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Smoking Cessation

Mark J. Chirico, Pharm. D.


Assistant Clinical Professor
AHEC Pharmacist
University of Florida
Objectives
 Appreciate the importance of smoking cessation based
on population data.
 Recognize the health risks and financial burden of
smoking.
 Realize that tobacco use is an addictive behavior similar
to that of other drugs with high abuse potential.
 Learn the “5 A’s” associated with health-provider
assisted smoking cessation.
 Become familiar with the various smoking cessation aids
available by prescription and OTC.
 Obtain the clinical knowledge necessary to recommend
smoking cessation aids and become confident in
counseling patients on their use.
Epidemiology of Tobacco Use
 Surgeon General’s Statement – 1982
“Cigarette smoking is the chief, single,
avoidable cause of death in our society
and the most important public health issue
of our time.”
- C. Everett Koop, M.D.
Public Health Tasks
 Focus on
 Prevention
 Teen smoking
 Advertisement
 Education
 Accessibility
 Cessation assistance
 Health care providers
 Insurers
 Employers
US Cigarette Consumption > 18 yrs old1
4500

4000

3500
per capita consumption
# cigs/person/yr

3000

2500

2000

1500

1000

500

0
00

30

40

60

70

00
10

20

50

80

90

04
19

19

19

19
19

19

19

19

19

19

20

20
Year
STATE-SPECIFIC
PREVALENCE of SMOKING
among ADULTS, 2002
Illinoi
Californi s
Kentuck
a 22.9
y
16.4% %
32.6%

Nevada
26.0% New York
22.4%
Utah
12.7% Florida
Texas 22.1 %
22.9%
Centers for Disease Control and Prevention. MMWR 2004;52:1277–1280.
TRENDS in ADULT SMOKING, by
SEX—U.S., 1955–2002
Trends in cigarette current smoking among persons aged 18 or older, by sex
60
22.5% of
50 Male adults are
40 current
30
smokers
Percent

25.2%
20
Female
20.0%
10

0
1955 1959 1963 1967 1971 1975 1979 1983 1987 1991 1995 1999
Year

70% want to quit


Graph provided by the Centers for Disease Control and Prevention. 1955 Current Population
Survey; 1965–2001 NHIS. Estimates since 1992 include some-day smoking.
Prevalence of Adult Smoking by Ethnic Group1
40

35

30
Native Amer/
Alaska Native
25
White Non-Hisp
% Smokers

20
Black Non-Hisp

15
Hispanic
10
Asian/ Pacific Isl

Ethnicity
Prevalence of Adult Smoking by Education1
50

45

40

35
% smoker

30

25

20

15

10

No HS GED HS Some Under- Graduate


diploma diploma college grad degree
degree
Smoking Cessation Among Adult Smokers by
Gender1

60

50

40

30
%

Male

Female
20

10

0
1965 1970 1975 1980 1985 1990 1995 2000 2003
Smoking Mortality
 Smoking remains the leading preventable
cause of death in the US
 1 out of 5 deaths
 438,000 deaths annually
 Projected death toll – end of 21st century
 Expected to reach 1 billion total
 100 million mark reached at the end of 1900’s
Economic Impact of Smoking
 Medical expenditures
 $75.5 billion
 Productivity
 $ 82 billion
 Total cost (annual)
 $ 157.5 billion
Health Risks
 Cardiovascular disease
 Lung disease (COPD)
 Cancer
 Sexual dysfunction
 Osteoporosis
 Delayed post-surgical healing
 Periodontal disease
Health Risks of 2 -Hand Smoke
nd

 SIDS
 Asthma
 Growth retardation (children)
 Cancer
 Cardiovascular disease
 Otitis media (↑ incidence in children)
Health Benefits of Quitting
 20 minutes - BP↓, HR↓
 8 hours – Carbon monoxide ↓, O2 ↑ to
normal levels
 24 hours – Risk of heart attack ↓
 48 hours – Nerve endings regenerate,
sense of taste and smell return to normal
QUITTING: HEALTH
BENEFITS2
Time Since Quit Date
Circulation improves, Lung cilia regain normal
walking becomes easier 2 weeks
to function
3 months
Lung function increases Ability to clear lungs of mucus
1 to 9
up to 30% months increases
Excess risk of CHD Coughing, fatigue, shortness of
1
decreases to half that of a year breath decrease
continuing smoker
5
Risk of stroke is reduced to that
Lung cancer death rate years of people who have never
drops to half that of a smoked
continuing smoker 10
years
Risk of cancer of mouth,
throat, esophagus, after Risk of CHD is similar to that of
bladder, kidney, pancreas 15 years people who have never smoked
decrease
BENEFICIAL EFFECTS of
QUITTING: PULMONARY
EFFECTS
AT ANY AGE, there are benefits of
quitting Never smoked
or not susceptible
100 to smoke
FEV1 (% of value at age 25)

