Step 3 Assist Smokers Willing to Quit Within the Next 30 Days

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1. Discuss a quit plan with patients. The patient should:

a. Set a quit date (ideally, within 2 weeks).

b. Tell family, friends, and coworkers about quitting and request support.

c. Anticipate what to do to meet challenges that occur, such as withdrawal symptoms and conditioned cravings.

d. Remove tobacco products from their environment prior to quitting.

2. Provide practical counseling and problem solving.

a. Total abstinence is essential. "Not a single puff past the quit date."

b. Find other ways to accomplish the positive things that smoking does for the patient, such as provide relief from stress and boredom, keep weight down, aid in socializing with friends who smoke, etc.

c. Review past quit attempts to identify what helped during the quit attempt and what lead to relapse.

d. Based on past experience and the patient's self-knowledge, discuss challenges to staying smoke-free and how the patient will overcome them. Discuss specific issues such as using alcohol without smoking or quitting while other smokers are in the house.

3. Provide support for patient.

a. Encourage patient to use clinic staff for advice and assistance during the quit period, particularly during the first week after quitting smoking. A daily phone call or brief clinic visit during the first several days (the withdrawal period) can be particularly helpful to the patient.

b. Encourage patient to obtain support from family and friends.

4. Recommend use of approved pharmacotherapy to reduce symptoms of withdrawal and increase smoking cessation success, except when con-traindicated by the patient's medical condition. There are five first-line approved medications:

a. Bupropion SR (Zyban). 150 mg QD for 3 days, then 150 mg BID for 4 weeks up to 6 months. Contraindications: history of seizures, history of eating disorder.

b. Nicotine replacement therapy in the form of the patch, gum, nasal spray, or inhaler. Generally used for 3-6 months. Initiate dose of nicotine replacement therapy at approximately the level of the smoker's current daily nicotine consumption. Note that nicotine replacement, in particular the nicotine patch, is safe and has not been shown to cause adverse cardiovascular effects (58). Second-line pharmacotherapy (clonidine or nortriptyline) may be used if firstline therapies are contraindicated.

5. Recommend use of behavioral techniques to deal with stress, withdrawal symptoms, and conditioned cravings for cigarets.

a. Use deep breathing and relaxation to make withdrawal symptoms easier and eliminate conditioned cravings.

b. During withdrawal, also have patient distract himself or herself with other activities when feeling uncomfortable.

c. Confront specific conditioned cravings by having the patient deliberately place himself or herself in the situation that evokes a craving, and then breathe deeply and relax to make the craving go away. Repeat until the situation no longer evokes a craving. Generally, this should be done after the 3-day withdrawal from nicotine, d. Recommend using a nonsmoking break for stress management. This is designed to mimic the behavioral stress management components of taking a smoke break, but without a cigaret. There are three steps: (1) get away from the stressor, (2) distract oneself with a minor activity, and (3) take several deep breaths to relax.

6. Provide supplementary information and brochures that are culturally, racially, and age appropriate for the patient.

Unless a patient has had a good experience in the past quitting with nicotine replacement therapy or is not able to tolerate Zyban, we generally do not recommend nicotine replacement in our clinic and suggest that the patient's quit day be the day they begin their 3-day withdrawal from nicotine. This allows the patient to deal with withdrawal upfront during a well-defined period that includes daily clinical contact by telephone or in person and pharmacotherapy assistance from Zyban. It is our experience that patients on nicotine replacement therapy are at increased risk of resuming smoking when they finally quit nicotine replacement, and go through withdrawal several weeks or months after their quit day.

Although Zyban is generally recommended for approximately 3 to 4 months following smoking cessation, when medication costs are a consideration we have found that patients find it helpful in reducing withdrawal symptoms when they use it for as little as 2 to 4 weeks (starting about 4 days prior to the quit day). Close contact with the patient during the first several days after quitting smoking is essential, and we recommend a daily phone call to an identified clinic staff person to report on difficulties and obtain support.

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