الدليل السعودي للتبغ

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اللجنه الوطنيه لمكافحه التبغ
National Committee for Tobacco Control

Saudi Guideline For Tobacco

Statement of the Secretary General

Tobacco Control, reduction of smoking prevalence and smoking cessation are one of the most important health programs. Due to the high risk of smoking on the individual and the community, tobacco control has been considered as one of the priorities of the Ministry of Health regarding the preventive and therapeutic measurements. The MOH represented by the National Committee for Tobacco Control has developed this version of the Saudi Guideline to improve the smoking cessation services. It was built on updated evidence based guidelines and reviewed by a scientific committee of different specialists of multiple medical fields from inside and outside MOH.
The upgrading of the Saudi Guidelines for Tobacco Cessation Services is matched with principles of the agreement of WHO Frame Work Convention of Tobacco Control (FCTC) which has been signed by Saudi Arabia on 2/3/1425 H. This agreement is insisting for offering a demand reduction measures concerning tobacco dependence and cessation (Article 14). It is crucial to mention that MOH has established 262 specialized clinics since 1432 H up until now to offer smoking cessation services in parallel with the training of many medical staff from different areas of Saudi Arabia for introducing treatment program with its behavioral and therapeutic components.
Lastly, I hope this Guideline will be a helpful reference for medical staff working at quit clinics for continuous improvement aiming to offer the best available medical care for the citizens of this country.
Secretary General of the National
Committee for Tobacco Control
Ali Mohammed Alwadey

اللجنه الوطنيه لمكافحه التبغ
National Committee for Tobacco Control

Contents
4 Introduction
6 Members of the Scientific Committee of the Saudi Guidelines for Tobacco Cessation Services
8 Ten Keys Guideline Recommendations
10 Summary of strength of evidence for recommendations
11 Health Consequences of Smoking
12 Clinical Intervention for Tobacco Use and Dependence
13 Tobacco Dependence as a Chronic Disease
15 For the Patient Willing to Quit
28 For the Patient unwilling to quit
31 For the Patient Who Has Recently Quit
33 Follow-chart of a smoker in a cessation clinic
34 Stop Smoking Interventions
35 Behavioral support (Counseling)
43 Pharmacotherapy
45 Nicotine replacement therapy (NRT)
49 Bupropion SR
50 Varenicline
52 Interactions of First-Line Tobacco Use Medications with Other Drugs
53 Benefits of Stopping Smoking
55 Smoking Reduction (Harm Reduction) Rather Than Smoking Cessation
55 Weight Gain after Stopping Smoking
57 Exercise
57 Other Specific Populations and Topics
60 Pregnant and breastfeeding Smokers

65 People with Psychiatric/Mental Disorders (MD)
67 Hospitalized Smokers
69 Light Smokers
70 People in prison
71 Older Smokers
71 Women
72 Medical Comorbid Conditions, Including Cancer, Cardiac Disease, COPD, Diabetes, and Asthma
72 Non-cigarette Tobacco Users (Non-cigarette Tobacco Products)
72 Smokeless Tobacco (ST) Products
74 Water-pipe WP (Hookah - Shisha)
75 Cigar and pipe
76 Electronic cigarettes (Electronic Nicotine Delivery Systems – ENDS)
77 Secondhand smoke (SHS)
79 References

Introduction
Tobacco use is one of the main preventable risk factor to human health and also a main cause of premature death worldwide. Around 7 million people annually die from tobacco use and exposure to tobacco smoke. It is the second leading cause of death. Approximately 63% of all deaths are caused by non-communicable diseases for which tobacco use is one of the greatest risk factors.
The prevalence of tobacco smoking among male persons aged 15 years and older is 27.9% has been recorded in WHO international prevalence charts.
(http://gamapserver.who.int/gho/interactive_charts/tobacco/use/atlas.html)
The last Saudi Arabian GYTS addressed on 2010 has revealed that 14.9% of students currently use various forms of tobacco; 8.9% currently smoke cigarettes; 9.5% currently smoke shisha; 11.0% currently use some other forms of tobacco.
Tobacco use presents a rare confluence of circumstance:
(1) A highly significant health threat
(2) The lack of consistent intervention by clinicians
(3) The presence of effective interventions.
Tobacco use intervention, if delivered in a timely and effective manner, can rapidly reduce the risk of suffering from smoking-related disease. Indeed, it is difficult to identify any other condition that presents such a mix of lethality, prevalence, and neglect, despite effective and readily available interventions.
Significant barriers interfere with clinicians' assessment and treatment of smokers. Many clinicians lack knowledge about how to identify smokers quickly and easily, which treatments are effective,

how such treatments can be delivered, and the relative effectiveness of different treatments.
Additionally, physicians may fail to intervene because of inadequate clinic or institutional support for routine assessment and treatment of tobacco use and for other reasons such as time constraints, limited training in tobacco cessation interventions and the lack of insurance coverage for tobacco use treatment. The most effective way to move clinicians to intervene is to provide them with information regarding multiple effective treatment options and to ensure that they have ample institutional support to use these options.
All tobacco products - not just cigarettes - exact devastating costs on the Nation's health and welfare; for most users, tobacco use results in true drug dependence; both chronic tobacco use and dependence warrant clinical intervention and, as with other chronic disorders, these interventions may need to be repeated overtime.
Most tobacco users in Saudi Arabia are cigarette smokers. As a result, the majority of clinician attention has focused on the treatment and assessment of smoking. Clinicians, however, should intervene with all tobacco users, not just with those who smoke cigarettes. Every effort has been made to describe interventions so that they are relevant to all forms of tobacco us
Finally, there is an increasing evidence that the success of any tobacco dependence treatment strategy can't be divorced from the health care system in which it is embedded. Health care policy significantly affects the likelihood that the smokers will receive effective tobacco dependence treatment and successfully stop tobacco use. For instance, making tobacco dependence treatment a covered benefit of insurance plans increases the likelihood that a tobacco user will receive treatment and quit successfully.

