Nicotine causes dependence, and withdrawal from it may cause irritability, anxiety, difficulty concentrating, and increased appetite.5 Dependence on tobacco is a chronic problem that will often require repeated interventions before a patient finally succeeds in quitting.4

COUNSELING IS IMPORTANT

A strong relationship has emerged between the intensity of counseling efforts and the effectiveness of the counseling. Treatments involving person-to-person contact are consistently effective. Even brief counseling at routine visits has been shown to help with smoking cessation. Counseling can provide the patient with reasons to quit smoking and with strategies that will help him or her to be successful.4

NICOTINE REPLACEMENT THERAPY

Nicotine replacement therapy (NRT) is available in several different dosage forms, including gum, inhaler, nasal spray, patch, and lozenge (see Table. “Nicotine replacement therapies” in the online version of this article). All NRT products should be used with caution in patients with recent MI, serious arrhythmia, or angina.6

OTHER PHARMACOLOGIC OPTIONS

Bupropion (Zyban) This drug blocks the neural uptake of dopamine and/or norepinephrine. It should be used with caution in patients who have a history of a seizure disorder, eating disorder, or bipolar disorder or who use monoamine oxidase inhibitors. It is dosed at 150 mg each morning for 3 days, then at 150 mg twice daily. Bupropion should be started 1 to 2 weeks before the quit date, used for 7 to 12 weeks after quitting, and may be continued for up to 6 months for maintenance. Side effects include insomnia and dry mouth. The average daily cost is $5.6

Varenicline (Chantix) This prescription agent blocks nicotine binding to certain receptors and partially stimulates the nicotinic receptor to reduce cravings and withdrawal symptoms. Dosing starts at 0.5 mg daily and is increased to 1 mg twice daily. Varenicline should be started 1 week before the quit date and used for 12 weeks. It may be used for an additional 12 weeks if the patient failed to quit after the initial 12-week treatment. Side effects include nausea, sleep disturbances, and headache.6 The FDA has warned about the possible risk of suicidal ideations, but it is unknown at this time whether the medication is to blame.7,8 The average daily cost is $4.6

BOTTOM LINE

Smoking is very common, and many patients desire to stop. Each patient should be assessed for his or her desire to quit smoking and provided with counseling and pharmacotherapy as appropriate. JAAPA

For patient information on this topic, please see the next section.

Angela Dunaway practices at the Immediate Care Clinic, Calhoun, Georgia. She has indicated no relationships to disclose relating to the content of this article.

Katie Iverson, PA-C, MPAS, department editor

REFERENCES

1. Cigarette smoking statistics. American Heart Association Web site. http://www.americanheart.org/presenter.jhtml?identifier= 4559. Accessed October 8, 2008.

2. 2004 Surgeon General's report—the health consequences of smoking. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_2004/index.htm. Accessed October 8, 2008.

3. Smoking and tobacco use. Fact sheet. Cessation. Centers for Disease Control and Prevention Web site. http://www.cdc. gov/tobacco/data_statistics/fact_sheets/cessation/cessation2.htm. Accessed October 3, 2008.

4. Fiore MC, Bailey WC, Cohen SJ, et. al. Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians. Rockville, MD: US Department of Health and Human Services, Public Health Service; October 2000.

5. Guide to quitting smoking. American Cancer Society Web site. http://www.cancer.org/docroot/PED/content/PED_10_13X_Guide _for_Quitting_Smoking.asp. Accessed October 8, 2008.

6. Smoking cessation drug therapy. Pharmacist's Letter/ Prescriber's Letter. 2006;22(12):221212.

7. Dispelling myths about nicotine replacement therapy. National Cancer Institute. http://www.smokefree.gov/docs/MythsaboutNRTFactSheet.pdf. Accessed October 8, 2008.

8. Chantix full prescribing information. http://www.chantix.com/content/Prescribing_Information.jsp. Accessed October 3, 2008.

HOW CAN I QUIT SMOKING?

Cigarette smoking is a common habit. In the United States, about 18% of women and 24% of men smoke cigarettes. Smoking increases the risk of many diseases. Some of them are cancers, heart and blood vessel disease, stroke, respiratory tract infections, stomach ulcers, fertility problems, gum disease, and sexual problems. About 70% of smokers in this country want to quit. Your doctor or PA can give you information and medicine that can help you quit.

