240SECT|ON‖· WHAT TO DO WITH THE INFORMAT○N Assist the patient in stopping. For those patients who express a sincere desire to stop smoking, the clinician should help them set a specific date for the next attempt. There is evidence that patients who set a "quit date are more likely to make a serious attempt to stop than those who do not(14). This date should be in the near future(generally within 4 weeks), but not immediate, giving the patient the necessary time to prepare to stop. Patients should b encouraged to announce their"quit date "to family, friends, and coworkers Once a patient has selected a specific date to stop, information must be provided so that he or she can prepare for that date. For patients who can read, this is easily accomplished by providing them with a self-help brochure. Effcctive brochures provide the patient with necessary information about smoking cessation(e. g, symptoms and time course of withdrawal,cessation tips, reasons to quit, answers to common questions). A list of print and online patient education materials is provided later in the"Resources-Patient Education Materials"section at the end of this chapter. Patients who cannot read need to acquire this information from other sources, such as audiotapes, video materials, or counseling by a clinician or health educator. Arrange follow-up visits. When patients know that their progress will be reviewed, their chances of successfully stopping improve. This monitoring may include a letter or telephone call from the office staff just before the quit date, reinforcing the decision to stop. Most relapses occur in the first weeks after cessation. A person who comes to the office after being a nonsmoker for 1-2 weeks has a much improved chance of remaining abstinent than those without follow-up (15). For this reason, it is critical that patients be contacted during their first 2 weeks of abstinence to reinforce their decision to stop Nurses or other clinicians as well as the physician may conduct this follow-up in the office or by telephone. It should consist of an assessment of the patient's progress, troubleshooting for any problems encountered or anticipated, and discussion of the effectiveness or side effects of cessation medications Although follow-up visits are critical during the first 2 weeks after cessation, clinic staff should remain in contact with the patient and schedule a formal follow-up visit in 1-2 months. For patients who cannot return for an appointment, contact by telephone or by mail may be helpful. Many patients can benefit from the social support and information offered through quit lines, Internet discussion sites, and local support group sessions offered y the American Cancer Society, the American Lung Association, or local churches or community organizations(see page 250). While onl ma proportion of patients referred to such programs actually participate(16), these programs have the potential for large public health impact. However, for individual patients, clinicians should consider these referrals as augmenting not replacing, a clinician's care
CHAPTER 9. TOBACCO USE 241 Patients may also express interest in techniques such as hypnosis and acupuncture. These have not been proved to be effective through randomized, controlled trials but are probably not harmful. Informed patients who wish to try these techniques should not be discouraged from doin g Pharmacologic Agents Clinicians should consider recommending over-the-counter nicotine replacement therapy or one of several prescription medications that can increase the success rate for quit attempts. Table 9.2 summarizes currentl available pharmacologic adjuvants for smoking cessation. U.S. Food ane Drug Administration(FDA)-approved pharmacotherapies recommended as first-line agents include bupropion, varenicline tartrate, nicotine gum, nicotine inhaler, nicotine nasal spray, nicotine patch, and nicotine lozenges Secondary pharmacotherapy options, not FDA-approved for use in smoking cessation but of proven benefit, include nortriptyline and oral clonidine(17, 18). A nicotine vaccine, which will prevent transfer of nicotine through the blood-brain barrier, is in early development Selection of an appropriate agent depends on patient contraindications, patient preference, cost/coverage issues, and clinician familiarity with the pharmacotherapy. Among over-the-counter options, patches offer simplicity, while lozenges or gum give patients more control over dosing schedules. All forms of nicotine replacement therapy can help patients stop smoking, almost doubling long-term success rates(19), with similar efficacy to prescription medication. The long-term use of nicotine replacement therapies does not pose a known health risk and may be helpful with smokers who report persistent withdrawal symptoms. However, use of any nicotine replacement therapy should be avoided for 1 month following myocardial infarction serious arrhythmia, or unstable angina Clinical trial data suggest that bupropion and varenicline tartrate are effective aids to smoking cessation. Bupropion can be paired safely with nicotine replacement therapy, although blood pressure may need more careful monitoring. Even when used alone, bupropion use leads to quit rates about double those achieved with the nicotine patch. The effects of bupropion go beyond antidepressant activity, but its mechanism of action in smoking cessation remains unknown. Additionally, the FDA has approved the use of bupropion sustained release for long-term maintenance. The more recently approved varenicline tartrate appears to be even more effective than ropE on Nortriptyline and clonidine have smoking cessation efficacy, and while these may produce a number of unpleasant side effects, they should be considered when FDA-approved medications are not available to patients due to cost issues