentration

  • Increased appetite

  • Insomnia

  • Depressed mood

• Health benefits

  • ↓ CV risk

  • Improved lung function

  • ↓ cancer risk

  • Better overall health

• Ask → Identify tobacco use

  • “Do you smoke or use any tobacco products?”

  • Identify use as a vital sign

• Advise → Strong personalized recommendation

  • “Quitting is the single most important thing you can do for your health.”

  • Deliver strong, personalized recommendation

• Assess → Readiness to quit

  • “Are you ready to quit in the next month?”

  • Gauge readiness

• Assist → Medication + plan

  • Provide medication choice, set quit date, develop plan

  • Support quit attempt

• Arrange → Follow-Up

  • “Let’s schedule a follow‑up in 2 weeks.”

  • Ensure ongoing support

Stage 1: Not Ready to Quit (Next Month)

• Patient Profile:

  • Ambivalent about quitting

  • Pros of tobacco use outweigh cons

  • Low motivation

• Goal: Start thinking about quitting

• Counseling DOs:

  • Strongly advise to quit

  • Help patient find personal motivation by:

  • Providing information

  • Asking noninvasive questions about tobacco use

  • Raising awareness of health risks

  • Demonstrate empathy and foster communication

Stage 1: Not Ready to Quit (Next Month)

• Techniques: The 5 R’s

  • Relevance – make quitting personally relevant

  • Risks – highlight health consequences

  • Rewards – identify benefits of quitting

  • Roadblocks – discuss barriers and strategies

  • Repetition – revisit motivation regularly

Stage 2: Ready to Quit (Next Month)

• Patient Profile:

  • Aware of need and benefits of quitting

  • Preparing to take action

• Goal: Achieve cessation

• Key Counseling Elements:

  • Assess tobacco use history

  • Current use (type, amount)

  • Past use and quit attempts

  • Confidence in ability to quit

  • Triggers and routines associated with use

  • Discuss key issues

  • Weight gain concerns

  • Withdrawal symptoms (peak 1 week, resolve 2–4 weeks)

  • Living with smokers and social triggers

  • Alcohol and socializing triggers

  • Situational triggers (after meals, boredom, etc.)

  • Practical counseling

  • Set a quit date

  • Use Tobacco Use Log to track triggers and habits

  • Teach cognitive coping strategies (positive self-talk, mental rehearsal)

  • Teach behavioral coping strategies (environment control, substitutes like gum/water)

  • Promote social support and stress management

  • Discuss pharmacotherapy as part of plan

• Follow-Up:

  • First week post-quit, first month, then as needed

  • Congratulate successes and address slips

Stage 3: Recent Quitter (≤6 Months)

• Patient Profile:

  • Quit within past 6 months

  • Experiencing withdrawal

  • At risk for relapse

• Goal: Maintain abstinence for at least 6 months

• Counseling Focus:

  • Evaluate quit attempt and medication adherence

  • Identify triggers and temptations (stress, social situations, cravings)

  • Promote healthy replacement behaviors

  • Reinforce coping strategies

  • Discuss slips vs. relapse: “let a slip slide”

Stage 4: Former User (>6 Months)

• Patient Profile:

  • Quit >6 months

  • Still vulnerable to relapse

• Goal: Remain tobacco-free for life

• Counseling Focus:

  • Assess quit status and congratulate success

  • Address any slips or relapse

  • Review relapse prevention strategies

  • Continue support and follow-up as needed

• Moderate smoker → Patch daily OR Gum PRN cravings

• Depressed patient → Bupropion + patch

• Heavy smoker → Varenicline OR combination NRT

GUM + LOZENGES

• Dose: 2 mg if first cigarette >30 min after waking; 4 mg if ≤30 min. Minimum 9 pieces/day for first 6 weeks.

• Advantages: Oral substitute; titratable; inexpensive

• Disadvantages: Requires proper chewing; oral irritation, hiccups; may interfere with dental work

Nicotine polacrilex gum'

• Gum provides a “busy‑hands” feel and lets you adjust the nicotine release by chewing more or less; it also offers a 6 mg option for those who need a higher dose.

