Smoking medical therapy

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Case #1

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Medical Therapy

General Principles

The 5As are an evidence-based framework for structuring smoking cessation in health care settings. The 5As include: Ask, Assess, Advise, Assist and Arrange follow-up.

The 5As Technique Ask Identify and document tobacco use status for every patient at every visit Advise In a clear, strong, and personalized manner, urge every tobacco user to quit. Advices should be: Clear: I think it is important for you to quit smoking now and I can help you. Cutting down while you are ill is not enough. Strong: As your clinician, I need you to know that quitting smoking is the most important thing you can do to protect your health now and in the future. The clinic staff and I will help you. Personalized: Tie tobacco use to current health, and its social and economic costs, motivation level to quit, and the impact of tobacco use on children and others in the household. Assess Assess willingness to make a quit attempt. Is the tobacco user willing to make a quit attempt within the next 30 days? Assist For the patient willing to make a quit attempt, offer medication and provide or refer for counseling or additional treatment to help the patient quit. For patients unwilling to quit at the time, provide interventions designed to increase future quit attempts. Arrange follow-up For the patient willing to make a quit attempt, arrange for followup contacts, beginning within the first week after the quit date. For patients unwilling to make a quit attempt at the time, address tobacco dependence and willingness to quit at next clinic visit.

Pharmacological Therapy

First-line pharmacotherapy includes the multiple forms of nicotine replacement therapy (patch, nasal spray, losenge, gum, inhaler), sustained- release bupropion hydrochloride, and varenicline. Second line therapy includes clonidine and nortriptyline and have been found to be efficacious.
The following is a description of the various treatment modalities available:

• Sustained release bupropion hydrochloride:
  • Dose: 150 mg every morning for 3 days, then 150 mg twice daily.
  • Duration: The duration of treatment is 7–12 weeks followed by a maintenance therapy up to 6 months.
  • Adverse effects: Insomnia and dry mouth.
  • Treatment must be initiated 1-2 weeks prior to the quit date.
• Nicotine gum:
  • Dose: 1–24 cigarettes/day: 2mg gum (up to 24 pieces/day). ≥ 25 cigarettes/day: 4 mg gum (up to 24 pieces/day).
  • Duration: Up to 12 weeks
  • Adverse effects: Mouth soreness and dyspepsia
• Nicotine inhaler:
  • Dose: 6–16 cartridges/day
  • Duration: Up to 6 months
  • Adverse effects: Local irritation of mouth and throat
• Nicotine lozenges:
  • Dose: Time to 1st cigarette > 30 min: 2 mg lozenge. Time to 1st cigarette ≤ 30 min: 4 mg lozenge. 4–20 lozenges/day can be used based on the need.
  • Duration: Up to 12 weeks
  • Adverse effects: Nausea and heartburn
• Nicotine nasal spray:
  • Dose: 8–40 doses/day
  • Duration: 3–6 months
  • Adverse effects: Nasal irritation
• Varenicline:
  • Dose: 0.5 mg/day for 3 days followed by 0.5 mg twice/day for 4 days. Then, 1 mg twice/day
  • Duration: 3–6 months
  • Adverse effects: Nausea, trouble sleeping, vivid/strange dreams and depressed mood