Frequently Asked Questions

Addressing the 5 A’s:

It seems like a bother to ask smokers every visit when they aren’t interested in quitting. Why should I do that?

Tobacco dependence is a chronic disease that requires repeated intervention. According to epidemiologic data, of the 45 million smokers in the US, 70 percent want to quit. Further, about 44 percent say they try to quit every year. However, few of those who attempt to quit without evidence-based assistance are successful. For most patients, repeated evidence-based interventions are needed. Adding counseling and medications to a quit attempt increases the chance for success by 4 to 7 times. return to top

I am frustrated because patients do not want to quit. What can I do?

If someone is unwilling to quit, the use of motivational treatments can increase effectiveness for future visits. Individualized motivational techniques including motivational interviewing appear to be effective in increasing a patient’s likelihood of making a future quit attempt. Evidence shows that physician advice to quit smoking increases abstinence rates. You can make a difference with every smoker. return to top

Other than write a prescription or suggest an over-the-counter medication, what can I do?

Individual, group and telephone counseling are effective. Their efficacy increases with treatment intensity. Two components of counseling found to be especially helpful are:

• Practical counseling (problem solving/skills training)
• Social support delivered as part of treatment

Telephone quitline counseling is effective. Quitlines provide broad reach and demonstrated efficacy in a diverse range of populations and can be an excellent treatment extender for clinicians. Two separate meta-analyses evaluated quitlines as compared with minimal or no counseling, and quitline use with medication. Both show improved abstinence rates. Quitlines are effective and available in all 50 states through the 1-800-QUIT-NOW network. Clinicians and health care delivery systems should ensure patient access to quitlines and promote quitline use. return to top

What resources are available to help patients quit smoking?

The Cease Smoking Today website has a number of tools that can be downloaded and given to patients to assist in their quit attempt. Toolkit section for Healthcare professionals includes information on quitlines, developing a quit plan, tips for quitting and information on obtaining prescription drugs with little or no cost associated. To access these materials you must be a registered user of the website. return to top

Are any of the medications more effective for cessation?

Clinicians should encourage all patients attempting to quit to use evidence-based, effective medications for tobacco dependence except where contraindicated. For special populations including light smokers, smokeless tobacco users, pregnant smokers, and adolescents the evidence does not support the use of medication. 7 first line FDA-approved medications are available for smoking cessation. They are:

• Bupropion SR
• Nicotine gum
• Nicotine inhaler
• Nicotine lozenge
• Nicotine nasal spray
• Nicotine patch
• Varenicline

Certain combinations of medications provide greater efficacy than monotherapy.

• The long-term nicotine patch (14 weeks) plus nicotine gum or spray
• The nicotine patch with bupropion SR

Counseling and medication together increase success. A strong relationship exists between the number of sessions of counseling, medication use, and the likelihood of successful smoking cessation. Clinicians should work with each individual making a quit attempt to help identify and use the most appropriate counseling and medication for that individual. return to top

I generally schedule to see patients back whenever their medical condition warrants. What is ideal follow-up with cessation patients?

For the patient willing to make a quit attempt, arrange for follow-up contacts, beginning within the first week after the quit date. This can be either a telephone or in-person visit. These follow-ups are to check on the quit attempt, ask about any challenges and to confirm medication adherence. return to top

Providing Counseling:

My patient doesn’t want counseling, only medication. What should I do?

Point out that medication plus counseling works better than medication alone. Explain the nature of counseling (or coaching) as providing the practical skills necessary to quit successfully. Use the motivational interventions designed for tobacco users who do not want to quit (see pages to 15 to 16) to motivate your patient to accept counseling. For example, develop discrepancy by noting the inconsistency between not using effective counseling for something that is as important and difficult as quitting tobacco. If the patient still declines counseling, then provide medication because medication alone has been shown effective. But during follow-up continue to provide the key elements of counseling: exposure to practical skills and support. return to top

My patient wants to use a method of quitting not known to be effective such as acupuncture, hypnosis, or laser therapy. What should I do?

Ask the patient to consider increasing the odds that efforts to quit will be successful by augmenting the selected method of quitting with appropriate medication and counseling. Do not denigrate any attempt to quit, as there is something to be learned from every effort. If the patient declines to augment the selected method of treatment, support the effort to quit, but ask for an agreement that should it not work the patient will consider methods that include medication and counseling. return to top

My patient is concerned about gaining weight. What should I recommend?

Steer toward bupropion, gum, or and/or lozenge as these can help delay, but do not prevent, weight gain. Recommend patient start or increase physical activity. For example, taking a walk at break time rather than smoke; walk at lunch. return to top

My patient is concerned about using NRT because they believe nicotine to be one of the harmful ingredients in tobacco products.

Explain that nicotine by itself is minimally harmful. The other thousands of chemicals, including 40 carcinogens, in cigarettes are what are harming their health. Nicotine in small doses has been proven to greatly reduce withdrawal symptoms in many people. return to top

My patient does not want to use medication because:

• Afraid the medication is addictive
• Don’t believe medication will help
• The patient has recovered from another dependency and believes recovery is not possible if a medication that contains nicotine is used

Point out:

• The medication is not like smoking and developing a dependency on the medication is rare
• The probability of successful quitting is much higher when medication is used
• Substance abuse counselors routinely use medication to help people quit; the goal remains not using any nicotine and the use of nicotine-containing medication is a transition step toward that goal that makes its achievement more likely
• Consider a medication that does not contain nicotine  return to top

My patient says their life is too stressful to quit smoking, and he needs to smoke to relax.