Nicotine nasal spray

• Dose: 0.5 mg per spray; 1 mg total dose = 2 sprays (one per nostril). 1–2 doses/hr, max 5 doses/hr

• Advantages: Rapid symptom relief; titratable

• Disadvantages: Nasal irritation; frequent dosing; contraindicated in chronic nasal disease

• Nasal spray is the most expensive (Average daily cost of a cigarette pack ≈ $9.74)

Bupropion SR

• Mechanism: atypical antidepressant; inhibits norepinephrine and dopamine reuptake.

• Dosing: start 150 mg AM for 3 days → 150 mg BID for 7‑12 weeks (no taper).

• C/Is: seizure disorder, bulimia/anorexia, abrupt alcohol/benzodiazepine cessation, MAO‑inhibitor use.

• Key ADRs: insomnia, dry mouth, nausea, possible neuropsychiatric symptoms (monitor).

• Generic bupropion SR is the cheapest cessation aid

Varenicline

• Mechanism: partial α4β2 nicotinic receptor agonist; reduces withdrawal & blocks nicotine reward.

• Dosing (Fixed Quit): start 0.5 mg daily Days 1‑3 → 0.5 mg BID Days 4‑7 → 1 mg BID Day 8‑end (12 weeks).

• Highest efficacy

Varenicline

• Day 1-3 = 0.5 mg qd

• Day 4-7 = 0.5 mg bid

• Day 8 to end of treatment = 1 mg bid

• Up to 12 weeks

• Shows stepwise increase from 0.5 mg to 1 mg twice daily.

• Common ADRs: nausea, abnormal dreams, insomnia, headache

Combination therapy

• Dose: Patch for baseline; gum/lozenge or spray for breakthrough cravings

• Advantages: Highest efficacy (see meta‑analysis)

• Disadvantages: More complex regimen; cost

• Patch + short‑acting NRT

  • Strong (first‑line)

  • Moderate‑to‑heavy smokers; need rapid craving control

• Varenicline + NRT

  • Moderate

  • Prior NRT failure or high dependence

• Bupropion + NRT

  • Moderate

  • Depressed patients or those intolerant to varenicline

• Varenicline + Bupropion

  • Limited

  • Considered in refractory cases

Nicotine Replacement Therapy (NRT)

All NRTs share precautions for pregnancy/breastfeeding, adolescents (<18), and recent (within 2 weeks) cardiovascular events (MI, arrhythmia, or worsening angina).

• Gum / Lozenge

  • Based on time to first cigarette:

    • ≤30 min: 4 mg

    • >30 min: 2 mg

• Patch (OTC)

  • Based on cigarettes per day:

    • >10 cigs: 21 mg starter

    • ≤10 cigs: 14 mg starter

  • Rotate sites daily. Remove at bedtime if sleep disturbances/vivid dreams occur.

• Nasal Spray (Rx)

  • 1–2 doses/hour (max 40/day)

  • Avoid in patients with chronic nasal disorders or severe reactive airway disease

Oral Non-Nicotine Medications (Rx)

• Bupropion SR (Generic)

  • Mechanism/Use: Often beneficial for patients with depression or those concerned about weight gain.

  • Dosing: 150 mg daily for 3 days, then 150 mg BID. Start 1–2 weeks before quit date.

  • Contraindications (Critical for Exams): * Seizure disorders.

    • History of Anorexia or Bulimia.

    • Abrupt withdrawal of alcohol or benzodiazepines.

    • MAO Inhibitor use within 14 days.

• Varenicline (Generic)

  • Mechanism/Use: Most effective monotherapy; offers a different mechanism for those who failed NRT.

  • Dosing: Gradual titration (0.5 mg daily → 0.5 mg BID → 1 mg BID). Start 1 week before quit date.

