1 Kaiser Permanente Colorado Region: Guideline for Tobacco Reduction Date: July 2011 (Next review: July 2013) Approving body: Tobacco Reduction and Quality (TRAQ) Steering Committee These guidelines are informational only and are not intended or designed to substitute for the reasonable exercise of independent clinical judgment by providers in any particular set of circumstances for each patient encounter. The guidelines are flexible and are intended to be used as a resource for integration with sound exercise of clinical judgment. They can be used to create an approach to care that is unique to the needs of each individual patient. The implementation of this guideline is not intended to conflict with any agreed upon health plan benefits nor is it intended to prevent access to care that the practitioner believes is warranted based on clinical judgment. Contents: Page Guideline Page Sources of Evidence Page 8 Brief Stop Smoking Advice and Assistance (one-page), Appendix 1 Page 9 Flowsheet for Providers, Appendix 2 Page 10 Flowsheet for Support Staff, Appendix 3 Page 11 Flowsheet for Pediatrics, birth -11 years, Appendix 4 Page 12 Flowsheet for Pediatrics, 12 -18 years, Appendix 4 page 2 Page 13 CQL Fax Referral Job Aid (Health Connect—Letter section), Appendix 5 Page 16 Pediatrics CQL Fax Referral Job Aid (Health Connect), Appendix 6 Page 17 HealthConnect Smart RX for NRT, Appendix 7, screen shot Page 18 Appendix 8, Tobacco Medication chart Page 19 Appendix 9, Tobacco cessation for special populations page Page 20 Appendix 9, Tobacco cessation for special populations page 2 Rationale for the guideline: Tobacco use is the leading preventable cause of mortality with over 443,000 deaths per year in the United States (1). It is estimated that smoking is directly responsible for 7.5% of all health care costs (3) In Colorado, approximately 17.3 percent of adults smoke cigarettes (17). The health benefits of tobacco cessation are substantial and well documented. Most tobacco users are interested in quitting (4). Brief, systematic tobacco interventions by medical staff more than double long-term quit rates over usual care (5-8) (Strength of evidence: United States Preventive Services Task Force Rating 1: Evidence obtained from at least one properly designed randomized controlled trial). Tobacco cessation interventions by medical staff are extremely cost-effective or even cost-saving: the cost per year of life saved for brief tobacco cessation counseling ($700-$2,000) is less than virtually any other medical service that has been evaluated, such as treatment of hypertension ($11,666) and bypass surgery ($28,000-75,000) (12-14).
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Kaiser Permanente Colorado Region: Guideline for Tobacco Reduction Date: July 2011 (Next review: July 2013) Approving body: Tobacco Reduction and Quality (TRAQ) Steering Committee These guidelines are informational only and are not intended or designed to substitute for the reasonable exercise of independent clinical judgment by providers in any particular set of circumstances for each patient encounter. The guidelines are flexible and are intended to be used as a resource for integration with sound exercise of clinical judgment. They can be used to create an approach to care that is unique to the needs of each individual patient. The implementation of this guideline is not intended to conflict with any agreed upon health plan benefits nor is it intended to prevent access to care that the practitioner believes is warranted based on clinical judgment.
Page 19 Appendix 9, Tobacco cessation for special populations page
Page 20 Appendix 9, Tobacco cessation for special populations page 2
Rationale for the guideline: Tobacco use is the leading preventable cause of mortality with over 443,000 deaths per year in the United States (1). It is estimated that smoking is directly responsible for 7.5% of all health care costs (3) In Colorado, approximately 17.3 percent of adults smoke cigarettes (17). The health benefits of tobacco cessation are substantial and well documented. Most tobacco users are interested in quitting (4). Brief, systematic tobacco interventions by medical staff more than double long-term quit rates over usual care (5-8) (Strength of evidence: United States Preventive Services Task Force Rating 1: Evidence obtained from at least one properly designed randomized controlled trial). Tobacco cessation interventions by medical staff are extremely cost-effective or even cost-saving: the cost per year of life saved for brief tobacco cessation counseling ($700-$2,000) is less than virtually any other medical service that has been evaluated, such as treatment of hypertension ($11,666) and bypass surgery ($28,000-75,000) (12-14).