75

Stopped smoking
Smoked
at 45 (mild COPD)
regularly and
50
susceptible to
effects of smoke
Disability
25
Stopped smoking
Death at 65 (severe
COPD)
0
25 50 75

Age (years)
COPD = chronic obstructive pulmonary disease

Reprinted with permission. Fletcher & Peto. Br Med J 1977;1(6077):1645–1648.


Nicotine Addiction
 1988 Surgeon General’s Report
 Nicotine is the drug in tobacco that causes
addiction
 Tobacco addiction is similar to drug addiction,
e.g heroin and cocaine

Fiore et al. Treating Tobacco and Dependence. Clinical Practice Guideline


Rockville, MD: USDHHS, PHS, 2000.
Nicotine Kinetics
 Absorbed in alkali environment (buccal
membranes, pH = 7)
 This accounts for nicotine absorption from chew,
cigars, and pipe tobacco
 Tobacco smoke is absorbed in the lung (alveolar
absorption, pH = 7.4)
- reaches brain in 11 sec., crosses BBB
- t½ = 2 hrs
 Nicotine also absorbed well by dermal tissue
Nicotine Pharmacodynamics
 CNS
 Pleasure (dopamine)
 Arousal (NE, Ach)
 Anxiolytic (endorphins, GABA)
 Circulatory
 ↑ HR (10-20 bpm)
 ↑ CO
 ↑ BP(5-10 mmHg)
 Vasoconstriction (coronary and cutaneous)
“Dopamine Reward Pathway”
 Stimulation of dopamine receptors in the
brain results in pleasure
 Reinforces repeated behavior
 Tolerance develops from up-regulation of
nicotine receptors which results in
increased consumption
Nicotine Withdrawal
 Expressed as a result of abrupt discontinuation –
fxn of absence of dopamine receptor stimulation
 Peak @ 24-48 hrs
 Dissipates after 2-4 weeks
 Symptoms
 Anger
 Irritability
 Anxiety
 Craving
Nicotine Withdrawal
 Symptoms (cont.)
 Sleep disturbances
 ↓ concentration
 Impaired task performance
 Activates “Nicotine Addiction Cycle”
NICOTINE ADDICTION
CYCLE

Reprinted with permission. Benowitz. Med Clin N Am 1992;2:415–437.


Factors Contributing to Tobacco
Dependence
 Environment
 Conditioning (cues and triggers)
 Social interaction (family, peers)
 Physiology
 Genetics
 Co-existing medical conditions (psychiatric)
 Pharmacology
 Withdrawal
 Weight control
 Pleasure
Assisting Patients With Quitting
 Behavioral intervention is just as important
as drug treatment
 Pharmacotherapy + Counseling > either
alone
 USPHS – June 2000
 Published “Treating Tobacco Use and
Dependence – Clinical Practice Guidelines”
The 5 A’s
 Ask
 Advise
 Assess
 Assist
 Arrange
Ask
 “Do you smoke or use other types of
tobacco?”
 Why?- it is important
 Link to other co-existing diseases (HTN, CVD,
Diabetes)
 Link to possible drug-drug interactions
 Non-judgmental tone
 Leads to withdrawal, incomplete disclosure
Advise
 “It’s important to quit as soon as possible, and I
can help.”
 Emphasize that you have specialized training
 Be:
 Clear of intent
 Strong - “…as soon as possible…”
 Personalized – tie to current health status, family
benefit (children, spouse, roommate), save $
 Sensitive – recognize difficulty in quitting
Assess
 “When would you like to quit?”
 Let patient establish a “quit date” (< 30 days)
 Make an appointment between 1st visit and quit date
 Previous attempts to quit?
 Scales and questionnaires
 Fagerstrom Test for Nicotine Dependence
 ↑score = ↑dependence

Heatherton TF, Kozlozwski LT, Frecker RC, Fagerstrom KO. The Fagerstrom
Test for Nicotine Dependence: a revision of the Fagerstrom Tolerance
Questionnaire. Br J Addict 1991;86:1119-1127.
IS A PATIENT READY TO
QUIT?
Does the patient use tobacco?
Yes No

Is the patient now Did the patient


ready to quit? once use tobacco?
No Yes Yes No

Promote Provide Prevent Encourage


motivation treatment relapse* continued
The 5 A’s abstinence

*Relapse prevention interventions not necessary


if patient has not used tobacco for many years
and is not at risk for re-initiation.