  • Precautions: Requires dose adjustment for severe renal impairment.

  • Administration: Take after eating with a full glass of water to minimize nausea.

Important Safety Comparisons

• Neuropsychiatric Symptoms

  • Both Bupropion SR and Varenicline carry warnings for treatment-emergent neuropsychiatric symptoms (e.g., agitation, depressed mood, suicidal ideation). Patients should stop the medication immediately if these occur.

• Side Effect Profiles

  • Mouth/Throat Irritation: Common in gum, lozenge, and spray.

  • Insomnia: Common in Bupropion SR (avoid bedtime dosing) and Varenicline.

  • Vivid Dreams: Associated with the Patch and Varenicline.

  • GI Issues (Nausea): Most common with Varenicline.

Gum + Lozenges

• To improve chances of quitting, when used a monotherapy, use at least nine pieces daily during the first 6 weeks

• The gum/lozenge will not provide the same rapid satisfaction that smoking provides

• The effectiveness of the nicotine gum/lozenge may be reduced by some foods and beverages: Coffee, Juices, Wine, Soft drinks

• Do NOT eat or drink for 15 minutes BEFORE or while using the nicotine gum or lozenge.

Chewing the lozenge or using incorrect gum chewing technique can cause excessive and rapid release of nicotine, resulting in:

• Lightheadedness/dizziness

• Nausea and vomiting

• Hiccups

• Irritation of throat and mouth

ADEs of nicotine gum and lozenge:

• Mouth and throat irritation

• Hiccups

• Gastrointestinal complaints (dyspepsia, nausea)

• ADEs associated with nicotine gum:

• Jaw muscle ache

• May stick to dental work

ADVANTAGES of Gums + Lozenges

• Oral substitute for tobacco

• Might delay weight gain

• Can be titrated to manage withdrawal symptoms

• Can be used in combination with other agents to manage situational urges

• Relatively inexpensive

DISADVANTAGES of Gums + Lozenges

• Need for frequent dosing can compromise adherence

• Gastrointestinal ADEs (nausea, hiccups, and dyspepsia) may be bothersome

• Specific to nicotine gum:

  • Problematic with significant dental work

  • Proper chewing technique is necessary for effectiveness and to minimize ADEs

  • Might not be acceptable or desirable for some patients

Nicotine transdermal patch (NRT)

• Continuous (24-hour) nicotine delivery system

• Nicotine is well absorbed across the skin

• Transdermal delivery to systemic circulation avoids hepatic first-pass metabolism

• Plasma nicotine levels are lower and fluctuate less than with smoking

1 pack = around 20 cigarettes

PATIENT EDUCATION for Nicotine Patches

• Water will not harm the nicotine patch if it is applied correctly; patients may bathe, swim, shower, or exercise while wearing the patch

• Do not cut patches to adjust dose

• Can unpredictably effect nicotine delivery

• Patch may be less effective

• Keep new and used patches out of the reach of children and pets

• Remove patch before MRI procedures

• Common ADEs include:

  • Irritation at patch application site (generally within the first hour)

    • Mild itching

    • Burning

    • Tingling

  • Sleep disturbances

    • Abnormal or vivid dreams

    • Insomnia

PATIENT EDUCATION for Nicotine Patches

• After patch removal, skin may appear red for 24 hours

  • If skin stays red more than 4 days or if it swells or a rash appears, contact health care provider—do not apply new patch

• Local skin reactions (redness, burning, itching)

  • Usually caused by adhesive

  • Up to 50% of patients experience this reaction

  • Fewer than 5% of patients discontinue therapy

  • Confirm patient is rotating patch application sites

  • Avoid use in patients with dermatologic conditions (e.g., psoriasis, eczema, atopic dermatitis)

ADVANTAGES for Nicotine Patches

• Once-daily dosing associated with fewer adherence problems

• Of all NRT products, its use is least obvious to others

• Can be used in combination with other agents; delivers consistent nicotine levels over 24 hrs