Members of the Scientific Committee of the Saudi Guidelines for Tobacco Cessation Services
Dr. Hani Abdulaziz Jokhdar
Deputy Minister for Public Health, Head of the Scientific Committee
Dr. Hesham Ibrahim Alkhashan
Assistant Deputy Minister for Primary Health Care
Dr. Ali Mohammed Alwadey
Supervisor General of TCP, General Secretary of the National Committee of Tobacco Control
Dr. Fayez Saad Basta
MS of Internal Medicine, TTS,TCP (MOH)
Dr. Mohammed Mahmoud Alshaibani
MBBS, Main Physician of TCP Clinic (MOH), TCP (MOH)
Dr. Najeeb Mubarak AlBriki
MBBS, TTS, TCP (MOH)
Dr. Mushabbab Ali Alasiri
MD, Executive Director of Medical Affairs, King Fahad Medical City, Consultant Clinical & Radiation Oncologist
Dr. Fahad Mohammed Alkhodairy
PhD, Principle Scientist and Head of Carcinogenesis Unit in Molecular
Oncology Dept. King Faisal Specialist Hospital and Research Center.
Dr. Mohammad J. Alyamani
PhD/Vice President of Naqa Anti – Smoking Society/ Dean, College of
Pharmacy, Almaarefa Colleges
Dr. Sami Saeed Almudarra
PhD, General Supervisor of Field Epidemiology Training Program

Dr. Yousef Ibrahim Abdulghani
Consultant Psychiatrist/ Director General of Mental Health and Social Service (MOH)
Dr. Samir Ibrahim Arif
Assistant Consultant Family Medicine/ Head of Clinical Practice Guideline Committee in Family Community Medicine Dept. King Saud University
Dr. Yahya Mohammed Abuhaider
Director of Finance and Administration/ Assistant Agency for Hospital's Affairs (MOH)
Nouf Abbas Aleisa
Educational Specialist, General Directorate of Clinical Health Education
Dr. Issa Zedan Almarzouki
MD, MPH, Advisor, Training &HE General Directorate for NCDs (MOH)
Hajer Yousef Almudaiheem
Pharmacist, Head of the National Drug Information Center
Dr. Saud Abdulaziz Alghamdi
Consultant, Family Medicine, General Directorate of Health Services MOI
Dr. Ahmad Elnagib Abdelrahim Ahmed
MBBS, MPH, TTS, Director of TCP, Northern Borders TCP (MOH)
Ohood Sulaiman Alhussaini
TCP (MOH)
Noura Nasser Altamimi
Pharmacist, TCP (MOH)

Ten Keys Guideline Recommendations
The general goal of these recommendations is that physicians strongly recommend the use of effective tobacco dependence counseling and medication treatments to their patients who use tobacco, and those health systems, insurers help clinicians in making such effective treatments available.
1. Tobacco dependence is a chronic disease that require repeated interventions and many tries to quit.
2. It is mandatory that physicians and health care providers invariably identify and document tobacco use status and provide treatment for every tobacco user seen in a health care setting.
3. Tobacco dependence treatments are effective. Physicians should motivate every patient who is willing to quit to apply the counseling treatments and medications recommended in this Guideline.
4. Transient tobacco dependence treatment is effective. Physicians have to offer every tobacco user at least the transient treatments proven to be effective in this Guideline.
5. Single (Individual), group, and telephone counseling are effective, and their successfulness rises with treatment potency. Two components of counseling are especially effective, and physicians have to use these when counseling tobacco users making a quit attempt:
● Practical counseling (problem solving/skills training)
● Social support delivered as part of treatment
6. A lot of effective medications are available for tobacco dependence, and physicians have to encourage their use for those who are attempting to quit smoking—except if they are contraindicated or with

specific populations if there is no evidence of effective use. (i.e., pregnant women, smokeless tobacco users, lightsmokers, and adolescents).
- There are seven first-line medications (5 Nicotinic and 2 Non-Nicotinic) reliably induce long-term smoking abstinence rates:
- Bupropion SR*
- Nicotine gum
- Nicotine inhaler
- Nicotine lozenge*
- Varenicline*
- Nicotine nasal spray
- Nicotine patch*
● Physicians also have to consider the use of some combinations therapy shown as effective in this Guideline.
7. Counseling and medication are enough when used alone each for treating tobacco dependence. The combination of counseling and medication together, however, has far better results. Thus, physicians should advise all users who attempt quitting to use both counseling and medication.
8. Telephone quit-line counseling is also effective with broad populations. Therefore, both physician and health care systems have to ensure the user access to a quit-line and support its use.
9. If a tobacco patient currently is unwilling to make a quit attempt, clinicians should use the motivational tools shown in this Guideline to be effective in increasing future quit attempts.
10. Tobacco dependence treatments are both clinically effective and cost-effective in relation to other interventions for other disorders. Delivering coverage for these treatments raises quit rates. Insurance must confirm that all plans include the counseling and medication indicated as effective in this Guideline as covered benefits.
*Medications which are available in KSA

