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Smoking cessation: integration of behavioral and drug therapies -- american family physician
Smoking Cessation: Integration
of Behavioral and Drug Therapies
ROBERT MALLIN, M.D., Medical University of South Carolina, Charleston, South Carolina
Family physicians should take advantage of each contact with smokers to encourage and
support smoking cessation. Once a patient is identified as a smoker, tools are available to
assess readiness for change. Using motivational interviewing techniques, the physician can
tion handout on howto stop smoking, writ-
help the patient move from the precontemplation stage through the contemplation stage
to the preparation stage, where plans are made for the initiation of nicotine replacement
and/or bupropion therapy when indicated. Continued motivational techniques and sup-
port are needed in the action stage, when the patient stops smoking. Group or individual
behavioral counseling can facilitate smoking cessation and improve quit rates. Combined
use of behavioral and drug therapies can dramatically improve the patient’s chance of quit-
ting smoking. A plan should be in place for recycling the patient through the appropriate
stages if relapse should occur. (Am Fam Physician 2002;65:1107-14,1117. Copyright 2002
American Academy of Family Physicians.)
Identification of the Smoker and
Assessment of Readiness to Quit
on smoking, heightenedawareness of the conse-quences of smoking, andconsiderable publicity
while a patient’s vital signs are being
nies, statistics published within the past
CAGE questionnaire (Table 1)
7 or an
8,9 can provide information
group, smoking rates increased by 32 per-
about whether a patient is addicted to or
patient’s readiness to change. The five-
help.3 The advice of a physician alone can
for “Practical Therapeu-tics.” This article is one
patient does not believe that smoking is a
every office or clinic visit. This article
cessation. In the contemplation stage, the
South Carolina. Guesteditor of the series is
age the patient in the precontemplation stage
Only 7.9 percent of smokers are able to quit without help.
to think about his or her smoking and to con-sider the possibility that smoking is a prob-
The combined use of nicotine replacement, social or behav-
ioral support, and bupropion can increase the quit rate to
Brief interventions can be effective in the
precontemplation stage and as the patientmoves from one stage to the next.12 Effectiveinterventions include the following:
preparation stage, the patient makes specific
1. Educate the patient about the effects of
plans to stop smoking, such as setting a quit
date and determining how smoking cessation
will be accomplished. In the action stage, the
patient stops smoking. Finally, the mainte-
nance stage is marked by the patient’s contin-
4. Discuss the patient’s reactions to the
physician’s feedback and recommendations.
smoking behavior is common. Patients often
cycle through the stages of change several
times before reaching stable abstinence.11
This process, known as “motivational inter-
viewing,” uses empathy rather than con-
frontation. It acknowledges that the patient,
not the physician, is responsible for changing
To select the most appropriate interventions,
the family physician needs to know thepatient’s present readiness to change. Offer-
ing a prescription for nicotine replacement to
If further discussion on the return visit
stage is unlikely to be successful, because
smoking is a problem and would like to con-
doing so essentially asks the patient to move
sider quitting, the patient has entered the
contemplation stage. Interventions to con-
sider at this stage include providing further
stages. Rather, the physician should encour-
education about the effects of smoking andencouraging the patient to consider the pos-itive aspects of not smoking, such asimproved health, a more positive self image,
CAGE Questionnaire for Smoking*
1. Have you ever tried to, or felt the need to, C
ut down on your smoking?
Once the patient agrees that the benefits of
2. Do you ever get A
nnoyed when people tell you to quit smoking?
not smoking outweigh the pleasure derived
3. Do you ever feel G
uilty about smoking?
from smoking and has decided to quit, he or
4. Do you ever smoke within one-half hour of waking up (E
she has entered the preparation stage. At thispoint, it is appropriate to discuss various
*—Two “yes” responses constitute a positive screening test.
nicotine replacement systems, the possibleuse of bupropion, and the need for social and
Adapted with permission from Lairson DR, Harrist R, Martin DW, Ramby R, RustinTA, Swint JM, et al. Screening for patients with alcohol problems: severity of
family support. The physician should also
patients identified by the CAGE. J Drug Educ 1992;22:337-52.
help the patient develop a clear plan forsmoking cessation.