• Relatively inexpensive

DISADVANTAGES for Nicotine Patches

• When used as monotherapy, cannot be titrated to acutely manage withdrawal symptoms

• Not recommended for use by patients with dermatologic conditions (e.g., psoriasis, eczema, atopic dermatitis)

Nicotine nasal spray (Rx/NRT)

• Aqueous solution of nicotine in a 10-ml spray bottle

• Each metered dose actuation delivers 50 mcL spray

• 0.5 mg nicotine

• ~100 doses/bottle

• Rapid absorption across nasal mucosa

DOSING for Nicotine Nasal Spray

• One dose = 1 mg nicotine (2 sprays, one 0.5 mg spray in each nostril)

• Start with 1–2 doses per hour

• Increase as needed to maximum dosage of 5 doses per hour or 40 mg (80 sprays; ~½ bottle) daily

• At least 8 doses daily for the first 6–8 weeks

• Termination:

  • Gradual tapering over an additional 4–6 weeks

  • Recommended maximum duration of therapy is 3 months

PATIENT EDUCATION for Nicotine Nasal Spray

• What to expect (first week):

  • Hot peppery feeling in back of throat or nose

  • Sneezing

  • Coughing

  • Watery eyes

  • Runny nose

• ADEs should lessen over a few days

  • Regular use during the first week will help in development of tolerance to the irritant effects of the spray

• If ADEs persist after a week, contact health care provider and consider alternative treatment

ADVANTAGES for Nicotine Nasal Spray

• Can be titrated to rapidly manage withdrawal symptoms

• Can be used in combination with other agents to manage situational urges

DISADVANTAGES for Nicotine Nasal Spray

• Need for frequent dosing can compromise adherence

• Nasal administration might not be acceptable/desirable for some patients; nasal irritation often problematic

• Not recommended for use by patients with chronic nasal disorders or severe reactive airway disease

• Cost of treatment

Bupropion SR (Rx)

• Non-nicotine cessation aid

• Mechanism of action: atypical antidepressant thought to affect levels of various brain neurotransmitters

  • Dopamine

  • Norepinephrine

•  Clinical effects

  • ↓ craving for cigarettes

  • ↓ symptoms of nicotine withdrawal

C/I for Bupropion

• Seizure disorder

• Current or prior diagnosis of bulimia or anorexia nervosa

• Abrupt discontinuation of alcohol, benzodiazepines, barbiturates and antiepileptic drugs

• Use of MAO inhibitors (within 14 days of initiating or discontinuing therapy)

WARNINGS and PRECAUTIONS for Bupropion

• Use with caution in the following populations:

• Patients with an elevated risk for seizures, including:

  • Severe head injury

  • Concomitant use of medications that lower the seizure threshold (e.g., other bupropion products, antipsychotics, tricyclic antidepressants, theophylline)

  • Severe hepatic impairment

• Patients with underlying neuropsychiatric conditions

• Neuropsychiatric symptoms and suicide risk

  • Changes in mood (including depression and mania)

  • Psychosis/hallucinations/paranoia/delusions

  • Homicidal ideation

  • Aggression/hostility/anxiety/panic

  • Suicidal ideation, suicide attempt, completed suicide

• FDA boxed warning removed

• Advise patients to stop taking bupropion SR and contact a health care provider immediately if symptoms such as agitation, depressed mood, or changes in behavior or thinking that are not typical are observed or if the patient develops suicidal ideation or suicidal behavior.

DOSING for Bupropion

• To ensure therapeutic plasma levels of the drug are achieved, begin therapy 1 to 2 weeks PRIOR to the quit date.