Summary of strength of evidence for recommendations
Strength-of-evidence classification
Criteria
Strength of Evidence = A
Multiple well-designed randomized clinical trials, directly relevant to the recommendation, yielded a consistent pattern of findings (The recommendation is supported by good [strong] evidence).
Strength of Evidence = B
Some evidence from randomized clinical trials supported the recommendation, but the scientific support was not optimal. For instance, few randomized trials existed, the trials that did exist were somewhat inconsistent, or the trials were not directly relevant to the recommendation (the recommendation is supported by fair [reasonable] evidence but there may be minimal inconsistency or uncertainty).
Strength of Evidence = C
Reserved for important clinical situations in which the Panel achieved consensus on the recommendation in the absence of relevant randomized controlled trials (The recommendation is supported by expert [published] opinion only)

Health Consequences of Smoking
Cancers
- Bladder/Kidney/Ureter
• Blood (Acute Myeloid Leukemia)
- Cervix
- Colon/Rectum
• Esophagus/Stomach
- Liver
- Lung
- Oropharynx/Larynx
- Pancreatic
Pulmonary Diseases
- Asthma
- COPD
• Pneumonia/Tuberculosis
• Chronic Respiratory Symptoms
Cardiovascular Diseases
- Aortic Aneurysm
• Coronary Heart Disease
• Cerebrovascular Disease
• Peripheral Vascular Disease
Reproductive Effects
• Reduced fertility in women
- Poor pregnancy outcomes (e.g., congenital defects, low birth weight, preterm delivery)
- Infant mortality
Other: Cataract, Diabetes (type 2), Erectile Dysfunction, Impaired immune function, Osteoporosis, Periodontitis, Postoperative complications, Rheumatoid Arthritis

Clinical Intervention for Tobacco Use and Dependence
Tobacco Dependence as a Chronic Disease
Tabacco dependence shows a lot of features of a chronic disease. A chronic disease model identifies the long-term nature of the disorder along with the prediction that patients may also have periods of relapse and remission (relapsing nature) and the need for continuous, rather than just acute care (Repeated intervention, and frequent attempts).
Screening for a current or past tobacco use will cause 4 possible reactions (Figure 1):
(A) Current tobacco users who are willing to try a quit now.
(B) Current tobacco users who are not willing to make a quit attempt at this time (strategy B1 and B2); and
(C) Former tobacco users who have recently quit (strategy C1 and C2).
(D) Patients who didn't use tobacco or who have been abstinent for a long period have to be praised about their status and supported to keep the tobacco-free lifestyle.
The five major parts (the "5A's") of a brief intervention ( \( \leq \) 3 minutes) in the primary health care setting are listed in Table 1. It is very important for a physician to Ask the patient if he/she uses tobacco (Strategy A1), Advise him\her to quit (Strategy A2), and Assess willingness to try a quit attempt (Strategy A3). Strategies A1 to A3 have to be applied to each tobacco patient, regardless of his\her desire to quit.
If the tobacco user is willing to quit, the physician have to Assist him\her in making a quit decision by offering medication and providing or referring for counseling or extra treatment (Strategy A4), and Arrange for follow-up contacts for relapse prevention. (Strategy A5).
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Figure 1. The “5 A’s”: Treating Tobacco Dependence as a Chronic Disease

ARRANGE FOLLOWUP

Table 1 the “5 A’s” model for treating tobacco use and dependence
Ask about tobacco use.
Identify and document tobacco use status for every patient at every visit. (Strategy A1)
Advise to quit.
In a clear, strong, and personalized manner, urge every tobacco user to quit. (Strategy A2)
Assess willingness to make a quit attempt.
Is the tobacco user willing to make a quit attempt at this time? (Strategy A3)
Assist in quit attempt.
For the patient willing to make a quit attempt, offer medication and provide or refer for counseling or additional treatment to help the patient quit. (Strategy A4)
For patients unwilling to quit at the time, provide interventions designed to increase future quit attempts. (Strategies B1 and B2)
Arrange follow-up.
For the patient willing to make a quit attempt, arrange for follow-up contacts, beginning within the first week after the quit date. (Strategy A5)
For patients unwilling to make a quit attempt at the time, address tobacco dependence and willingness to quit at next clinic visit.
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For the Patient Willing To Quit
Strategy A1. Ask—systematically identify all tobacco users at every visit

- Current smoker : complete 5A's
- Ex-smoker :
- Declare decision to quit and record smoking status (ex-smoker)
- Give the patient a relapse prevention advice if he quit <1 year ago.
- Ongoing support at least up 5 years quitting.
- Never smoke again: Affirm choice not to smoke and write down a smoking status.
Recommendation: Patients have to be asked if they use tobacco and also have their tobacco use condition documented regularly. Evidence has shown that clinic screening systems, such as expanding the vital signs to include tobacco use status or the use of other reminder systems such as chart stickers or computer prompts, significantly increase rates of clinician intervention. (Strength of Evidence = A)

