Assessment
Ask every patient at every visit: "Do you smoke?" Document: current, former, never. If current: cigarettes per day, years, quit attempts, readiness. Secondhand smoke exposure. Other tobacco: e-cigarettes, chew, cigars, hookah. Assess readiness: Stages of Change. Assess dependence: Fagerstrom test (time to first cigarette, CPD). Assess barriers: stress, weight gain, social, environment, psychiatric comorbidity. Carbon monoxide: level in smokers (6-50 ppm), breath test. Health effects: lung cancer, COPD, CHD, stroke, PAD, pregnancy complications, wound healing, osteoporosis.
5 As
Ask: screen all patients. Advise: clear, strong, personalized — "Quitting is the most important thing you can do for your health." Assess: readiness to quit (Stages of Change), prior attempts, barriers. Assist: provide counseling, set quit date, provide resources, pharmacotherapy. Arrange: follow-up, referral to quit line (1-800-QUIT-NOW), support. Even brief intervention (3 minutes) increases quit rates. Motivational interviewing for those not ready. Relapse prevention for those who have quit.
Pharmacotherapy
Nicotine replacement therapy (NRT): patch (21 mg/day, taper over 8-12 weeks), gum (2-4 mg, q1-2h), lozenge (2-4 mg), inhaler, nasal spray. Combination: patch + short-acting NRT (gum/lozenge) more effective. Bupropion (Zyban): 150 mg daily x3 days, then BID, start 1-2 weeks before quit date. Varenicline (Chantix): 0.5 mg daily, titrate to 1 mg BID, start 1 week before. Side effects: nausea (varenicline), insomnia (bupropion), vivid dreams (varenicline). Contraindications: seizures (bupropion), pregnancy (relative). Efficacy: varenicline > bupropion > NRT. Combine counseling + pharmacotherapy for best results.
Important Notes
- Ask about tobacco use at every visit and advise every smoker to quit — even brief counseling (3 minutes) increases quit rates.
- Combination NRT (patch + short-acting gum/lozenge) is more effective than single NRT — use both for best results.
- Varenicline (Chantix) is the most effective single pharmacotherapy — start 1 week before quit date, titrate dose.
Clinical Tips
- 1-800-QUIT-NOW: free telephone counseling — increases quit rates when combined with pharmacotherapy.
- Bupropion contraindicated in seizure disorders and eating disorders — lowers seizure threshold.
- Start all cessation medications 1-2 weeks before the quit date to build therapeutic levels before withdrawal begins.
Summary
Smoking cessation uses the 5 As (Ask, Advise, Assess, Assist, Arrange), pharmacotherapy (NRT, bupropion, varenicline), and counseling (quit line, motivational interviewing) — combination therapy is most effective.