Tasks for the patient and physician during the
preparation stage may include the following10:
Once a patient is in the preparation stage for quitting smok-
1. Setting a definite quit date. Often, a
ing, it is appropriate to discuss specific smoking cessation
meaningful date, such as a birthday or anni-
versary, provides the patient with increasedmotivation.
tion. The patient should let family members
meetings, frequent office visits, and/or tele-
and other significant persons know that he or
she has decided to quit smoking on a certain
enhance the effectiveness of the cessation
date, and should ask those individuals for
should be to support continued smoking ces-
patient to take part in a support group or a
sation in the recently abstinent smoker. These
contacts should be made at least weekly in the
3. Preparing the environment. The patient
should be counseled to remove cigarettes,
ashtrays, and other smoking-related para-
It is important for the patient to report per-
ceived benefits from having stopped smok-
office. The patient should ask others not to
ing, side effects of medications, and current
or anticipated difficulty in maintaining absti-
4. Formulating plans to avoid triggers. When
prompted, many patients can identify images,rituals, sensory experiences, and emotional
Brief Fagerström Test for Nicotine Dependence
rewards that they associate with smoking. Thephysician and patient can begin to discuss
Answer the two questions below. Check your total score against the scoring key.
healthy substitution behaviors that might help
1. How soon after waking do you smoke your first cigarette?
prevent relapse. Counseling patients to avoid
alcohol is a good strategy because drinking
chance of successful smoking cessation.
5. Selecting a nicotine replacement system,
2. How many cigarettes do you smoke each day?
bupropion is part of the smoking cessation
plan, treatment should be initiated one to twoweeks before the quit date.
SCORING KEY: 5 to 6 points = heavy nicotine dependence; 3 to 4 points = mod-erate nicotine dependence; 0 to 2 points = light nicotine dependence.
ACTION AND MAINTENANCE STAGES
The action stage begins on the quit date. By
FIGURE 1. Abbreviated Fagerström Test for Nicotine Dependence. Fam-
this date, bupropion should have been started
ily physicians can use this quickly administered tool to evaluate inten-
(if used), the nicotine replacement system of
sity of nicotine dependence or addiction in their patients.
choice should be on hand (if used), and the
Adapted with permission from Rustin TA. Pharmacologic treatment of nicotine
dependence. In: The certification review course in addiction medicine for theAmerican Society of Addiction Medicine. Chevy Chase, Md.: American Society of
cleared of smoking-related materials.
Addiction Medicine, 1998; based on information in Heatherton TF, Kozlowski LT,
During the action stage, behavioral support
Frecker RC, Fagerström KO. The Fagerström Test for Nicotine Dependence: a revi-
through self-help or professionally run group
sion of the Fagerström Tolerance Questionnaire. Br J Addict 1991;86:1119-27.
Include “Do you smoke?” with questions routinely asked while taking the patient’s vital signs.
Assess the patient’s nicotine dependence using the modified CAGE questionnaire
(see Table 1) and/or the abbreviated Fagerström test (see Figure 1).
Use the five-stage transtheoretical model to assess the patient’s readiness to change.
(the patient thinks smoking is not a problem)
Interventions: Educate the patient about the effects of smoking, introduce
ambivalence (inquire about decision to continue smoking), express concern, and recommend quitting.
Physician statement introducing ambivalence: “Today most people agree that
smoking is not good for your health. What do you think about that?”
Physician statement expressing concern and encouraging contemplation: “I am
concerned about your health and believe you should stop smoking. I am wondering how I can help you with that.”
(the patient thinks smoking may be a problem)
Interventions: Assess positive and negative thinking about smoking.
Physician statement resolving ambivalence: “Your cough will improve when
(the patient wants to quit smoking)
Interventions: Set a quit date, select smoking cessation strategies, determine dosage
of nicotine replacement if indicated, identify triggers, gather social support for quitting, and begin bupropion (Zyban) if indicated.