Acknowledge that for many people smoking is one way to deal with stress. But it is only one way. And counseling will help him develop new ways. It will take some time and at first the new ways will not be as good as smoking, but over time he will have even better, more effective ways to deal with stress. And his health will be so much better. return to top

My patient says he has been smoking for (20, 30, etc) years without any health problem, plus his grandfather smoked two packs a day and lived to be 105.

Consider saying something like, “There are certainly people who smoke for many years without apparent tobacco-related diseases. But about half of those who smoke will die from a tobacco-related illness, and the average smoker lives 10 years shorter than nonsmokers. I know it is hard to quit, but is that any reason to play gamble with your health when you know that there is a 50% chance you will die from a tobacco related disease?” return to top

Providing Medication:

Are there contraindications, warnings, precautions, other concerns, and side effects regarding the first-line medications recommended in the guideline update?

All seven FDA-approved medications have specific contraindications, warnings, precautions, other concerns, and side effects. Please refer to FDA package inserts for this complete information and FDA updates.  return to top

What other factors may influence medication selection?

Pragmatic factors may also influence selection such as insurance coverage or out-of-pocket patient costs, likelihood of adherence, dentures when considering the gum, or dermatitis when considering the patch. return to top

Is a patient’s prior experience with a medication relevant?

Prior successful experience (sustained abstinence with the medication) suggests that the medication may be helpful to the patient in a subsequent quit attempt, especially if the patient found the medication to be tolerable and/or easy to use. However, it is difficult to draw firm conclusions from prior failure with a medication. Some evidence suggests that retreating relapsed smokers with the same medication produces small or no benefit while other evidence suggests that it may be of substantial benefit. return to top

What medications should a clinician use with a patient who is highly nicotine dependent?

The higher dose preparations of nicotine gum, patch, and lozenge have been shown to be effective in highly dependent smokers. Also, there is evidence that combination NRT therapy may be particularly effective in suppressing tobacco withdrawal symptoms. Thus, it may be that NRT combinations are especially helpful to highly dependent smokers or those with a history of severe withdrawal. return to top

Is gender a consideration in selecting a medication?

There is evidence that NRT can be effective with both sexes; however, evidence is mixed as to whether NRT is less effective in women than men. This may encourage the clinician to consider use of another type of medication with women, such as bupropion SR or varenicline. return to top

When should second-line agents be used for treating tobacco dependence?

Consider prescribing second-line agents (clonidine and nortriptyline) for patients unable to use first-line medications because of contraindications or for patients for whom the group of first-line medications has not been helpful. Assess patients for the specific contraindications, precautions, other concerns, and side effects of the second-line agents. Please refer to FDA package inserts for this information. return to top

Which medications should be considered with patients particularly concerned about weight gain?

Data show that bupropion SR and nicotine replacement therapies, in particular 4 mg nicotine gum and 4 mg nicotine lozenge, delay, but do not prevent, weight gain. return to top

Are there medications that should be especially considered in patients with a past history of depression?

Bupropion SR and nortriptyline appear to be effective with this population, but nicotine replacement medications also appear to help individuals with a past history of depression. return to top

Should nicotine replacement therapies be avoided in patients with a history of cardiovascular disease?

No. The nicotine patch in particular has been demonstrated as safe for cardiovascular patients. return to top

May tobacco dependence medications be used long-term (e.g. up to six months)?

Yes. This approach may be helpful with smokers who report persistent withdrawal symptoms during the course of medications, who have relapsed in the past after stopping medication, or who desire long-term therapy. A minority of individuals who successfully quit smoking use ad libitum NRT medications (gum, nasal spray, inhaler) long-term. The use of these medications for up to six months does not present a known health risk and developing dependence on medications is uncommon. Additionally, the FDA has approved the use of bupropion SR, varenicline, and some NRT medications for six-month use. return to top

Is medication adherence important?

Yes. Patients frequently do not use cessation medications as recommended (e.g., they don’t use them at recommended doses or for recommended durations) and this may reduce their effectiveness. return to top

My patient can’t afford medications and doesn’t have insurance or insurance doesn’t cover it. What can I do?

• Instruct the patient to set aside all the money they would have spent on tobacco once they quit. After initial use of medication they will be able to afford medication going forward.
• Many clinics that serve people with no health insurance will provide treatment for tobacco dependence, including medication. Check for ones in your area and have them available for staff and patients as a referral source.
• As a clinician, you can call the tobacco quitline and ask about any sources of free or reduced-cost medication for your patients. 1.800.QUIT.NOW works nationwide and seamlessly routes you to the quitline in the state you are calling from.
• If your patient qualifies for Medicaid or Medicare, these programs cover some tobacco dependence treatment medications. Get this information for your state and have available for staff and patients.
• Most pharmaceutical companies have programs to provide medications to those who cannot afford them.