Strategy A2. Advise—strongly urge all tobacco users to quit
Action
In a clear, strong, and personalized manner, urge every tobacco user to quit.
Strategies for implementation
Advice should be:
- Clear—"It is important that you quit smoking (or using chewing tobacco) now, and I can help you." "Cutting down while you are ill is not enough." "Occasional or light smoking is still dangerous."
- Strong—"As your clinician, I need you to know that quitting smoking is the most important thing you can do to protect your health now and in the future. The clinic staff and I will help you."
- Personalized—Tie tobacco use to current symptoms and health concerns, and/or its social and economic costs, and/or the impact of tobacco use on children and others in the household. "Continuing to smoke makes your asthma worse, and quitting may dramatically improve your health." "Quitting smoking may reduce the number of ear infections your child has."
Recommendation: All doctors have to advise each patient who smokes to stop smoking because evidence shows that the physician advice to quit enhances abstinence rates. (Strength of Evidence = A)
- Advice should be given to all smokers' respects if whether they want to stop smoking or not.
- Brief advice would work by triggering a quit trial rather than by raising the chances of success of a quit attempt. It also seems to have its best effect on less dependent smokers. For more dependent smokers, it is critical that brief advice is combined with an offer to use medications and referral to a smoking cessation service.
- There is no evidence that adding self-help written materials to brief advice gives any additional benefits, but providing written materials to support the advice that is given may strengthen the importance of quitting and give information about cessation support.
- The evidence for the efficacy of brief advice provided by health care employees other than doctors is less clear. However, clear advice from nurses, dentist, dental hygienists, pharmacists and all health care workers is likely beneficial.

Strategy A3. Assess—Determine willingness to make a quit

Specialized Assessment
It may be done to make information available for tailoring treatment and predict a quitting success. It refers to the use of formal instruments (e.g., questionnaires, clinical interviews, or physiologic indices such as carbon monoxide, serum nicotine/cotinine levels) that may be corresponding with cessation result. Some of the variables targeted by specialized assessments that predict quitting success are listed in Table 2.

Variables associated with higher abstinence rates
<table><tr><td>Variable</td><td>Examples</td></tr><tr><td>High motivation</td><td>Tobacco user reports a strong motivation to quit.</td></tr><tr><td>Ready to change</td><td>Tobaccouserreadytoquitwithin a 1-month period.</td></tr><tr><td>Moderate to high self-efficacy</td><td>Tobacco user is confident in his or her ability to quit.</td></tr><tr><td>Supportive social network</td><td>A smoke-free workplace and home; friends who do not smoke in the quitter&#x27;s presence.</td></tr></table>
Variables associated with lower abstinence rates
<table><tr><td>Variable</td><td>Examples</td></tr><tr><td>High nicotine dependence.</td><td>Tobaccousersmokes heavily(≥20cigarettes/day), and/or has first cigarette of the day within 30 minutes afterwaking in the morning</td></tr><tr><td>Psychiatric comorbidity and substance use</td><td>Tobaccousercurrentlyhas elevated depressive symptoms, active alcohol abuse, or schizophrenia.</td></tr><tr><td>High stress level</td><td>Stressful life circumstances and/or recent or anticipated major life changes (e.g., divorce, job change).</td></tr><tr><td>Exposure to other smokers</td><td>Other smokers in the household.</td></tr></table>
Evidence suggests that treatment can be great even if the risk factors for relapse are present (e.g., high nicotine dependence, other smokers in the home), but abstinence rates in tobacco users with these features tend to be lower than rates in those without them.

Assessment of readiness to quit
Smokers go through multiple of stages from pre-contemplation to maintenance (see the diagram).
- Pre-contemplation: not thinking about quitting in next six months.
- Contemplation: thinking about quitting in next six months.
- Preparation: preparing to quit in next month and have tried to quit in the past year.
- Action: successfully quit for up to six-month period.
- Maintenance: continue to remain smoke free for more than six months.
- Stage specific advice increases short-term movement through the stages of change.
- Most smokers are probably not in the action stage. It is estimated that :
- 50%-60% are in the pre-contemplation stage.
- 30%-40% are in the contemplation stage.
- 10%-15% are in the preparation stage.
- Smokers have an average of 3 to 4 quit attempts over 7 to 10 years before they achieve long-term maintenance.
Readiness to Quit: A review

The 5 A's
M

Assessment of nicotine dependence
DSM5 diagnostic criteria of Nicotine dependence
- Nicotine is a high addictive and psychoactive substance that has a strong reinforcing effects, demonstrates the development of short and long-term tolerance, and is associated with withdrawal symptoms upon sudden reduction or discontinuation of use.
- Nicotine Dependence is a collection of cognitive, behavioral and physiological symptoms showing that the individual continues use of the substance in spite of substance-related problems.
2 or more of the following in a 12-month period
- Tobacco is mostly taken in larger amounts or over a longer period than was intended.
- Persistent desire or unsuccessful efforts to cut down or control tobacco use.
- Excessive time spent obtaining and use.
- Craving or strong desire to use tobacco.
- Its use is resulting in failure to fulfill major role obligations at work, school or home.
- Continuous use in spite of persistent or recurrent social or interpersonal problems caused by or exacerbated by tobacco use.
- Important social, occupational, or recreational activities are given up reduced of tobacco use.
- Recurrent tobacco use in situations where it is physically dangerous
- Continued use despite persistent, related psychological or physical problems.
- Tolerance.
- Withdrawal manifestations.