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Target population: Adults and children age 12 and older for tobacco use assessment and intervention.
All ages for Environmental Tobacco Smoke exposure (ETS).
Guideline: This guideline outlines a 5-step evidence-based approach to reducing tobacco use:
1. Ask: Systematically identify all tobacco users at every visit.
2. Advise: Strongly urge all tobacco users to quit.
3. Assess: Determine willingness to make a quit attempt.
4. Assist: Aid the patient with behavioral support and pharmacotherapy.
5. Arrange: Schedule follow-up contact.
Guideline for tobacco reduction
1. Ask: Systematically identify tobacco users at every visit Multiple randomized clinical studies have shown that systematically identifying tobacco users significantly increases clinician interventions with their patients who smoke (18).
a. At EVERY visit ask EVERY patient 12 and older whether he or she uses tobacco.
b. At EVERY visit ask EVERY patient if he or she is exposed to second-hand smoke.
c. Circle “tobacco prompt” on the Patient Visit Record of every tobacco user.
d. Document tobacco use and second-hand smoke exposure in KP HealthConnect.
Note: Tobacco use and exposure to second-hand smoke should be documented by support staff during the “rooming-in” process or by providers during the visit.
Document tobacco use and second-hand smoke exposure on the vitals tab
If tobacco use information is present and correct, click “Mark as Reviewed”
If information is missing or incorrect, click “Edit” and enter correct information on the next screen
Click “Yes” or “No” to the questions: Ready to Quit (in the next 30 days), and Counseling given. Counseling defined as: 1) Quitline referral offered and/or 2) saying “Quitting tobacco is the most important thing you can do for your health” and/or 3) recommending a tobacco cessation class or webinar
Code for nicotine dependence on the problem list in HealthConnect (health educators, registered nurses and tobacco coaches may code nicotine dependence or any tobacco use code on the problem list)
If in a telephone encounter, document tobacco use and second-hand smoke exposure: Click on History, select Substance and Sexuality, then fill in tobacco status box, answer Ready to Quit and Counseling given as appropriate, click “Mark as Reviewed”.
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2. Advise: Strongly urge all tobacco users to quit Multiple randomized clinical studies show that physician advice to quit smoking increases abstinence rates (18). Some studies further suggest that patients who smoke are more satisfied with primary care physicians who offer advice to quit (19, 20). Therefore:
a. Offer clear, strong, personalized advice to quit.
Clear – “I think it is important for you to quit using tobacco now and I can help you.” “Cutting down while you are ill is not enough.”
Strong – “As your clinician, I need you to know that quitting tobacco is the most important thing you can do to protect your health now and in the future. Our health education staff and I can help you.”
Personalized – Tie tobacco use to current health/illness (i.e., tobacco use within 2 years increases cardiovascular risk), and/or its social and economic costs, motivation level/readiness to quit and/or the impact of tobacco use on children and others in the household.
b. Document advice to quit in the patient’s medical record.
Advice to quit may be documented using any of the following dot phrases.
.tob second hand smoke
.tob advice
.tob brief advice
Dot phrases may also be placed in patient instructions, printed and given to the patient.
3. Assess: Ask if tobacco user is willing to quit in next 30 days Half of all smokers try to quit each year (18). Asking tobacco users if they are ready to quit communicates seriousness about the risks of tobacco use and permits clinicians to offer assistance to their patients who are ready to quit.
a. Ask if tobacco user is willing to quit in next 30 days.
b. For those who say “yes”: Offer assistance in quitting (Step 4a, below)
For those who say “No”: Offer empathy and motivation. (Step 4b, below)
4. Assist: Offer behavioral support and tobacco cessation medication Multiple well-designed randomized clinical studies have shown that (18):
Even minimal interventions (less than 3 minutes) increase overall abstinence rates.
Telephone coaching, group coaching and individual coaching formats are all effective and should be used in tobacco cessation interventions
There is a strong dose-response relation between the session length of person-to-person contact and successful outcomes. Intensive options should be used whenever possible.
