LMCC/Smoking Cessation

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Epidemiology[edit | edit source]

  • single most preventable cause of illness and death
  • 70% of smokers will see a physician every year
  • of those aged 15 or older:
    • 22% are current smokers
    • average 16 cigarettes /day
    • highest prevalence between 20-24
    • higher in teen girls than teen boys
    • more individuals are quitting than in past

Management[edit | edit source]

General approach[edit | edit source]

  • identify users, elicit their smoking habits and establish the results of prior quit attempts
  • every smoker should be offered treatment
  • Highest yield technique is to host >4 counselling session of > 10 minutes in length over a 12 month period
    • 14% will remain abstinent with counselling vs. 10%

Willing To Quit?[edit | edit source]

The 5 A's for patients willing to quit[edit | edit source]

Ask if patient smokes

Advise patient to quit

Assess willingness to quit

Assist in quit attempt

Arrange follow-up

Use a STAR to assist patients in developing a quit plan[edit | edit source]

Set quit date

Tell family and friends

Anticipate challenges

Remove tobacco products

  • if a patient is pregnant advise them to quit without using pharmacotherapy

Nicotine Replacement Therapies (NRT)[edit | edit source]

  • 20% abstinence @ 12 months
  • Form of NRT is irrelevant to abstinence rates
  • Contraindications: recent MI, serious or worsening angina, serious arrhythmia
Type Dosage Comment Side Effects
Nicotine gum 2mg if < 25 cig/day

4mg if > 25 cig/day 1 piece q1-2h for 1-3 months, maximum 24 pieces/day

Chew until "peppery" taste, then place between gum and cheek to maximize absorption, continuing for 30 minutes Usually transient:

mouth soreness hiccups dyspepsia jaw ache

Nicotine Patch Use for 8 weeks

21 mg/d x 4 weeks 14mg/d x 2 weeks 7mg /d x 2 weeks

Start with lower dose if <10cigs/day

Change to patch q24h and rotate sides

skin irritation


Nicotine Inhaler 6-16 cartridges per day for 3 months with gradual tapering afterward Cough

irritation rhinitis

Nicotine Nasal Spray 1-2 sprays/hour

Do not exceed 10 sprays per hour Do not exceed 80 sprays per day

Higher rate of dependence irritation


Buproprion (Zyban)[edit | edit source]

  • 21% abstinence @ 12 months
  • inhibits dopamine and norepinephrine reuptake
  • patient is to smoke for first 2 weeks of treatment and then completely stop
  • can be used with nicotine replacement therapy
  • Contraindications: seizure disorder, eating disorder, MAOI use in past 15 days, use of Wellbutrin (an alternative labelling of buproprion marketed for depression)
  • side effects: insomnia, dry mouth

Unwilling To Quit?[edit | edit source]

The 5 R's for patients unwilling to quit[edit | edit source]

Relevance to patient Risks of smoking Rewards of quitting Roadblocks to quitting Repetition of motivational intervention at each visit

Risks of smoking[edit | edit source]

Short term:

  • shortness of breath
  • asthma exacerbation
  • impotence
  • infertility
  • pregnancy complications

Long term:

  • increased risk of heart attack and stroke
  • chronic obstructive pulmonary disease (COPD)
  • lung cancer/other cancer


  • higher cancer risks in spouse and children
  • increase in sudden infant death syndrome
  • asthma/respiratory infections in housemates

Benefits of smoking cessation[edit | edit source]

  • improved health
  • improved finances
  • improved taste and smell
  • sets a good example for children

Obstacles to smoking cessation[edit | edit source]

  • fear of withdrawl
  • weight gain
  • fear of failure
  • lack of support

Repetition[edit | edit source]

  • reassure an unsuccessful patient that most people have multiple attempts before succeeding.

Recent quitter?[edit | edit source]

  • the highest rate of relapse is within the first 3 months, therefore prevention at this time is imperative!
    • minimal practice: congratulate on success and encourage ongoing abstinence, reviewing the benefits of quitting and any unforeseen problems
    • prescriptive interventions can be used to address problems of weight gain, negative mood, withdrawal and lack of support.

References[edit | edit source]

Toronto Notes 2005