Physician statement encouraging planning and action: “Let’s set a date for you to
quit smoking and make plans for how you can do it.”
(the patient quits smoking)
Interventions: Begin nicotine replacement and continue bupropion.
Physician and staff maintain frequent contact with the patient to provide support
and help provide solutions for dealing with specific triggers.
(the patient starts smoking again)
Interventions: Reassess readiness to change and enter at appropriate stage;
identify reasons for relapse and consider how things might be done
Physician supports another attempt and, when the patient is ready, works
with the patient to develop a more effective smoking cessation plan.
FIGURE 2. A suggested approach to smoking cessation, based on the transtheoretical model forreadiness to change.
nence. Healthy substitution behaviors may
ily nicotine-dependent smokers.17 Nicotine
replacement is initiated on the quit date.
A number of transdermal
tion, based the transtheoretical model, is out-
nicotine replacement systems (Habitrol, Nico-
derm CQ, Nicotrol) are available over thecounter. The results of the Fagerström Test for
Nicotine Dependence can be used to deter-
mine the appropriate starting patch strength
drawal include irritability, anxiety, decreased
for a patient.9 However, the proper initial
heart rate, increased appetite, food cravings,
dose can be determined more quickly using
restlessness, and difficulty concentrating.15 In
the patient’s score on the abbreviated Fager-
ström test (Figure 1
: a score of 5 to 6 war-
dependence (Figure 1),
8,9 medications that
rants use of the 21-mg nicotine patch; a score
lessen these signs and symptoms can help to
of 3 to 4 means that the 14-mg nicotine patch
prevent relapse in the early stages of smoking
is appropriate for initial therapy; and a score
of zero to 2 indicates initial use of the 7-mgnicotine patch.8
Adverse reactions to transdermal nicotine
Nicotine replacement by any delivery sys-
replacement systems seldom cause discontinu-
ation of therapy. From 30 to 50 percent of
cessation rate.16 Currently, four forms of nico-
patients experience mild skin irritation under
tine delivery are available: patch, gum, inhaler,
the patch. In most patients, this problem can
and nasal spray. Some data indicate that use of
be alleviated by rotating patch application
a combination of delivery methods, such as
sites. Sleep disruption is usually resolved by
the gum and the patch, may be useful in heav-
TABLE 2Effective Pharmacotherapy for Nicotine Withdrawal
*—Estimated cost to the pharmacist for 30 days of treatment, based on average wholesale prices (rounded to the nearest dollar) in Redbook. Montvale, N.J.: Medical Economics Data, 2001. Cost to the patient will be higher, depending on prescription filling fee.
It is important to discourage patients from
available by prescription. The nicotine is pri-
smoking while they are using the nicotine
patch. The combination of smoking and nico-
(36 percent) and the esophagus and stomach
tine patch use results in discomfort from
(36 percent), rather than through the lungs
higher nicotine levels; more importantly, it
(4 percent). Currently, four inhalers a day
increases the likelihood of relapse to virtually
must be used to achieve adequate nicotine
100 percent.18 Concerns about sudden cardiac
levels. Hence, frequent dosing is required,
death as a result of concomitant smoking and
with each inhaler containing 500 puffs. Side
nicotine patch use have been allayed by two
effects include mouth and throat irritation.21
clinical trials19,20 that showed no increase in
Nicotine Nasal Spray.
morbidity or mortality associated with nico-
can also be accomplished with a nasal spray
tine patch use in smokers with heart disease.