Fiore et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline.
Rockville, MD: USDHHS, PHS, 2000.
Assist
 Not ready to quit
 Motivational intervention
 Repeat offers at future visits
 Ready to quit
 Enroll in smoking cessation program
 Recently quit
 Continued support
Assisting Patients With Quitting
 Discuss key issues
 Motivation to quit
 Confidence in abiltiy to quit
 Triggers
 Routines associated with smoking
 Stress-related smoking
 Social support (family, friends)
 Weight gain
 Withdrawal
Assisting Patients With Quitting
 Facilitate
 Tobacco use log
 Identifies smoking patterns and triggers
 When and why
 Pros & cons of different cessation methods
 Coping strategies
 Environmental control
 Behavior modification
Assisting With Weight Gain
 Average ↑ = 10 lbs.
 Good eating habits
 Discourage dieting while trying to quit
 Recommend healthy snacks, sugarless gum
 Increase physical activity
 Non-food rewards
Assisting With Withdrawal
 Educate patient to recognize
 Anger, irritability
 Anxiety
 Cravings
 Restlessness
 Impatience
 Sleep disturbances
 Nervousness
Arrange
 Follow-up care
 In person or by phone
 Verify phone #, cell, HIPPA
 Increased # of visits = higher success rate
 First appointment – 1 week after quit date
 Second appointment – 30 days or less
 Depends on progress, pt needs
Quit Rate : Visit Ratio 2