Diagnostic criteria
Coding based on severity
- Mild : 2-3 symptoms
- Moderate, 4-5 symptoms.
- Sever, 6+ symptoms.
-Most tobacco users are nicotine-dependent.
-Dependence can happen quickly and, in some cases, even after a few cigarettes. As nicotine addiction is under-recognized by physicians, routine assessment of nicotine dependence can help predict the severity of withdrawal symptoms that they may experience and can indicate the most appropriate type of medication and level of behavioral support required.
Nicotine withdrawal symptoms are abrupt cessation of tobacco use, or reduction in the amount of tobacco used, followed within 24 hours by
- Irritability, frustration, anger.
- Anxiety
- Difficulty in concentration
- Increased appetite / weight gain
- Restlessness / impatience
- Depressed mood / depression
- Insomnia
- Impaired performance
Most symptoms manifest within the first 1-2 days, peak within the first week, and subside within 2-4 weeks
Assessing a user's dependence on nicotine could help predict whether a he is likely to experience nicotine withdrawal upon quitting, and the intent-

sity and type of support that may be required to assist quitting.

A. Quantitative approach
Cigarette smoking alone is not a valid indicator of dependence, as it does not take into account the different ways in which and the intensity with people smoke their cigarettes. For example, smokers who cut down the number they smoke often continue to get the same amount of nicotine by taking deeper and multiple puffs, smoking more of each cigarette or blocking the vent holes. This is often referred to as compensatory smoking. The Fagerstraom test for cigarette dependence (FTCD) provides a quantitative measure and is the most widely used. It consists of six questions. Scores of each answer are in brackets, and the higher the score the more nicotine dependent clients are.
The Fagerström test for cigarette dependence
1. How soon after you wake up do you smoke your first cigarette?
<table><tr><td>After 60 minutes.</td><td>(0)</td></tr><tr><td>31 to 60 minutes.</td><td>(1)</td></tr><tr><td>6 to 30 minutes.</td><td>(2)</td></tr><tr><td>Within 5 minutes.</td><td>(3)</td></tr></table>
2. How many cigarettes per day do you smoke?
<table><tr><td>10 or less.</td><td>(0)</td></tr><tr><td>11 to 20.</td><td>(1)</td></tr><tr><td>21 to 30</td><td>(2)</td></tr><tr><td>31 or more</td><td>(3)</td></tr></table>
3. Do you find it difficult to refrain from smoking in places where it is forbidden?
<table><tr><td>No.</td><td>(0)</td></tr><tr><td>Yes.</td><td>(1)</td></tr></table>
4. Which cigarette would you hate most to give up?
<table><tr><td>The first in the morning.</td><td>(0)</td></tr><tr><td>Any other.</td><td>(1)</td></tr></table>
5. Do you smoke more frequently during the first hours after awakening than during the rest of the day?
<table><tr><td>No.</td><td>(0)</td></tr><tr><td>Yes.</td><td>(1)</td></tr></table>
6. Do you smoke even if you are so ill that you are in bed most of the day?
<table><tr><td>No.</td><td>(0)</td></tr><tr><td>Yes.</td><td>(1)</td></tr></table>
Heaviness of smoking index
The two most important indicators of dependence, however, are considered to be: 'How soon after you wake do you smoke your first cigarette?' and 'How many cigarettes per day do you smoke?' It is therefore accept-

able to use just these two questions alone as a shortened version of the FTCD, called the Heaviness of Smoking Index. As with the full FTCD, the higher the score the greater the level of nicotine dependency. High Nicotine dependence: means smoking ≥20 cigarettes per day, and or smoking of first cigarette of the day within 30 minutes after waking in the morning.
B- Objective approach
1. Carbon monoxide.
It's unreliable to take into account a self-reported smoking status, therefore CO-verification rate is a very important marker of quality these days. CO testing have to be done on all adult smokers to provide, as a minimum, both a baseline (per-quit) level and a four-week validation (post-quit) level. CO testing is fast to carry out, non-invasive and cost-effective. It validates the smoking status of significant number of patients.
-A CO reading of or below 10 ppm is counted as that of a non-smoker (For pregnant women it should be 6 ppm).
-CO monitoring can be used for behavioral support technique, it is evidence-based and can be highly motivating for patients. To achieve an accurate reading, patients are asked to hold their breath for 15 seconds (10 seconds minimum) before blowing into the CO monitor.
2. Cotinine
Cotinine is a metabolite of nicotine produced when nicotine is broken down inside the body and it can be found in blood, urine or saliva. Whilst CO monitoring is currently the most cost-effective method of confirming four-week quits, but specific projects or groups may need more specific monitoring by using either urinary or salivary cotinine samples. However, unfortunately cotinine testing does not allow instant feedback for patient cause the samples need to be tested at labs, so it cannot be used as a motivational (persuading) tool. Furthermore, the test cannot differentiate between nicotine from tobacco and nicotine from NRT and can therefore be unreliable as a marker of smoker-free status where NRT is being used.
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Recommendation:
1. The physician should assess the patient's willingness after a tobacco user is identified and advised to quit, (as a part of specialized assessments) to quit at this time. (Strength of Evidence = C)
- If the tobacco user is willing to quit at this time, interventions identified as effective in this Guideline should be provided (Behavioral support/counselling and mediation)
-If the tobacco user is unwilling to quit at this time, an intervention designed to raise future quit attempts should be elaborated. (Motivational Interviewing)
2. Tobacco dependence treatment is effective and should be delivered regardless the specialized assessments are not used or available. (Strength of Evidence = A)
Strategy A4. Assist—Aid the patient in quitting (provide counseling and medication)
Action
Help the patient with a quit plan
(STAR)
Recommend the use of approved medication, except when contraindicated or with specific populations for which there is insufficient Evidence of effectiveness (i.e., pregnant women, smokeless tobacco users, light smokers, and adolescents).
Strategies for implementation
A patient's preparations for quitting:
- Set a quit date. Ideally, the quit date should be within 2 weeks.
- Tell family, friends, and coworkers about quitting, and request understanding and support.
- Anticipate challenges to the upcoming quit attempt, particularly during the critical first few weeks. These include nicotine withdrawal symptoms.
- Remove tobacco products from your environment. Prior to quitting, avoid smoking in places where you spend a lot of time (e.g., work, home, car). Make your home smoke-free.
Recommend the use of medications found to be effective in this Guideline. Explain how these medications increase quitting success and reduce withdrawal symptoms. The first-line medications include: bupropion SR, nicotine gum, nicotine inhaler, nicotine lozenge, nicotine nasal spray, nicotine patch, and varenicline; second-line medications include: clonidine and nortriptyline. There is insufficient evidence to recommend medications for certain populations (e.g., pregnant women, smokeless tobacco users, light smokers, adolescents).

