Smoking
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Smoking has historically been the #1 preventable cause of death in the U.S. Although numbers of total smokers have gone down it disproportionately affects the lower SES and underserved populations. Smoking is usually not at the top of the list for providers or patients given the other chronic and acute complaints that they present with. Because of the significant impact it has on health there are a number of resources available for patients regardless of the clinic they go to for care.
The Arizona Smokers Helpline is a great free resource for patients with quit coaches who are experts on behavior change and the available smoking cessation aids.
KNOW YOUR SMOKING CESSATION AIDS
NICOTINE REPLACEMENT THERAPY (NRT)
Because NRT can be purchased over the counter, both patients and providers think it can be taken without much instruction and because of this it is often taken incorrectly and is ineffective. When prescribing NRT the PATCH(+) method should always be used. The patch comes in 21mg, 14mg and 7mg and is meant to be tapered off over at least 8 weeks. If the patient smokes <1/2 packs per day or is <45kg then start with the 14mg patch, if more than ½ pack a day start the 21mg patch. The patch is applied in a non-hairy body part and the location is changed every 24 hours. For NRT to be effective the patch provides a baseline level of nicotine while the gum or lozenge provide relief during cravings. They are typically dosed at 2mg and 4mg and the higher dose is used when the patient smokes more than 25 cigarettes per day or smokes a cigarette first thing when they wake up.
The gum is absorbed through the buccal mucosa just like chewing tobacco and is meant to be parked in the cheek. The sig should read chew and park and repeat for up to 30 minutes and can be done prn q30 minutes based on cravings.
NRT can be combined with varenicline or bupropion for improved outcomes.
BUPROPION
Bupropion does not have nicotine and works on the dopamine center in order to decrease addiction/cravings. The prescription should start at 150mg daily for 3 days then increased to bid and the patient should be on the bid dosing for 1 week prior to quitting. The course is 12 weeks and up to 6 months and has the benefit of an antidepressant effect for those with comorbid depression. Bupropion can be taken in combination with NRT. Bupropion is on the higher tier on the $4 list.
CHANTIX (Varenicline)
Is a partial agonist at the nicotine receptor and will displace nicotine and block the receptor in order to reduce withdrawal and reward if smoking continues. The medication is started at 0.5mg x3 days then increased to 0.5mg bid for 4 days and at that point is increased to 1mg bid for 12 weeks and is typically prescribed as a starter pack (53 pills) and maintenance packs (56 pills). The patient will start taking varenicline one week prior to their quit date. There is a patient assistance program (PAP) for this medication (see medications tab for PAP instructions)