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Patients attempting to quit should be encouraged to use effective pharmacotherapies along with behavioral coaching except in the presence of special circumstances.
a. Encourage patient to take advantage of stop-tobacco assistance.
Medication, plus coaching, can triple a smoker’s chances of staying quit.
Phone coaching is free and available days, evenings and weekends.
Provider-ordered NRT and prescription medication are available at copay (enrollment in a class, webinar or telephone program is encouraged). RN’s may order OTC NRT patches, gum or lozenges, see the Nicotine Smart RX in HealthConnect for more detailed information, Type “NRT” or “Nicotine” in Orders section and see appendices in this document.
All classes and webinars are free to members.
b. Refer the smoker to Health Education or the Colorado Quit Line:
Print a KP HealthConnect patient instruction in an AVS (all begin “.tob”, see below) ; or
Circle the phone number listed on the PVR tobacco prompt; or
Enter a referral to the Colorado Quitline (Order entry: Ref Tob), fill in required information and sign (A coach will call your patient); or
Give patient a stop smoking handout (see below for standard stock numbers);
“Ready to Quit: We Can Help: SS# 0023-4900
“Second Hand Smoke and Your Child:” SS# 0005-3044
“Smoking and Diabetes:” SS# 0025-2532
“Pregnancy and Smoking:” SS# 0005-3464
“What’s the Real Deal? Information for teens about tobacco”: SS# 0029-5483
Letter template TOBFORMCQLPEDS (for parents) (20942) a fax requesting an outreach call from a QuitLine coach. Must be signed by parent/tobacco user, then faxed to the Quitline. This fax is used when there is no permission to go into the parents’ chart directly.
.tob meds: stop smoking or chewing medications
.tob teens: teen prevention and quitting resources
.tob relapse prevent: suggestions on how to stay quit
.tob second hand smoke: suggestions on second hand smoke exposure
Patient instructions (PI’s): type Tob in the “Match” field, then hit enter for a list of available PI’s (Smoking cessation PI National has a Spanish version)
c. Review the basics of making a “quit plan” (time permitting)
Set a quit date—ideally within 2 weeks.
Tell family friends and co-workers that you are quitting—request their understanding and support.
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Remove tobacco products from home, car and workplace.
Review previous quit attempts—what helped, what led to relapse.
Warn that drinking alcohol often leads to relapse.
4b. Assist: Enhance motivation of smokers not ready to quit. Motivation interventions are most likely to be successful when the clinician is empathetic, promotes patient autonomy, (e.g., offers choices) avoids arguments, and supports the patient’s self-efficacy (e.g. by identifies previous successes in behavior change efforts) (18) Key topics for motivational discussions are:
Relevance: Encourage the patient to discuss why he or she might want to quit in the future. Be as specific as possible. Question: “When you have thought about quitting, what made you want to make that change?”
Risks: Encourage the patient to identify potential risks of tobacco use. Highlight those that seem most relevant to the patient. Question: “What worries you most about continuing to smoke?”
Rewards: Encourage the patient to identify potential benefits of stopping tobacco use. Question: “How would your life be better if you succeeded in quitting smoking?”
Roadblocks Ask the patient to identify barriers to quitting and note possible ways to overcome them (problem-solving, pharmacotherapy). Question: “What are some things that have made it hard for you to quit smoking?”
Repetition: Repeat this discussion every time an unmotivated patient visits.
Other key messages
Coaching and medication can really help.
It’s never too late to quit.
Although it often takes more than one attempt, most smokers do succeed in quitting.
Classes and medications are free or low-cost.
We’re here to help when you’re ready.
5. Arrange: Schedule follow-up. In some ways tobacco use resembles a chronic disease as well as an addiction. Most tobacco users cycle through multiple periods of relapse and remission. Smokers who have quit within the past few months are particularly vulnerable to relapse. Follow-up contact can help them stay quit. Motivated health care teams may wish to:
a. Schedule a follow-up phone call within 2 weeks of the planned quit date.
b. During the call congratulate success and offer encouragement and support.
c. If the patient is struggling or has relapsed, urge him/her to make another quit attempt and to contact health education for additional support.
d. If the patient is seen within 12 months of quitting, consider using the dot phrase “.Tob relapse prevent” to encourage continued cessation.