Table 3: Common elements of practical counseling (problem-solving/skills training)

Provide basic information – Provide basic information about smoking and successful quitting.
•The fact that any smoking (even a single puff) increases the likelihood of a full relapse
- Withdrawal symptoms typically peak within 1–2 weeks after quitting but may persist for months. These symptoms include negative mood, urges to smoke, and difficulty concentrating.
•The addictive nature of smoking
Table 4: Common elements of intra-treatment supportive interventions
<table><tr><td>Supportive treatment component</td><td>Example</td></tr><tr><td>Encourage the patient in the quit attempt.</td><td>-Note that effective tobacco dependence treatments are now available.-Note that one-half of all people who have ever smoked have now quit.-Communicate belief in patient&#x27;s ability to quit.</td></tr><tr><td>Communicate caring and concern.</td><td>-Ask how patient feels about quitting.-Directly express concern and willingness to help as often as needed.-Ask about the patient&#x27;s fears and ambivalence regarding quitting.</td></tr><tr><td>Encourage the patient to talk about the quitting process.</td><td>Ask about:-Reasons the patient wants to quit.-Concerns or worries about quitting.-Success the patient has achieved.-Difficulties encountered while quitting</td></tr></table>
Recommendation: See Behavioral Support

Strategy A5. Arrange—Ensure follow-up contact
Action
Arrange for follow-up contacts, either in person or via telephone
Strategies for implementation
Timing: Follow-up contact should begin soon after the quit date, preferably during the first week. A second follow-up contact is recommended within the first month. Schedule further follow-up contacts as indicated.
Actions during follow-up contact: For all patients, identify problems already encountered and anticipate challenges in the immediate future. Assess medication use and problems. Remind patients of quit-line support. Address tobacco use at next clinical visit (treat tobacco use as a chronic disease).
For patients who are abstinent, congratulate them on their success.
Iftobacco use has occurred, review circumstances and elicit recommittent to total abstinence. Consider use of or link to more intensive treatment.
For smokers unwilling to quit at the time
Promoting the motivation to quit (Motivational Interviewing).
Recommendation:
The assessment of abstinence for every patient at the end of treatment should be done. (1) Abstinent patients should have their quitting success praised, and the physician have to assist the patient with problems with his current quitting attempt (see page 33, For the Patient Who Has Recently Quit). (2) In relapsed patients, assessment has to be done to determine if they are willing to quit again.
(Strength of Evidence = C).
If the patient is willing to make another try, offer additional treatment (Behavioral support and medications).
If the patient is not willing to quit at all, deliver an intervention specialized to raise the likelihood of future quit attempts (Motivational Intervention - MI).

B. For the Patient Unwilling To Quit
Promoting the Motivation to Quit (Motivational Interviewing / MI)
Patients unwilling to make a quit attempt during a visit may:
- Lack information about the harmful effects of tobacco use and the benefits of quitting.
- Lack the required financial resources.
- Have fears or concerns about quitting.
- Be depressed because of previous relapses.
Such patients may respond to brief motivational interventions that are based on principles of Motivational Interviewing (MI), a directive, patient-centered counseling intervention. There is evidence that MI is effective in increasing future quit attempts. However, it is unclear that MI is successful in boosting abstinence among individuals motivated to quit smoking.
Motivational interviewing (MI) is a specific counseling strategy that is intended to increase a person's motivation for behavior change. MI comprises a variety of strategies that are designed to help individuals resolve ambivalence about such change. The technique has been used successfully to help individuals attempt and achieve many types of behavior change, including reduced drinking and illicit drug use, and reduction of HIV risk behaviors.
The spirit of MI (a way of being with people) is collaboration not confrontation, Evocation not education / advice and autonomy not authority. Patient's motivations mean importance of change, confidence in one's ability to change and readiness to change.
The techniques (Methods of communication) used in MI are:
- Open-ended questions.
- Affirm.
- Reflective listening.
- Summary.
Forthose who are less motivated to quit, it's mandatory to explore the issues behind their disinterest or hesitance. Patient-centered counseling can decrease their defensiveness. MI techniques have to focus on exploring a tobacco user's feelings, beliefs, ideas, and values regarding tobacco use in an effort to uncover any hidden agenda about tobacco use. Once the agenda is uncovered, the physician specifically elicits, supports, and enforces the patient's "change talk" (e.g., desire, ability, reasons, needs and commitment) and "commitment language".

