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Over 400,000 individuals die prematurely each year in the United States from cigarette use: one out of every five deaths nationwide. Approximately 40% of smokers will die prematurely unless they are able to quit; major diseases caused by cigarette smoking are listed in Table 204-1.



All pts should be asked whether they smoke, how much they smoke, how long they have smoked, their past experience with quitting, and whether they are currently interested in quitting; even those who are not interested should be encouraged and motivated to quit. Provide a clear, strong, and personalized message that smoking is an important health concern. A quit date should be negotiated within a few weeks of the visit, and a follow-up contact by office staff around the time of the quit date should be provided. Incorporation of cessation assistance into a practice requires a change of the care delivery infrastructure. Simple changes include:

  • Adding questions about smoking and interest in cessation on pt-intake questionnaires

  • Asking pts whether they smoke as part of the initial vital sign measurements made by office staff

  • Listing smoking as a problem in the medical record

  • Automating follow-up contact with the pt on the quit date


  • Clinical practice guidelines suggest a variety of pharmacologic and nonpharmacologic interventions to aid in smoking cessation (Table 204-2).

  • Numerous nicotine-replacement products exist, including over-the-counter nicotine patches, gum, and lozenges, as well as nicotine nasal and oral inhalers available by prescription; these products can be used for 3–6 months with a gradual step-down in dosage with increasing duration of abstinence.

  • Prescription medications that have been shown to be effective include antidepressants such as bupropion (300 mg/d in divided doses for up to 6 months) and varenicline, a partial agonist for the nicotinic acetylcholine receptor (initial dose 0.5 mg daily increasing to 1 mg twice daily at day 8; treatment duration up to 6 months). Antidepressants are more effective in pts with a history of depressive symptoms.

  • Clonidine or nortriptyline may be useful for pts who have failed first-line therapies.

  • Current recommendations are to offer pharmacologic treatment, usually with nicotine replacement ...

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