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Source of Evidence: Parts of the following references were used only as guidance in the development of these materials. Their inclusion does not imply individuals using this guideline have complete knowledge of the reference in its entirety. Main sources of evidence for the guideline I. US Department of Health and Human Services Clinical Practice Guideline: “Treating Tobacco
Use and Dependence.” May 2008. II. Agency for Health Care Policy and Research Clinical Practice Guideline April 1996. III. Trends in Tobacco Use, American Lung Association, Research and Program Services, July 2008 References for the rationale are as follows: 1. U.S. Department of Health and Human Services. How Tobacco Smoke Causes Disease: The Biology
and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2010..
2. Office on Smoking and Health / National Center for Chronic Disease. Prevention and Health Promotion -CDC- Tobacco Use in Colorado Statistics.
3. Medical-care expenditures attributable to cigarette smoking- United States; 1993. MMWR Morb Mortal Wkly. Rep 1994; 43:469-472.
4. Hollis JF, Whitlock E. Vogt TM. How well are we serving our members who smoke? Center for Health Research., Kaiser Permanente Northwest Region, 1995 (internal publication).
5. Kottke TE. Battissta RN, DeFriece GH, Brekke ML. Attribution of successful smoking cessation intervention in medical practice: A meta-analysis of 39 controlled trials. JAMA 1988: 259:2883- 2889.
6. Hollis JA, Lichtenstein E. Vogt TM, et al. Nurse-assisted counseling for smokers in primary care. Ann Int. Med. 1993; 118: 521-525.
7. Burns DM, Gritz ER (Eds). Tobacco and the clinician: intervention for medical and dental practice (Monograph 5) NCL, NIH Publication No. 94-3693, 1994.
8. Okene JK. Physician delivery interventions for smoking cessation: strategies for increasing effectiveness. Prev Med 1987; 16:723-737.
9. Physician and other health care professional counseling for smokers to quit- United States, 1991 MMWR Morbid Mortal Wkly. Rep 1993; 42:854-857.
10. Anda RF, Remington PL, Sienko DG, et al. Are physicians advising smokers to quit? The patient’s perspective. JAMA 1987:257:1916-1919.
11. A survey concerning cigarette smoking, health check-ups and cancer detection tests: A summary of the findings. Conducted by the Gallup Organization. NY; Am Cancer Soc., 1977.
12. Fuhrmans,Vanessa. Case grows to cover quitting. Wall Street Journal, 2005: April 26. 13. Edelson, JT. Weinstein MC, Tosteson AN, et al. Long term cost effectiveness of various initial
monotherapies for mild to moderate hypertension. JAMA 1990; 19: 407-13. 14. Tengs TO, Adams ME, Pliskin JS, et al. Five-hundred life-saving interventions and their cost-
effectiveness. Risk Anal 1995; 15:369-90. 15. Glassman AH, Helier J. Corey L et al. Smoking, Smoking Cessation and Major Depression.
JAMA 1990: 264: 1564-69. 16. AHCPR (Agency for Health Care Policy and Research) Smoking Cessation Guideline. April 1996. 17. Colorado Tobacco Attitudes and Behaviors Survey. 2008. 18. US Department of Health and Human Services Clinical Practice Guideline: “Treating Tobacco
Use and Dependence.” May 2008. 19. Solberg L, Boyle RG, Davidson G et. al. Patient Satisfaction and Discussion of Smoking
Cessation During Clinical Visits. Mayo Clinic Proceedings. February 2001 76(2); 138-143. 20. Weingarten SR, Stone E, Green A, et. al. A Study of Patient Satisfaction and Adherence to
Preventive Care Practice Guidelines 1995 99(6); 590-96.
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Settings for Application: Health Education and all departments with patient contact. Methods for Measuring Compliance: The monthly Rooming Guidelines Report documents the percentage of visits in which tobacco use has been asked or verified for each Primary Care department in the region. A regional tobacco report is posted monthly on the Primary Care web site. Tobacco report includes data on: Colorado Quit Line referrals and tobacco medication prescriptions are reported monthly by clinic and by individual referrer. An annual survey of health plan members asks smokers whether they have been advised to quit and whether they received information about medications and strategies to help them quit during a medical visit during the past 12 months. Results are included in a HEDIS (Health Employer Data Information Set) measure that is widely reported throughout the organization each year.
