Tobacco Treatment Service

Physicians and other health care providers are in an excellent position to influence tobacco user's desire to quit as well as their ability to succeed.

Referral Sources

· National Quitline 1-800-QUIT-NOW (1-800-784-8669)

· Referral to a formal smoking cessation program is appropriate for all smokers, but especially for those who have a high level of  nicotine dependence (e.g., smoke > 1 pack per day, smoke within 30 minutes of awakening or have had severe nicotine withdrawal symptoms on prior quit attempts), psychiatric comorbidity, other substance abuse, little social support for nonsmoking, or low level of confidence in their ability to quit. The Mass General TTS offers a group counseling program and nicotine replacement therapy at low cost for those smokers who are participating in the program.

·
Similar services are provided by Massachusetts General Hospital Community Health Associates at other locations in Boston and surrounding areas. Smokers with significant psychiatric comorbidity should have treatment for that problem begun simultaneously with referral to a smoking cessation program.

· In 2008, the U.S. Public Health Service released a set of evidence-based guidelines, Treating Tobacco Use and Dependence. The purpose of these guidelines is to help clinicians understand tobacco dependence and to provide appropriate treatment for all tobacco users.

Tobacco Use and Dependence: Quick Reference Guide for Clinicians
Summarizes the key strategies from the guidelines. The full text of the guidelines is also available online at the Virtual Office of the Surgeon General.

A Guide for Hospital Patients Who Smoke
Summarizes medications available for patients while in the hospital as well as resources within the community.

List of online materials that provide useful information and tips about quitting


Drug Therapy

Drug therapy is appropriate for all smokers except those with a medical contraindication.
The U.S. FDA has approved seven products as first-line cessation aids

(1) Nicotine Patch: easiest to use. Best compliance.  Dose: 21mg for smokers using 10 or more cigarettes per day (CPD);14mg for smokers using less than 10cpd. Consider combination of long-acting (i.e.patch) with short-acting (i.e. gum/lozenges/inhaler) with smokers >1/2ppd. Consider high dose patch for smokers>1-2ppd (i.e. 42mg or 2 x 21mg patches).

(2) Nicotine lozenges: 2 or 4mg prn up to 16/day. They also come in a “mini” version (same dosages) which are preferred by many smokers.

(3) Nicotine gum: 2 or 4mg prn up to 16 pieces/day. They come in various flavors.

(4) Nicotine Inhaler: 10mg cartridges. Available by prescription only

(5) Nicotine spray: Available by prescription only. Generally has more complaints of local side effects (irritation of nose + throat from spray).

(6) Bupropion SR: The dose is 150mg for three days, then 150mg BID x 12 weeks. Should be started approx. 1 week prior to quit date. Combination with NRT is considered safe and clinically useful.

(7) Varenicline (Chantix): A partial agonist of the a4B2 receptor, is also FDA-approved for smoking cessation. It is recommended to avoid nausea to begin with 0.5mg qd Day 1-3, then 0.5mg BID Day 4-7, then 1mg BID. Treatment is 12 weeks. For those who are smoke free at end of treatment may benefit from an additional 12 weeks. Patients quit between day 7 and 28.

(8) Nortriptyline and clonidine are two second-line therapies that may be considered if nicotine replacement therapy, bupropion SR, or varenicline are ineffective or medically contraindicated. These treatments, however, are not FDA-approved for smoking cessation and have more side effects than the other treatments.