WHY IS QUITTING SO HARD?

Quitting is hard because smokers are addicted to nicotine. Nicotine is a chemical in cigarettes. With repeated use, the body can become dependent on it. After this happens, withdrawal from nicotine may cause unpleasant symptoms. Some of these are irritability, nervousness, trouble concentrating, and increased appetite. Use of tobacco is usually a long-term problem and will often require repeated attempts to quit.

WHY IS COUNSELING IMPORTANT?

Your chances of quitting smoking go up when you speak with your doctor or PA about quitting. Even brief talks at routine visits may help you quit smoking. Your doctor or PA can provide you with reasons to quit smoking. He or she can suggest strategies that will help you to succeed.

WHAT NICOTINE REPLACEMENT THERAPY CAN I TRY?

Nicotine replacement therapy (NRT) comes in different forms. You can use NRT as a gum, inhaler, nasal spray, patch, or lozenge. All NRT products should be used with caution in people with certain health problems. Talk to your doctor or PA before you start NRT to make sure it is safe.

NRT gum The gum comes in 2-mg and 4-mg forms. Which one you use depends on how many cigarettes you smoke per day. More details are on the package. Or your doctor or PA can tell you how much to use. Do not use more than the recommended dose. You can use the gum for 12 weeks or for as long as your doctor or PA advises. The gum may cause upset stomach, mouth soreness, and hiccups. The gum costs about $6 a day.

NRT inhaler Most people use the inhaler 6 to 16 times per day. You can use the inhaler for up to 6 months or for as long as your doctor or PA tells you. You will use the inhaler less and less over the last 6 to 12 weeks of use. Do not use the inhaler more than directed. The inhaler may cause an irritated mouth and throat, coughing, and runny nose. It costs about $6 a day. You must have a prescription to obtain the inhaler.

NRT nasal spray Most people use 8 to 40 doses per day. The spray is used for 3 to 6 months or for as long as advised. The spray may irritate your nose. It costs about $3 a day. The nasal spray requires a prescription from your doctor or PA.

NRT patch The patch comes in 21- mg, 14-mg, and 7-mg forms. Which one you use depends on the number of cigarettes you smoke per day. More details are on the package. Or your doctor or PA can tell you how much to use. You apply the patch to your skin when you wake up on your quit date. You must remove the old patch before you put on a new one. The patch may irritate your skin or cause sleep problems. The patch costs about $4 a day.

NRT lozenge These come in 2-mg and 4-mg forms. If you wait more than 30 minutes after you wake up before you smoke your first cigarette, use the 2-mg lozenge. If you smoke your first cigarette sooner, use the 4-mg lozenge. More details are on the package. Or your doctor or PA can tell you how much to use. The lozenge may cause nausea and sore throat. It costs about $5 a day.

WHAT PRESCRIPTION MEDICINES ARE AVAILABLE?

Bupropion (Zyban) This drug affects natural chemicals in the brain in a way that makes it easier to quit smoking. Do not use bupropion if you have a history of seizures, an eating disorder, or bipolar disorder. Tell your doctor or PA if you are using any other medicines. Bupropion is usually used for 7 to 12 weeks and up to 6 months for maintenance. Start taking it 1 to 2 weeks before you quit smoking. It may cause sleep problems and dry mouth. It costs about $5 a day.

Varenicline (Chantix) This medicine blocks some of the effects of nicotine. It reduces the craving to smoke and reduces withdrawal symptoms. Your doctor or PA will tell you how to take the medicine. You start taking it 1 week before you quit smoking. Usually, you keep using it for 12 weeks. You may be able to use varenicline for 12 more weeks if you failed to quit. The medicine may cause nausea, sleep problems, and headache. Take it with food and a full glass of water to help prevent nausea. The FDA has warned about the possible risks of suicidal thoughts, but it is unknown whether varenicline is to blame. Talk to your doctor or PA about the side effects before you start the medicine. It costs about $4 a day.

BOTTOM LINE

Smoking is a very common habit, and many smokers have a desire to stop smoking. Smoking can cause many health problems. If you smoke, talk to your doctor or PA about why you should quit. They can provide ways to help you quit successfully.