• Initial treatment

  • 150 mg orally in the morning for 3 days

• Then…

  • 150 mg orally twice daily for 7–12 weeks

  • Doses must be administered at least 8 hours apart

  • Tapering not necessary when discontinuing therapy

ADEs for Bupropion

• Common ADEs include the following:

  • Insomnia (avoid bedtime dosing)

  • Dry mouth

  • Nausea

• Less common but reported effects:

  • Anxiety/difficulty concentrating

  • Constipation

  • Tremor

  • Skin rash

ADVANTAGES for Bupropion

• Twice daily oral dosing is associated with better adherence

• Might delay weight gain

• Might be beneficial in patients with depression

• Can be used in combination with

• NRT agents

• Relatively inexpensive

DISADVANTAGES for Bupropion

• Seizure risk is increased

• Several contraindications and precautions preclude use in some patients

• Patients should be monitored for neuropsychiatric symptoms

Varenicline (Rx)

• Non-nicotine cessation aid

• Mechanism of action: partial nicotinic receptor agonist that binds with high affinity and selectivity at α4β2 neuronal nicotinic acetylcholine receptors

  • Stimulates low-level agonist activity

  • Competitively inhibits the binding of nicotine

• Clinical effects

  • ↓ symptoms of nicotine withdrawal

  • Blocks dopaminergic stimulation responsible for reinforcement & reward associated with smoking

WARNINGS and PRECAUTIONS for Varenicline

• Neuropsychiatric symptoms and suicide risk

• Changes in mood (including depression and mania)

• Psychosis/hallucinations/paranoia/delusions

• Homicidal ideation

• Aggression/hostility/anxiety/panic

• Suicidal ideation, suicide attempt, completed suicide

• FDA boxed warning removed Dec 2016

• Advise patients to stop taking varenicline and contact a health care provider immediately if symptoms such as agitation, depressed mood, or changes in behavior or thinking that are not typical are observed or if the patient develops suicidal ideation or suicidal behavior.

STANDARD DOSING for Varenicline

• FIXED QUIT

  • Set quit date for 1 week after starting varenicline

  • Continue treatment for 12 weeks

• FLEXIBLE QUIT

  • Start taking varenicline and pick a quit date between 8 to 35 days from treatment initiation

  • Continue treatment for 12 weeks

• GRADUAL QUIT

  • Start taking varenicline and reduce smoking by 50% within the first 4 weeks, an additional 50% in the next 4 weeks, and continue until complete abstinence by 12 weeks

ADEs for Varenicline

• Common ADEs include the following:

  • Nausea

  • Abnormal dreams

  • Insomnia

  • Headache

  • Less common ADEs:

  • Gastrointestinal (flatulence, constipation)

  • Taste alteration

PATIENT EDUCATION for Varenicline

• Doses should be taken after eating, with a full glass of water

• Nausea and insomnia are usually temporary side effects

• If symptoms persist, notify your health care provider

• May experience vivid, unusual or strange dreams during treatment

• Use caution driving, drinking alcohol, and operating machinery until effects of quitting smoking with varenicline are known

ADVANTAGES for Varenicline

• Twice daily oral dosing is associated with better adherence

• Offers an alternative mechanism of action for individuals who have not tolerated or have not responded to other agents

• Most effective agent for smoking cessation

DISADVANTAGES for Varenicline

• Cost of treatment

• Patients should be monitored for potential neuropsychiatric symptoms

Combination therapy

• Combination NRT [first-line, recommended treatment approach]

• Long-acting formulation (patch)

  • Produces relatively constant levels of nicotine

• AND

• Short-acting formulation (gum, lozenge, nasal spray)

  • Allows for acute dose titration as needed for nicotine withdrawal symptoms

• Other combinations [evidence less compelling]

  • Bupropion + NRT

  • Varenicline + NRT

  • Varenicline + bupropion SR

• Strong evidence that combination NRT and varenicline are more effective than bupropion SR or NRT monotherapy

KNOW IMAGE

Combination NRT [first-line, recommended treatment approach]

•  Long-acting formulation (patch)

  • Produces relatively constant levels of nicotine

AND

• Short-acting formulation (gum, lozenge, nasal spray)

  • Allows for acute dose titration as needed for nicotine withdrawal symptoms

EAGLES STUDY (Varenicline, Bupropion SR, Nicotine patch, Placebo)

• No significant differences in neuropsychiatric events by treatment arm

• Highest efficacy with varenicline

ASK

• Ask about tobacco use; with a tone that conveys sensitivity, concern and is non-judgmental

• Consider tobacco use assessment to be as important as other vital signs

  • “Do you smoke or use other types of tobacco or nicotine, such as e-cigarettes?”