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Appendix 1: Brief Stop Smoking or Chewing Advice and Assistance
(KPCO Tobacco Reduction Guideline 2011)
Ask: Identify tobacco users and exposure to tobacco smoke Ask about tobacco use in patients 12 and older.
Ask about second-hand smoke exposure in all patients.
If “Yes” circle information on the PVR (Patient Visit Record) prompt.
Document tobacco use on the “vitals tab” of KP HealthConnect.
If information is correct and current, click “Mark as Reviewed”; or
If information about tobacco use is missing or incorrect, click “Edit”
Select “Yes” or “No” if Ready to quit (in next 30 days), or Counseling given
Advise: Offer clear, strong, personal advice to quit smoking or chewing “I’m concerned about your health.”
“It’s really important that you quit smoking/chewing.”
“Cutting down while you are ill is not enough.”
“We offer free telephone coaching, classes, webinars and covered medications that can triple your chances of quitting for good.”
Assess: Ask if the smoker/chewer is willing to quit in the next 30 days
Assist: If “Yes,” offer medication and counseling Encourage patient to take advantage of tobacco cessation assistance.
Coaching plus medication can triple your chances of quitting for good this time.
Kaiser Permanente (KP) classes and webinars are free to members.
The Colorado Quitline (CQL) is free and offered days, evenings and weekends, and offers 4 weeks free nicotine patches or gum.
NRT is available for a $15 co-pay regardless of members prescription benefit with a prescription order, and formulary prescription medications are available for their generic Rx co-pay (enrollment in a class, webinar or telephone program is encouraged but not required). RN’s may order OTC NRT patches, gum or lozenges, see the Nicotine SmartRx in HealthConnect for more detailed information, Type “tobacco” or “nicotine” in order entry section. See appendix 7 page 1 and 2. From mid 2011 through the end of 2011 KP employees and family may be reimbursed for any costs purchasing NRT patches, gum or lozenges, or payments for prescription formulary medication, Bupropion XL. (See Employee Health and Wellness for more information). Note: For all members beginning 2012 a new benefit will cover NRT lozenges, patches or gum and 2013 will cover Bupropion XL for a zero copay.
Refer the smoker or chewer to Health Education or the Colorado Quit Line:
Give patient a stop smoking handout (see next page for standard stock numbers);
Print a KP HealthConnect tobacco Patient Instruction and give to patient (all begin “.tob”);
Circle the phone number listed on PVR tobacco prompt;
Enter a referral to the Colorado Quitline (Order entry: Ref Tob); (Fill in required information, associate with history of tobacco use and sign. A counselor will call your patient)
Assist: If “No,” offer support and explore motivation (as time allows) Offer support: “When you are ready to quit, please ask me about stop smoking/chewing medication and our free classes webinars and phone coaching. They can triple your chances of quitting for good.
Offer information about stop smoking/chewing help (see handout options, above)
Explore motivation (if time allows): Have you ever thought about quitting? Why or why not? How do you think your life might improve if you quit? Did you know that most smokers eventually quit…after a few attempts?
Appendix 2 Tobacco Reduction Flowsheet for Providers
• Ask: Tobacco use should be documented on
vital signs tab by support staff.
- Code for nicotine dependence on the problem list.
As your doctor I urge you to quit smoking. When you’re ready, we offer free telephone help, classes and covered medications that can triple your chances of quitting and staying quit.