Number of visits % Quit Rate

0-1 12.4

2-3 16.3

4-8 20.9

>8 24.7
Methods For Quitting
 Non-Pharmacologic
 “Cold turkey”
 Unassisted tapering
 Lighter brand
 ↓ allotment per day
 Special filters or holders
 Assisted tapering
 LifeSign® - computerized schedule with telephone
support
Methods For Quitting
 Self-help programs
 Massage therapy
 Acupuncture
 Hypnosis
Pharmacologic Methods For
Quitting
 Nicotine Replacement Therapy (NRT)
 Gum, lozenge, patch, nasal spray, inhaler
 Psychotropics
 Bupropion SR
 Partial nicotine agonist
 Varenicline (Chantix®)
 Other
 Clonidine, nortriptyline, etc.
Nicotine Replacement Therapy
 Reduces intensity of physical withdrawal
symptoms from nicotine
 Allows patient to focus on behavioral and
psychological aspects of smoking
cessation
 Beware: Nicotine replacement therapy
can also be addicting!
Nicotine Replacement Therapy
 Advantages
 No carcinogens or toxic agents
 Slower, lower, less variable nicotine levels
 Antagonizes the reinforcing action of repeated
smoking
 Delays weight gain
Nicotine Replacement Therapy
 Disadvantages
 Cardiovascular
 CI in post-MI (< 2 weeks), arrhythmias, unstable
angina
 TMJ
 Gum only
 Pregnancy and lactation
 Category D
Nicotine Replacement Products
 Nicotine Gum (Nicorettte®, generics) OTC
 Nicotine polacrilex resin complex
 Sugar-free
 Buffered to ↑ buccal absorption
 Flavored (regular, mint, orange)
 Strengths – 2 mg, 4 mg
 Dose
 > 25 cigs/day – 4 mg
 < 25 cigs/day – 2 mg
Nicotine Gum
 Peak effect – 30 min (cigs = 10 min)
 Fixed dosing schedule
 Weeks 1-6 – 1 pc. Q 1-2 hrs (9 pc./d, max 24)
 Weeks 7-9 – 1 pc. Q 2-4 hrs
 Weeks 10-12 – 1 pc. Q 4-8 hrs
 RCT’s – 50% higher success rate than
placebo , 4 mg > 2 mg in heavy smokers
Nicotine Gum
Patient Information
 Place 1 piece of gum at a time in mouth
 Chew slowly
 Stop chewing at first sign of taste
 Park between cheek and gum
 Repeat prn (fades in ~ 30 min.)
 Do not eat or drink for 15 min. before or
while chewing gum. Coffee, cola, acidic
juices, wine decrease absorption
Nicotine Gum
ADR’s
 Lightheadedness
 Belching
 Hiccups
 Headache
 GI upset
 Jaw muscle ache
Nicotine Lozenge
 Commit OTC
 Nicotine polacrilex
 25% more nicotine absorption than gum
 Sugar-free
 Mint flavored
 Buffered
 Strengths – 2 mg, 4 mg
Nicotine Lozenge
 Dose – based on “Time to First Cigarette”
(TTFC) after waking
 TTFC < 30 min – 4 mg
 TTFC > 30 min – 2 mg
 Max = 9pc./day
 Based in fixed schedule like gum
 RCT’s – 50% higher success rate than
placebo
Nicotine Lozenge
Patient Information
 Place one lozenge at a time in mouth and allow
to dissolve slowly
 Will experience warm, tingling sensation
 Switch lozenge from side to side
 Do not chew or swallow
 Effect will last 20-30 minutes
 Do not eat or drink for 15 min. before or while
using. Coffee, cola, acidic juices, wine decrease
absorption
Nicotine Patch
 Nicoderm CQ, Nicotrol®, generics OTC
 General composition
 Top layer - impermeable surface layer
 Middle layer – nicotine reservoir
 Bottom layer (closest to skin) – adhesive layer
 Nicotine absorption via skin avoids 1st
pass metabolism
TRANSDERMAL NICOTINE
PATCH:
COMPARISON2
Product Nicotrol Nicoderm Generics
CQ
Nicotine
delivery 16 hours 24 hours 24 hours
Strength 5 mg patch 7 mg patch 7 mg patch
10 mg 14 mg patch 14 mg patch
patch 21 mg patch 21 mg patch
15 mg
patch
NICOTINE PATCH: DOSING2
Product Light Smoker Heavy Smoker
Nicotrol ≤10 cigarettes/day >10 cigarettes/day
Not indicated Step 1 (15 mg x 6 weeks)
Step 2 (10 mg x 2 weeks)
Step 3 (5 mg x 2 weeks)
Nicoderm CQ ≤10 cigarettes/day >10 cigarettes/day
Step 2 (14 mg x 6 weeks) Step 1 (21 mg x 6 weeks)
Step 3 (7 mg x 2 weeks) Step 2 (14 mg x 2 weeks)
Step 3 (7 mg x 2 weeks)
Generic ≤10 cigarettes/day >10 cigarettes/day
(formerly Habitrol) Step 2 (14 mg x 6 weeks) Step 1 (21 mg x 4 weeks)
Step 3 (7 mg x 2 weeks) Step 2 (14 mg x 2 weeks)
Step 3 (7 mg x 2 weeks)
Generic ≤15 cigarettes/day >15 cigarettes/day
(formerly ProStep) 11 mg x 6 weeks 22 mg x 6 weeks
Nicotine Patch Facts
 Plasma levels 50% less than cigarettes
 Slow delivery system
 Alleviates withdrawal (not so with gum,
lozenge, spray, inhaler)
 RCT’s – 50% higher abstinence rate vs.
placebo
 Highest compliance rate among NRT’s
Nicotine Patch
Patient Information
 Choose area on upper body or arm
 Choose hairless area (do not shave)
 Avoid inflamed or irritated areas
 Rotate sites daily
 Do not use same area for at least a week
 Do not cut patches
 Wash hands after application, avoid eyes
 OK to swim, bathe, shower
 Do not smoke while on the patch
Nicotine Patch
ADR’s
 Mild redness (24 hrs) after removal
