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Information for Providers * To refer an inpatient click here (only available within the Partners system) or call the MGH TTS directly at 617-726-7443 * To refer an outpatient click here (only available within the Partners system) Physicians and other health care providers are in an excellent position to influence smokers' desire to quit as well as their ability to succeed. In 2000, 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 smokers. Click here to go to Tobacco Use and Dependence: Quick Reference Guide for Clinicians, which 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. Click here to go to A Guide for Hospital Patients Who Smoke, which summarizes medications available for patients while in the hospital as well as resources within the community. Click here for a list of online materials that provide useful information and tips about quitting. In addition, some useful recommendations for providers are listed below: 1. The smoking status of every patient should be assessed, as if a vital sign, at every visit. This information should be displayed prominently in the medical record. Assessment of smoking status can be done efficiently by nonphysician staff who can communicate the information to the physician with a chart note or label. 2. Smoking cessation counseling by a clinician is recommended on a regular basis for all patients who smoke. Because repeated messages over time produce better success, counseling should ideally be done at each patient visit. At a minimum, it should occur once per year (e.g., at a periodic health examination) and at any problem visit for a potentially smoking-related condition. All smokers should receive clear, strongly-worded and personalized advice from physicians and nurses to quit smoking. Pregnant women and parents with children at home should be counseled on the effects of smoking on fetal and child health. Advice to avoid tobacco use should be included in health promotion counseling for all adolescents and young adults, even those who do not use tobacco. 3. Each smoker should be asked whether he/she is willing to attempt cessation. Physicians should attempt to motivate those who are not willing to quit. For smokers who are willing to attempt quitting, physicians should provide specific help including: • Advice to set a quit date within 4 weeks. • Written self-help materials on quitting (e.g., the American Psychiatric Association's "Treatment Works.When you Choose to Stop Smoking," the American Lung Association's "Quit Smoking Action Plan," or the Massachusetts Tobacco Control Program's "Life After Cigarettes." • Consideration of referral to a formal smoking cessation program (see (4) below) or to a free telephone counseling service like the Massachusetts Quitline: 1-800-Try-To-Stop. • Recommendation for therapy with nicotine replacement, Varenicline, or bupropion SR, unless medically contraindicated (see (5) below). • A plan for in-person or telephone follow-up soon after the quit date. 4. 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 MGH TTS offers a group counseling program and nicotine replacement therapy at low cost for those smokers who are participating in the program. Click here for a full description of our services. Contact us if you would like to refer a smoker to our program or click here for our electronic referral form. Similar services are provided by MGH 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. 5. Drug therapy is appropriate for all smokers except those with a medical contraindication. The U.S. FDA has approved seven products as cessation aids; five of these are forms of nicotine replacement therapy (gum, patch, nasal spray, lozenge, and vapor inhaler). Contraindications include myocardial infarction within the past 2 weeks, severe or worsening angina, life-threatening cardiac arrhythmia, and pregnancy. Even in these situations, nicotine replacement may be preferable to continued smoking, if cessation is not otherwise possible. Pharmacotherapy should be used for at least 8 weeks. Patches are generally easier to use than gum. Nicotine nasal spray and nicotine inhaler are available by prescription. They might best be used in combination with the nicotine patch. Pharmacotherapy is effective alone, but cessation rates are higher when it is combined with a formal smoking cessation program and this should be recommended. 6. Bupropion SR (sustained-release) is also FDA-approved for smoking cessation. The dose is 150 mg qd for three days, then 150 BID, starting one week before the quit date and continuing for 8-12 weeks. Combinations of bupropion and nicotine replacement are safe and clinically appropriate, especially in heavily nicotine-addicted smokers. 7. Varenicline (Chantix), a partial agonist of the a4ß2 nicotinic acetylcholine receptor, is also FDA-approved for smoking cessation. The dose is 1 mg BID for a total of 12 weeks, with an initial one-week dose titration to avoid nausea (Day 1-3: 0.5 mg qd; Day 4-7: 0.5 BID; then 1 mg BID) The quit date should be one week after start of treatment. Patients who have stopped smoking at end of treatment benefit from an additional 12 weeks of treatment to maintain long-term abstinence. In two randomized controlled trials, varenicline was more effective than bupropion and than placebo for smoking cessation. Varenicline has not been compared to nicotine replacement. The safety and efficacy of combining varenicline with nicotine replacement or bupropion has not been tested. 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. Click here for a table that summarizes important information about drugs to treat tobacco use, including dosages, side effects, advantages and disadvantages. Click here for a table that summarizes health insurance coverage of drugs used to treat tobacco use. This download requires Adobe Acrobat Reader. If you do not have Adobe Acrobat, click here to download it. |