- Document in patient instructions (see dot phrases)
• Congratulate • Add “.tob relapse prevent” to
patient instructions (PI) and print
3. Assess: Are you ready to quit in the next 30 days?
5. Arrange: Set a follow-up visit to monitor progress and or drug therapy
No
Yes
Avoid argument. • Offer help when the patient is ready • Give handout or add “.tob advice”
to PI and print • Explore motivation as time allows
Yes
4. Assist: I’d like you to consider medication and classes or telephone support. They really help. • Free classes and webinars • Free phone help on days, evenings, weekends • Prescriptions for nicotine patch, gum or lozenge • Formulary prescription medication at co-pay
KP HealthConnect “Smart Sets” SmartSet for initiating Bupropion XL (8-week supply) Tobacco cessation Bupropion XL1 SmartSet for initiating Nicotine Replacement (4-week supply) Tobacco cessation Nicotine Replacement SmartSet for initiating Nortriptyline (8-week supply) Tobacco cessation Nortriptyline 1 CO SmartSet for initiating Chantix (Vanenicline) non-formulary Tobacco cessation Varenicline (Chantix)
KP HealthConnect “Dot Phrases” and Letters Advice to Quit .tob advice Brief Advice to Quit .tob brief advice Relapse Prevention .tob relapse prevent Teen Prevention and Cessation .tob teens Tobacco Medications .tob meds Second-hand Smoke .tob second hand smoke Patient Instructions Type “tob” in match section
Yes
Refer for coaching and medication:
Active referral for phone coaching: • Order referral: Ref Tob, fill in required info, associate
with history of tobacco use, sign. CQL will call patient Passive referral to class/webinar or phone coaching • Give tearsheet from standard stock; or • Circle phone number on PVR prompt • Put dot phrase in PI and choose “Print AVS”
Handouts from Standard Stock Ready to Quit: We Can Help: SS# 0023-4900 Second Hand Smoke and Your Child: SS# 0005-3044 Smoking and Diabetes: SS# 0025-2532 Pregnancy and Smoking: SS# 0005-3464 What’s the Real Deal? Info for Teens about tobacco: SS# 0029-5483
3. Assess: Ask, “Do you want to quit in the next 30 days?”
a. Avoid argument. b. Offer Ready to Quit tip sheet: “When you are ready to quit, here are some options.”
Yes
4. Assist: a) Order CQL referral in HealthConnect Go to Orders Entry Type “Ref Tob”, Fill in required information Associate with diagnosis “history of tobacco use” Add PCP’s name Sign (Patient will be called by CQL in 48 hours, advise patient they can call directly if they do not hear from CQL, 1-800-784-8669)
1. Ask: Does the patient currently use tobacco? Document answer on vital signs tab. If info is correct, click “Mark as Reviewed” If info is incorrect, click “Edit Select “Ready to quit”, “Counseling given”
Tobacco Reduction Flowsheet for Support Staff
Yes
2. Advise: Quitting tobacco is the most important thing you can do for your health. (Circle information if listed on PVR)
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KP HealthConnect “Dot Phrases” and Letters Advice to Quit .tob advice Brief Advice to Quit .tob brief advice Tobacco Medications .tob meds Second-hand Smoke .tob second hand smoke Relapse Prevention .tob relapse prevent Teen Prevention and Cessation .tob teens Tobacco status verify .tobverify Patient Instructions Type in “tob” in match section
Handouts from Standard Stock Ready to Quit: We Can Help: SS# 0023-4900 Second Hand Smoke & Your Child: SS# 0005-3044 Smoking and Diabetes: SS# 0025-2532 Pregnancy and Smoking: SS# 0005-3464 What’s the Real Deal? Info for Teens about tobacco: SS# 0029-5483
Population and Prevention Services (Rev. 5-11).