  • “We ask all of our patients, because tobacco smoke can affect how some medicines work.”

  • We care about your health, and we have resources to help our patients quit smoking.”

• “Has there been any change in your smoking/tobacco use/vaping status?”

ADVISE

• Advise tobacco users to quit (clear, strong, personalized)

  • “Quitting smoking is the most important thing you can do for your health.”

  • “Quitting is the most important thing you can do to...[control your asthma, reduce your chance for another heart attack, better manage your diabetes, etc.]”

  • “The best way to quit is to combine a tobacco cessation medication with a support program—we are trained to help our patients quit.”

  • “I can help you select medications to increase your chances of quitting for good.”

ASSESS

• Assess readiness to make a quit attempt

ASSIST

• Assist with the quit attempt

  • Not ready to quit: enhance motivation

  • Ready to quit: design a treatment plan

  • Recently quit: relapse prevention

ARRANGE

• Arrange follow-up care

• Provide assistance throughout the quit attempt.

• Ask → about tobacco USE

• Advise → tobacco users to QUIT

• Assess → READINESS to make quit attempt

• Assist → with the QUIT ATTEMPT

• Arrange → FOLLOW-UP care

STAGE 1: Not ready to quit in the next month

• Some patients are aware of the need to quit.

• Patients struggle with ambivalence about change.

• Patients are not ready to change, yet.

• Pros of continued tobacco use outweigh the cons.

• Patients have inadequate motivation to quit.

• GOAL: Start thinking about quitting

• Counseling DO’S

  • Strongly advise to quit

  • Guide patient to find a strong personal motivation to quit by:

    • Providing information

    • Asking noninvasive questions; identify reasons for tobacco use

    • Raising awareness of health consequences/concerns

  • Demonstrate empathy, foster communication

• Counseling DON’TS

  • Persuade

    • Leave decision up to patient

  • “Cheerlead”

  • Tell patient how bad tobacco is, in a judgmental manner

  • Provide a treatment plan

The 5 R’s—Methods for enhancing motivation:

• Relevance

• Risks

• Rewards

• Roadblocks

• Repetition

STAGE 2: Ready to quit in the next month

• Patients are aware of the need to, and the benefits of, making the behavioral change.

• Patients are getting ready to take action

• GOAL: Achieve cessation.

• Assess tobacco use history

  • Current use: type(s) of tobacco, amount

  • Past use: duration, recent changes

  • Past quit attempts:

    • Number, date, length

    • Methods/medications used, adherence, duration

    • Reasons for relapse

STAGE 2: Ready to quit in the next month

• When fear of weight gain is a barrier to quitting

  • Consider pharmacotherapy with evidence of delaying weight gain (bupropion SR or 4-mg nicotine gum or lozenge)

  • Assist patient with weight maintenance or refer patient to specialist or program

• W/D Sxs

  • Most pass within 2–4 weeks after quitting

  • Cravings can last longer, up to several months or years

    • Often can be ameliorated with cognitive or behavioral coping strategies

  • Refer to Withdrawal Symptoms Information Sheet

    • Symptom, cause, duration, relief

• Most symptoms manifest within the first 1–2 days, peak within the first week, and subside within 2–4 weeks.

• Tobacco Use Log: Instructions for use

  • Continue regular tobacco use for 3 or more days

  • Each time any form of tobacco is used, log the following information:

    • Time of day

    • Activity or situation during use

    • “Importance” rating (scale of 1–3)

  • Review log to identify situational triggers for tobacco use; develop patient-specific coping strategies

Cognitive coping strategies

• Thinking about cigarettes doesn’t mean you have to smoke one:

  • “Just because you think about something doesn’t mean you have to do it!”