(Nicotrol NS), which is available by prescrip-
Nicotine patches should be used for about
tion. The use of four sprays per hour or a
eight to 12 weeks. Tapering to the next lowest
dose (e.g., 21 mg to 14 mg) can be done after
mended. Nasal and throat irritation, rhinor-
four to six weeks. The patient who starts with
rhea, and nausea are common side effects.
the 7-mg patch should continue using that
Comparison of Delivery Systems.
lacking on which nicotine delivery system is
Nicotine polacrilex (Nico-
most effective. Because all four systems appear
rette) is available over the counter in 2-mg and
to be efficacious, patient preference usually
4-mg strengths. The gum is most effective in
determines the choice of nicotine replacement
the 4-mg strength, with initial use of 10 to 15
modality. For example, the patient who needs
pieces of gum per day. After two weeks, most
to be doing something with his or her hands
patients can change to the 2-mg strength.
may prefer the nicotine inhaler over the nico-
The most important adverse events associ-
ated with nicotine gum appear to be gastroin-
about gaining weight may prefer to use nico-
testinal side effects from swallowing large
tine gum, which has been shown to delay (but
improperly. Nicotine gum is intended to be
parked in the buccal area and chewed once ortwice every few minutes. If the gum is chewed
too quickly, nicotine is swallowed with saliva,
been shown to have similar positive effects on
A nicotine inhalation sys-
tem (Nicotrol Inhaler) has recently become
appears to be the most effective treatment fornicotine dependence.
nephrine, serotonin, and dopamine. Themechanism by which bupropion enhances
the ability of patients to abstain from smok-
ROBERT MALLIN, M.D., is assistant professor in the Department of Family Medicine at
ing is unknown; however, the drug is believed
the Medical University of South Carolina, Charleston. He received his medical degreefrom the University of South Carolina School of Medicine, Columbia, where he also
to reduce the urge to smoke through its effect
completed a family practice residency at Richland Memorial Hospital. Dr. Mallin is
on the norepinephrine and dopamine neuro-
board certified in family practice and is also certified by the American Society of Addic-
One controlled trial5 found that bupropion
Address correspondence to Robert Mallin, M.D., Department of Family Medicine,
therapy resulted in a 12-month abstinence
Medical University of South Carolina, 295 Calhoun St., P.O. Box 250192, Charleston,SC 29425 (e-mail: firstname.lastname@example.org). Reprints are not available from the author.
rate of 30 percent, compared with 16 percent
for nicotine replacement therapy alone. Com-bination therapy using bupropion plus nico-
If bupropion is to be used in smoking cessation, the drug
tine replacement resulted in an even higher
should be started one to two weeks before the planned
Bupropion therapy is initiated in a dosage of
150 mg per day for three days. The dosage is then increased to 150 mg twice daily. Thequit date should be set for one to two weeks
to review the treatment plan to determine
after bupropion therapy is initiated. Bupro-
pion therapy is usually continued for eight to
A patient may not return immediately after
12 weeks after the patient has quit smoking.
a relapse and may smoke for months before
Contraindications to the use of bupropion
another visit. At that point, the patient’s readi-
include a history of seizure disorder and the
ness to change needs to be reevaluated, and the
presence of eating disorders or uncontrolled
smoking cessation process must be repeated.
hypertension. The most common side effects
Nicotine dependence is a tenacious and dif-
of the drug are dry mouth and sleep distur-
ficult addiction to treat successfully. Clearly,
perseverance on the part of the patient and
the physician is most effective for achieving
permanent abstinence. The use of nicotinereplacement and bupropion can improve
results, and the application of readiness-to-
Silver acetate, which causes cigarettes to have
change strategies and motivational interview-
a bad taste, has been used as a smoking ces-
ing techniques are essential for success.
sation aid for many years. The literature con-
Behavioral therapy and support in a group
tains no support for this agent as an effective
rates. Individual counseling can also be effec-
tive. A supportive telephone call during the
azepines have been used to reduce the anxiety
first few days of abstinence may help the
associated with nicotine withdrawal. However,
patient who is trying to quit smoking.26,27
treatment with benzodiazepines has not beenshown to improve smoking cessation rates.
The author indicates that he does not have any con-
Clonidine (Catapres) initially appeared to
flicts of interest. Sources of funding: none reported.
be useful in the treatment of nicotine with-drawal,24 but long-term quit rates did not im-
1. State-specific prevalence of cigarette smoking
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