Appendix 4 (1 of 2 pages): Tobacco Reduction Flowsheet for Pediatric Support Staff
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Appendix 4 (2 of 2 pages): Tobacco Reduction Flowsheet for Pediatric Support Staff
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Appendix 5: QuitLine Referral in HealthConnect Job Aid pg. 1
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Appendix 5: QuitLine Referral in HealthConnect Job Aid pg. 2
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Appendix 5: QuitLine Referral in HealthConnect Job Aid pg. 3
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Appendix 6: QuitLine Fax Referral Job Aid for Pediatrics
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Appendix 7: HealthConnect Smart Rx for NRT Screen shot
First Line Therapy: Nicotine Replacement Therapy (NRT) NRT Patch (OTC, RN”s may order)
<0.5 ppd : 7mg/d x 4 wks 0.5-1 ppd: 14mg/d x 4 wks, then 7mg/d x 4 wks 1-1.5 ppd: 21mg/d x 4 wks, then 14mg/d x 4 wks, then 7mg/d x 4 wks >1.5 ppd: 21mg/d+14mg/dx4 wks then 21mg/d x 4 wks, then 14mg/d x 4 wks, then 7mg/d x 4 wks
Precautions: Avoid during pregnancy; use with caution if history of CAD, angina, hypertension, hyperthyroidism, esophagitis, peptic ulcer, hepatic dysfunction Side effects: tachycardia, headache (mild), increased appetite, local skin irritation, insomnia, vivid dreams
1. For nausea or dizziness, use lower strength patch 2. Skin irritation: rest area at least 5 days before using site again. May use OTC hydrocortisone cream for rash 3. Weaning 7mg patch: put patch on later in day and take off earlier in evening so total time with patch is decreased before stopping
NRT Gum (OTC, RN”s may order)
If <24 cigs/day or smoke >30mins after waking use 2mg If >24cigs/day or smoke <30mins after waking use 4mg Can be used as rescue med in comb with other controller med
Precautions: Do not exceed 15 pieces/day; consult physician if pregnant; caution with dentures Side effects: mouth soreness, nausea, hiccups, dyspepsia, jaw ache
1. Instruct pt to chew briefly, park between gum and cheek until loses tingle, chew again and park 2. Do not eat or drink 15 min before or during use 3. If hiccups or throat burning, advise pt to chew few times then park
NRT Lozenge (OTC, RN”s may order)
If <24 cigs/day or smoke >30mins after waking use 2mg >24cigs/day or smoke <30mins after waking use 4mg Can be used as rescue med in comb w/ other controller med
Precautions: Do not exceed 20 lozenges/day; use at least 9 lozenges/day during first 6 weeks to improve quit success; consult physician if pregnant Side effects: insomnia, nausea, hiccups, coughing, heartburn, headache, flatulence
1. Use only 1 lozenge at a time 2. Decrease number lozenges/d to reduce dose, do not switch lozenge dose mid-treatment 3. If hiccups or throat burning, advise patient to limit swallowing until lozenge dissolved
First Line Therapy: Antidepressants Bupropion XL
150 mg XL, one tablet daily for three days, then two tablets daily for 8-16 weeks or 150 mg XL, one tablet daily for 8-16 weeks
Contraindications: hx of seizure disorder or eating disorder; use of MAO inhibitor within prev 14 days Precautions: avoid use during pregnancy; risk of seizures with renal or hepatic impairment Side effects: dry mouth, insomnia Warnings: FDA boxed warning for neuropsychiatric effects when used in smoking cessation
1. Start therapy 1-2 weeks prior to anticipated quit date
Nortriptyline
Initial dose: 25mg HS Gradually increase over 1-2 weeks by 25mg at a time up to 75mg HS Continue for 12 weeks after quit date
Contraindications: Acute recovery period after MI, use of MAO inhibitor within prev 14 days Precautions: avoid use during PG/lactation, narrow-angle glaucoma. Use caution in patients with cardiac conduction disturbances Side effects: dizziness, drowsiness, dry mouth, HA, constipation, nausea, weight gain
1. Start therapy 1-2 weeks prior to anticipated quit date
Second Line Therapy: Varenicline Varenicline (Non-formulary)
Start 0.5mg daily for days 1-3, then 0.5mg BID days 4-7, then 1mg BID Continue for 12 weeks, may continue additional 12 weeks if initial 12 weeks was successful
Precautions: suicidal ideation, suicide, depression, agitation, behavior changes; avoid during PG/lactation; use caution when driving; caution in renal and cardiovascular disease Side effects: nausea, vomiting, insomnia, constipation Warnings: FDA boxed warning for neuropsychiatric effects when used in smoking cessation
1. Start therapy 1 week prior to anticipated quit date 2. Take after eating with full glass of water 3. take 2nd dose late afternoon to prevent insomnia
Appendix 9: Tobacco Cessation for special populations (page 1 of 2)
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Appendix 9: Tobacco Cessation for special populations page 2 of 2