The 4 general principles that underlie MI are:
(1) Express empathy.
(2) Develop discrepancy
(3) Roll with resistance
(4) Support self-efficacy.
Specific MI counseling strategies that are based on these principles are listed in Strategy B1.
Strategy B1. Motivational interviewing strategies
Express empathy.
- Use open-ended questions to explore:
- The importance of addressing smoking or other tobacco use (e.g., "How important do you think it is for you to quit smoking?"
- Concerns and benefits of quitting (e.g., "What might happen if you quit?")
- Use reflective listening to seek shared understanding:
- Reflect words or meaning (e.g., "So youthink
smoking helps you to maintain your weight.").
- Summarize (e.g., "What I have heard so far is that smoking is something you enjoy. On the other hand, your wife hates your smoking, and you are worried you might develop a serious disease.").
- Normalize feelings and concerns (e.g., "Many people worry about managing without cigarettes.").
- Support the patient's autonomy and right to choose or reject change (e.g., "I hear you saying you are not ready to quit smoking right now. I'm here to help you when you are ready.").
Develop
discrepancy
- Highlight the discrepancy between the patient's present behavior and expressed priorities, values, and goals (e.g., "It sounds like you are very devoted to your family. How do you think your smoking is affecting your children?").
- Reinforce and support "change talk" and "commitment language:
- "So, you realize how smoking is affecting your breathing and making it hard to keep up with your kids."
- "It's great that you are going to quit when you get through this busy time at work."
- Build and deepen commitment to change:
- "There are effective treatments that will ease the pain of quitting, including counseling and many medication options."
- "We would like to help you avoid a stroke like the one your father had."

The content areas that should be addressed in a motivational counseling intervention can be captured by the “5 R’s”: relevance, risks, rewards, roadblocks, and repetition (Strategy B2). Research suggests that the “5 R’s” enhance future quit attempts.
Strategy B2. Enhancing motivation to quit tobacco—the “5 R’s”

Recommendation
Motivational intervention techniques have shown to be to be reliable in enhancing a patient's probability of making a future quit attempt. Therefore, physicians have to use motivational methods to encourage smokers who are not willing to quit at this time to consider making a quit attempt later in the future. (Strength of Evidence = B)
C. For the Patient Who Has Recently Quit
Treatments for the Recent Quitter (Relapse prevention Intervention) Tobacco users who did quit recently face a high risk of relapse. Although most relapse happens early while in the quitting process, some relapses happens months or even years after the quit date. That is why relapse prevention intervention methods have to be added in the initial treatment plan in addition to follow-up sessions.
The best strategy for establishing a high long-term abstinence rates appears to be use of the most effective cessation treatments available; that is, the use of evidence-based cessation medication during the quit attempt and relatively potent cessation counseling (e.g., four or more sessions that are 10 minutes or more in length).

Strategy C1. Intervening with the patient who has recently quit
The former tobacco user have to get acknowledged on any success and encouraged strongly to keep him abstinent.
When encountering a recent quitter, use open-ended questions relevant to the subjects below to uncover if the patient wishes to any discuss problems related to quitting:
- The benefits, including potential health benefits, the patient may derive from cessation.
- Any success the patient had in quitting (duration of abstinence, reduction in withdrawal, etc.).
- The problems encountered or anticipated threats to maintaining abstinence (e.g., depression, weight gain, alcohol, other tobacco users in the household, significant stressors).
- A medication check-in, including effectiveness and side effects if the patient is still taking medication.
Strategy C2. Addressing problems encountered by former smokers
A patient who previously smoked might identify a problem that negatively affects health or quality of life. Specific problems likely to be reported by former smokers and potential responses as follow:

* Lapse: means isolated or single use of tobacco, a "slip". (Relapse: means return to regular use of tobacco, after a period of abstinence).
Follow-Chart of a Smoker in a Cessation Clinic

Stop Smoking Interventions
Evidence has proved that a combination of behavioral therapy (counseling) from a trained smoking cessation practitioner and approved pharmacotherapy can greatly enhance a smoker's chances to quit.
All interventions have in common properties (such as the provision of behavioral support, a structured approach and the offer of licensed pharmacotherapy) and they all contain multiple sessions. Stop smoking intervention can be provided in a number of ways, and it is important that the range of support options is ready to allow people to pick the type of intervention that is best for them. More dependent (addicted) smokers will be in the need for higher levels of behavioral support and a extra dose of or extended medication. They may also require to make multiple quit trials. The best and most consistent evidence for the efficacy and of stop smoking interventions is for those that decided an 'abrupt' quit trial (choosing a quit date and aiming to maintain a complete abstinence after that day by applying the 'not-to-puff' rule).
TOBACCO DEPENDENCE: A 2-PARTs PROBLEM

Methods of stopping
When attempting to stop smoking there are a number of methods that smokers commonly use, including
• Unassisted ('cold turkey')
- Using nicotine replacement therapy bought over the counter (OTC).
- Using a stop smoking medicine provided on prescription.
- Using a stop smoking services (behavioral support + Access to stop smoking medicine).
Figure 2: Methods of stopping smoking and their success rates.

