Table 1                        Tobacco cessation therapeutic goals and interventions based on the stages of change12

 

Stage

Goal

Intervention

Precontemplation

• to help patient begin to think seriously about quitting in the next 6 months

• ask patient about his or her feelings about smoking

• ask about the pros and cons of smoking

• assist by assuring patient that you will not push him or her to stop

• offer patient quitting information

Contemplation

• to help patient make a decision to stop smoking in the near future

• to help patient feel more confident

• ask about the pros and cons of smoking cessation

• assist by reinforcing the reasons for change and exploring new ones

• suggest patient cut back or stop for a day

• suggest a future visit and offer information

Preparation

• to help patient prepare for change and begin to use quitting skills

• ask about concerns, preparations and lessons learned from previous attempts

• advise by identifying barriers to stopping and eliciting solutions

• assist by providing material (booklet) and help regarding action plan, date for quitting and nicotine replacement therapy (NRT)

Action

• to help patients stay off tobacco products and recover from slips and relapse

• ask how patient is doing (relapses, temptations, successes, NRT use)

• advise (relapse prevention, weight gain, triggers, etc.)

• assist by focusing on successes; encourage self-rewards and increased support; elicit solutions to problems

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Table 2                               NRT and adjunctive pharmacotherapy use

 

NRT

NRT formulation in Canada

• chewing pieces: 2 mg, 4 mg

• transdermal patches: 7 mg, 14 mg and 21 mg

 

How NRT works

• reduces withdrawal symptoms

• reduces smoking urge by sustaining tolerance (however, even a puff can lead to relapse)

• may maintain mood, attentiveness and stress handling (where these are affected as part of withdrawal)

 

Use of chewing pieces

• stop smoking

• substitute chewing piece for cigarette

• chew slowly

• use several pieces per day (depending on severity of addiction)

• stay on therapy for sufficient time

• plan staged reduction

• stop using

 

Use of NRT patch

• stop smoking

• apply to non-hairy, clean, dry, intact skin on arm or torso

• remove old patch and apply new patch according to directions

• choose new site each time

• use for approximately 3 months

Adjunctive Pharmacotherapy17

How bupropion (Zyban) works

• inhibits dopamine re-uptake and alters norepinephrine activity

• has more effect (for smoking cessation) than placebo (up to 52 weeks)

• reduces weight gain

• has minimal side effects

 

Considerations

• bupropion hydrochloride is an anti-depressant approved for use in tobacco cessation treatment by Health Canada

• it should not be used in patients with seizure disorders or with prior diagnosis of bulimia or anorexia nervosa

• its use is contraindicated in patients taking other anti-depressants and monoamine oxidase inhibitors

• patients who are allergic to bupropion hydrochloride can be prescribed Clonidine16

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Table 3                        Suggestions for the clinical use of pharmacotherapies for smoking cessation16                                                                    


Pharmacotherapy

Precautions/

Contraindications

Adverse Effects

Dosage

Duration

Availability

Nicotine patch

 

Local skin reaction

Insomnia

21 mg/24 hr

14 mg/24 hr

 7 mg/24 hr

4 weeks

then 2 weeks

then 2 weeks

Prescription and

over the counter

Nicotine gum

 

Mouth soreness

Dyspepsia

1-24 cigarettes/day:

2 mg gum up to 24 pieces/day

> 25 cigarettes/day:

4 mg gum up to 24 pieces/day

Up to 12 weeks

Over the counter

Sustained releasea bupropion hydrochloride

History of seizure

History of eating disorder

Insomnia

Dry mouth

150 mg every morning for 3 days then

150 mg twice daily

(begin treatment 1-2 weeks prior)

7-12 weeks maintenance

up to 6 months

Prescription

Clonidineb

Rebound hypertension

Dry mouth

Drowsiness

Dizziness

Sedation

0.15-0.75 mg/day

3-10 weeks

Prescription

 

Modified from JAMA16

a           The patient’s physician must conduct a physical examination and complete the patient’s medical history

b           If bupropion hydrochloride is contraindicated

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Table 4                        Facts about the use of pharmacotherapy for smoking cessation18

 

  1. Nicotine is not the harmful substance in cigarettes. There are about 4,000 compounds in tobacco smoke and many of them cause cancer.
  2. Cigarettes are far more addictive than the nicotine patch or gum primarily because of the way in which they deliver nicotine.
  3. NRT is safe for smokers.
  4. Use of NRT while smoking does not increase the smoker’s cardiovascular risk.
  5. It is safer for patients with heart disease to use NRT than to continue smoking.
  6. NRT is safer for a pregnant woman and her fetus than smoking.
  7. NRT is safe to use for all ages.
  8. NRT and bupropion are safe and effective. NRT and bupropion have both been found to double quit success rates compared to placebo.
  9. The nicotine patch and gum can be used at the same time and in combination with bupropion.
  10. Smokers can control the dose of NRT. It takes time for smokers to learn how to maximize NRT’s effects.
  11. The nicotine patch and gum can be used as long as needed; there are no time limitations.
  12. The nicotine patch and gum can be used by people who are not yet ready or able to quit
  13. The use of NRT and bupropion in smoking cessation is cost effective.