 Itching, burning, tingling – 50%
 OK to try OTC topical steroid or H1 antagonist
 Headache
 Vivid dreams (remove HS)
Nicotine Nasal Spray
 Nicotrol NS® Rx
 Aqueous nicotine solution
 Metered dose delivers 0.5 mg
nicotine/spray
 Rapid mucosal absorpton
 Fastest onset of all NRT’s (11-13 min.)
 Dose = 2 sprays (1mg)
 One bottle = 160 sprays
Nicotine Nasal Spray
 Dosing schedule
 Initial = 1-2 sprays q nostril/hr prn
 Max 10 sprays/hr
 Titrate up prn
 Usual dose = 16 sprays/day x 6-8 weeks,
taper down over subsequent 4-6 weeks
 Precautions – nasal disorders, asthma
 High abuse potential d/t fast nicotine
release
Nicotine Nasal Spray
Patient Information
 Remove cap (safety cap)
 Prime pump before first use or if > 24 hrs since
last use
 Blow nose if necessary
 Tilt head back, insert tip and spray into nostril
 Do not sniff in or inhale while spraying
 Wait at least 3 min before blowing nose again
 Do not smoke while using the spray
 Wait 5 min before driving or operating machinery
Nicotine Nasal Spray
ADR’s
 Hot, peppery sensation in nose and back
of throat – 94%
 Cough
 Watery eyes
 Runny nose
 Most sx diminish in 3 weeks
 81% report continued sx at lower intensity
Nicotine Inhaler
 Nicotrol Inhaler® Rx
 Nicotine oral inhaler system
 Re-usable mouthpiece and porous cartridge (10 mg)
 Delivers 4 mg nicotine vapor + menthol to decrease
irritation
 Buccal absorption
 Active puffing x 20 min = ~ 4 mg nicotine (2 mg
absorbed)
 Satisfies hand-to-mouth behavior
Nicotine Inhaler
 Dosing
 6 cartridges/day
 Increase prn to max 16 cartridges/day
 12 weeks duration
 Taper over subsequent 6-12 weeks
 Peak
 30 min
 50-70% lower plasma levels than cigarettes
Nicotine Inhaler
Patient Information
 Take small puffs as if lighting a pipe
 Actively puff for 20 minutes (not necessarily all
at once)
 Avoid deep inhalation (↑lung absorption,↑SE)
 Discard cartridge after 24 hrs
 Wash mouthpiece regularly
 Do not smoke while using the inhaler
 Do not eat or drink for 15 min. before or while
using inhaler. Coffee, cola, acidic juices, wine
decrease absorption
Nicotine Inhaler
ADR’s
 Mild mouth and throat irritation
 Unpleasant taste
 Cough
 Dyspepsia
 Hiccups
 Headache
 Rhinitis
Bupropion SR
 Zyban®, generics Rx
 Oral tablet formulation
 Antidepressant
 NE and dopamine
 Cravings – dopamine reward pathway
 Withdrawal - NE
Bupropion SR
 Kinetics
 5-20% bioavailable
 CYP2B6 metabolism (tegretol↓, ritonavir↑)
 MAOI interaction
 87% renal elimination
 t1/2 = 21 hrs (parent drug)
20-27 hrs (metabolite)
Steady state 5-8 days
Bupropion Dosing
 Day 1-3 – 150mg qd
 Thereafter 150mg bid x 7-12 weeks
 Studies > 12 weeks show lower relapse rate
 Begin treatment 1 week prior to quitting
Bupropion Contraindications
 Seizure disorder
 Anorexia
 Bulemia nervosa
 Abrupt d/c of alcohol or benzodiazepines
Bupropion ADR’s
 Insomnia (30-40%)
 Take second dose 8 hrs later
 Dry mouth (11%)
 Tremor (3%)
 Skin rash (2%)
Bupropion
 Advantages
 No adverse effects of nicotine
 Can be used in combination with NRT
 Disadvantages
 Seizure risk
 Drug interactions
 If ineffective after 7 weeks then d/c
Other Pharmacologic Therapies
 Clonidine
 Nortriptyline
 SSRI’s
 Mecamylamine
 Benzodiazepines
 Rimonabant (Acomplia®)
 Nicotine vaccine (NicVax®)
Combination Therapies
 Long-acting + short-acting
 Patch + (gum, lozenge, inhaler, spray)
 Use only in patients unable to quit on
monotherapy
 Risk of toxicity
 No long term studies
 Bupropion + patch
 ↑ 5.2% in RCT over either agent alone
 Not statistically significant
Varenicline
 Chantix® Rx
 May 2006
 Oral dosage form
 Alpha-4-beta-2 nicotinic acetylcholine receptor
agonist - ↓ cravings
 Concomitantly blocks nicotine-receptor binding -
↓ satisfaction from smoking
 Stimulates receptor at lower intensity than
nicotine - ↓ withdrawal
Chantix® Dosing
 Days 1-3 0.5 mg qd
 Days 4-7 0.5 mg bid
 Days 8 – end of tx 1 mg bid
 Recommended tx duration = 12 weeks
 subsequent 12 weeks tx = ↑ abstinence rate
 Renal dosing
 CrCl < 30 ml/min = 0.5mg bid
 CrCl < 10 ml/min = 0.5mg qd
Chantix® ADR’s
 Nausea (30%)
 Full glass water, after meals
 Insomnia (18%)
 Headache (15%)
 Abnormal dreams (13%)
 Other GI (5-8%)
Chantix® Information
 No drug interactions to date
 Pregnancy category C
 Not recommended in combination with NRT
 GET QUIT - Patient support program
 1-877-CHANTIX or www.chantix.com
 2 studies vs. bupropion3,4
 12 weeks
 +40 week follow-up
 Conclusion – at least “as effective as” bupropion
 Superior at 24 week point
LONG-TERM (>5 month) QUIT
RATES for AVAILABLE
CESSATION MEDICATIONS
35
Active drug 30.5 30.5
30
Placebo
25 23.7 23.9
22.8
Percent quit

