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: Usama Talib, BSc, MD [2]

## Overview

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Some general principles including the 5 As (ask, Assess, Advise, Assist and Arrange follow-up), non-pahramcological strategies like nicotine gum and nicotine patch and pharmacological strategies including bupropion, varenicline, inhalers and nasal sprays can be used to help quit smoking.[1][2][3][4][5]

## Medical Therapy

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### General Principles

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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.[1][2][3][4][5]

| 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

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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.[6]
The following is a description of the various treatment modalities available:[7]

* 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

### Effect of Smoking Cessation on various Risks

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* Quitting smoking cuts cardiovascular risks. Just 1 year after quitting smoking, your risk for a heart attack drops sharply.
* Within 2 to 5 years after quitting smoking, your risk for stroke may reduce to about that of a nonsmoker’s.
* If you quit smoking, your risks for cancers of the mouth, throat, esophagus, and bladder drop by half within 5 years.
* Ten years after you quit smoking, your risk for lung cancer drops by half.

## References

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1. ↑ 1.0 1.1 "CDC - 2010 Surgeon General's Report - Consumer Booklet - Smoking & Tobacco Use".
2. ↑ 2.0 2.1 "QuickStats: Number of Deaths from 10 Leading Causes — National Vital Statistics System, United States, 2010".
3. ↑ 3.0 3.1 "CDC - 2014 Surgeon General's Report - Smoking & Tobacco Use".
4. ↑ 4.0 4.1 "CDC - Fact Sheet - Current Cigarette Smoking Among Adults in the United States - Smoking & Tobacco Use".
5. ↑ 5.0 5.1 WYNDER EL, GRAHAM EA (1951). "Etiologic factors in bronchiogenic carcinoma with special reference to industrial exposures; report of eight hundred fifty-seven proved cases". AMA Arch Ind Hyg Occup Med. 4 (3): 221–35. PMID 14867935.
6. ↑ "www.vapremier.com" (PDF).
7. ↑ Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update Panel, Liaisons, and Staff (2008). "A clinical practice guideline for treating tobacco use and dependence: 2008 update. A U.S. Public Health Service report". Am J Prev Med. 35 (2): 158–76. doi:10.1016/j.amepre.2008.04.009. PMC 4465757. PMID 18617085.CS1 maint: Multiple names: authors list (link)

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