  • Tell yourself, “It’s just a thought,” or “I am in control.”

• ◼ As soon as you get up in the morning, look in the mirror and say to yourself:

  • “I am proud that I made it through another day without tobacco.”

• Reframe how you think about yourself:

  • Begin thinking of yourself as a non-smoker, instead of as a struggling quitter

STEP 1

• Ask:

  • “What could you do differently in this situation so you won’t be prompted to want a cigarette?”

  • “How could you think differently in this situation, so that you aren’t triggered to want to smoke?”

STEP 2

• If they provide a reasonable alternative, be supportive

• If they say “I don’t know” or “I can’t think of anything”

  • Suggest a coping technique (or two)

  • Make suggestions appropriate to their lifestyle

Offer to assist throughout quit attempt

• Follow-up contact #1: first week after quitting

• Follow-up contact #2: in the first month

• Additional follow-up contacts as needed

STAGE 3: Recent quitter, quit within past 6 months, Actively trying to do good

• Patients have quit using tobacco sometime in the past 6 months and are taking steps to increase their success.

• Withdrawal symptoms occur.

• Patients are at risk for relapse

• GOAL: Remain tobacco-free for at least 6 months.

STAGE 3: Recent quitter, quit within past 6 months, Actively trying to do good

• Evaluate Quit Attempt

  • Tailor interventions to match each patient’s needs

  • Status of attempt

    • Ask about social support

    • Identify ongoing temptations and triggers for relapse (negative affect, others who smoke, eating, alcohol, cravings, stress)

    • Encourage healthy behaviors to replace tobacco use

  • Slips and relapse

    • Has the patient used tobacco/inhaled nicotine at all—even a puff?

  • Medication adherence, plans for termination

    • Is the regimen being followed?

    • Are withdrawal symptoms being alleviated?

    • How and when should pharmacotherapy be terminated?

STAGE 3: Recent quitter, quit within past 6 months, Actively trying to do good

• Relapse Prevention

  • Congratulations on your success!

  • Encourage continued abstinence

    • Discuss benefits of quitting, problems encountered, successes achieved, and potential barriers to continued abstinence

    • Ask about strong or prolonged withdrawal symptoms (change dose, combine or extend use of medications)

    • Promote smoke-free environments

  • Schedule additional follow-up as needed

STAGE 4: Former tobacco user, quit > 6 months ago

• Patients differ in their readiness to quit.

• Assessing a patient’s readiness to quit enables clinicians to deliver relevant, appropriate counseling messages.

• For most patients, quitting is a cyclical process, and their readiness to quit (or stay quit) will change over time.

• Patients remain vulnerable to relapse.

• Ongoing relapse prevention is needed.

• GOAL: Remain tobacco-free for life.

• Former Tobacco Users

  • Assess status of quit attempt

  • Congratulate continued success

  • Inquire about and address slips and relapse

  • Plans for termination of pharmacotherapy

  • Review tips for relapse prevention

• Continue to assist throughout the quit attempt.

WHAT ARE “TOBACCO QUITLINES”?

• Tobacco cessation counseling, provided at no cost via telephone to all Americans

• Staffed by highly trained specialists

• Up to 4–6 personalized sessions (varies by state)

• Some state quitlines offer pharmacotherapy at no cost (or reduced cost)

• Nearly 30% success rate for patients who use the quitline and a medication for cessation (versus 13% for quitline use alone)

• Quitlines have broad reach and are recommended as an effective strategy in the Clinical Practice Guideline.

WHEN a PATIENT CALLS the QUITLINE

• Contact and demographic information

• Smoking behavior

• Choice of services

  • Individualized telephone counseling

  • Quitting literature mailed within 24 hrs

  • Referral to local programs, as appropriate

• The Tobacco Quitline is a formal cessation program, with multiple sessions. It is NOT a crisis hotline.