20
17.1 17.7 17.3
15 13.9
12.3
10.0 10.5
10

0
Nicotine gum Nicotine patch Nicotine Nicotine nasal Nicotine Bupropion
lozenge spray inhaler
Data adapted from Fiore et al. Treating Tobacco Use and Dependence. Clinical Practice
Guideline. USDHHS, PHS, 2000 and Shiffman et al. Arch Int Med 2002;162:1267-
COMBINATION THERAPY:
PATCH PLUS BUPROPION
Percentage of patients quit at 12 months after
Nicotine patch
cessation
plus bupropion 35.5%

Bupropion
30.3%

Nicotine patch
16.4%

Placebo
15.6%

0% 5% 10% 15% 20% 25% 30% 35% 40%

Jorenby et al. N Engl J Med 1999;340(9):685–691.


COMPARATIVE DAILY COSTS
of PHARMACOTHERAPY
Chantix $4.00
Inhaler $6.07
Gum $5.77
Lozenge $4.98
Cigarettes (1 PPD) $4.50
Bupropion $4.02
Patch $3.93
Nasal spray $3.40

0 1 2 3 4 5 6 7

Cost per day (in U.S. dollars)


Quitting Facts Sheet
 Smokers of non-filtered cigarettes less
likely to quit than filtered smokers
 First cigarette < 30 minutes from waking
less likely to quit
 Purchase by the carton less likely to quit
 Smokers of regular cigarettes less likely to
quit than smokers of “lites”
 Dieting while trying to quit decreases
success rate
Case Study
 AJ – 49 yo HM being discharged from hospital
for pneumonia and COPD exacerbation
 PMH – COPD, HTN, pre-diabetes
 Personal – Divorced, 3 children
 Meds – Levaquin 500mg qd x 10d
HCTZ 50mg qd
Advair 250/50 1 puff bid
albuterol 2 puffs qid prn
Case Study (AJ)
 What question would you ASK first?
 Do you smoke or use other forms of tobacco?
 This is important to me since I have a duty to be
concerned for your well being
 How may you ADVISE this patient on quitting?
 Personalize – COPD, HTN, diabetes risk
 This is a good opportunity to quit since you have not
been able to smoke while in the hospital
 Empathize and don’t judge – It’s not easy to quit
Case Study (AJ)
 What ASSESS-ment tools can you use?
 Fagerstrom questionnaire
 How much?, How long?, When?
 Previous attempts to quit?, What products?
 What made you go back to smoking?
 Are you ready to quit?
 How confident are you that you will succeed?
Case Study (AJ)
 How can you ASSIST AJ in quitting?
 Set a quit date
 How soon would you see him?
 Select a product
 Identify triggers
 Make him aware of the reality of withdrawal
symptoms and cravings
 Coping strategies
Case Study
 What ARRANGE-ments would you make
for AJ?
 Follow up appointments
 Rx from provider if necessary
 On-line help
 Smoking cessation clinic
 Toll-free numbers
 Make it personal!
 Get contact numbers (home, cell, work)
Helpful Web Sites
 U.S. Department of Health and Human Services
 www.surgeongeneral.gov/tobacco/
 UCSF School of Pharmacy
 http://rxforchange.ucsf.edu/
 American Lung Association
 www.lungusa.org/
 Centers for Disease Control and Prevention
 www.cdc.gov/tobacco/how2quit.htm
References
1. Trends in Tobacco Use, American Lung
Association-Epidemiology and Statistics
Unit, Jan 2006.
2. RX for Change: Clinician-Assisted
Tobacco Cessation Faculty Coordinator’s
Guide. June 2003.
References
3. Jorenby DE, et al. Efficacy of varenicline, an
alpha4beta2 nicotine acetylcholine receptor
partial agonist, vs. placebo or sustained release
bupropion for smoking cessation: a randomized
controlled trial JAMA 2006;296:56-63.
4. Gonzales D, et al. Varenicline, an alpha4beta2
nicotine acetylcholine receptor partial agonist,
vs. sustained release bupropion and placebo for
smoking cessation: a randomized control trial
JAMA 2006;296:47-55.

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