This figure shows that OTC medication has no greater effect on smoking cessation rates than quitting unassisted.

Treatment program content
The treatment program should, as minimum, include:
- Building rapport and boosting motivation throughout.
- Assessing and confirming current readiness and ability to quit.
- Informing clients about the treatment program.
- Assessing current smoking behavior.
- Assessing past history of quit attempts.
- Explaining how tobacco dependence develops and assessing level of nicotine dependence (using diagnostic criteria such as the Heaviness of Smoking Index (HSI) or the Fagerstrom Test for Cigarette Dependence (FTCD).
• Measuring carbon monoxide (CO).
- Explaining the importance of abrupt cessation and the 'not-a-puff' rule.
- Discussing withdrawal symptoms and craving / urges to smoke and how to deal with them.
- Discussing stop smoking medications; confirming choice, correct usage and sufficient supply.
- Discussing the client's smoking contacts and how the client can get support to quit.
- Setting quit date.
- Discussing any potential high-risk situations in the coming week.
- Advising on changing routine.
- Prompting commitment from clients (confirm the importance of the 'not-a-puff' rule).
- Discussing future preparations and plans.
- Relapse prevention.
- Providing a summary to the client.
Cost-Effectiveness of Tobacco Dependence Interventions
Recommendation: The tobacco dependence treatments shown to be effective in this Guideline (both counseling and medication) are highly cost-effective relative to other reimbursed treatments and should be provided to all smokers. (Strength of Evidence = A)
Providing Treatment for Tobacco Use and Dependence as a Covered Benefit
Recommendation: Providing tobacco dependence treatments (both medication and counseling) as a paid or covered benefit by health insurance plans has shown to increase the number of smokers who use cessation treatment, attempt to quit, and successfully quit.
Therefore, treatments shown to be effective in the Guideline should be included as covered services in public and private health benefit plans.
(Strength of Evidence = A)
Behavioral support (counseling)
Behavioral support involves delivering evidence-based behavior change techniques, most commonly provided face to face (individually or groups). It increases quitting success rates by:
- Aiding patient to avoid, escape from or copy with urges to smoke and to manage withdrawal symptoms.
- Maximizing the motivation to remain abstinent and scoring the goal of a life lasting cessation.
- Self-confidence boosting.
- Sharply increasing self-control.
- Optimizing the use of medications.

FACTORS CONTRIBUTING to TOBACCO USE

- Conditioned stimuli: All drug-taking behavior is learnt, a result of conditioning. Drug-taking behavior is strengthened by the consequences of the pharmacologic effects of the medication. At the same time, smokers begin to relate specific moods, situations, or environmental factors with nicotine's reward effects. The relation between them and anticipated drug effects and the resulting urge to use tobacco is another type of conditioning between the use and these other events, many times repeated, causes the environmental situations to become powerful cues for the urge to use.
- Conditioning is a major risk factor that leads to relapse. As such, it must be addressed as an important part of the behavioral therapy for nicotine addiction.
Behavioral support sessions (minimum support for the first six weeks)
- Session 1: pre-quit.
- Session 2: quit date.
- Session 3: 1 week post-quit.
- Session 4: 2 weeks post-quit.
- Session 5: 3 weeks post-quit.
- Session 6: 4 weeks post-quit.
Intensity of Clinical Interventions
Recommendation:
- Minimal interventions of less than 3 minutes enhance overall tobacco abstinence rates. Every tobacco user have to be offered at least a minimal intervention, whether or not he or she is referred to an intensive intervention. (Strength of Evidence = A)

- There is a strong dose-response relation between the session length of person-to-person contact and successful treatment outcomes. Intensive interventions are more effective than less intensive interventions and should be used whenever possible. (Strength of Evidence = A)
- Person-to-person treatment delivered for four or more sessions appears especially effective in increasing abstinence rates. Therefore, if feasible, clinicians should strive to meet four or more times with individuals quitting tobacco use. (Strength of Evidence = A)
-Intensity of person-to-person (one to one) clinical contact :
- Minimal counseling brief intervention (Longest session ≤ 3 minutes in duration)
- Low intensity counseling
(Longest session > 3 minutes and ≤ 10 minutes in duration)
- Higher intensity counseling Intensive Intervention (Longest session > 10 minutes)
-closed supportive group therapy:
It should be at least an hour in length weekly over a 6-weeks treatment period.
Type of Clinician
Recommendation:
- Treatment given by a variety of clinician types, increases abstinence rates. Therefore, all clinicians should provide smoking cessation interventions. (Strength of Evidence = A)
- Treatments delivered by multiple types of clinicians are more effective than interventions delivered by a single type of clinician. Therefore, the delivery of interventions by more than one type of clinician is encouraged. (Strength of Evidence = C)
Formats of Psychosocial Treatments
Recommendation:
- Proactive telephone counseling, group counseling, and individual counseling formats are effective and should be used in smoking cessation interventions. (Strength of Evidence = A)
- Smoking cessation interventions that are delivered in multiple formats increase abstinence rates and should be encouraged. (Strength of Evidence = A)
- Tailored materials, both print and Web-based, appear to be effective in helping people quit. Therefore, clinicians may choose to provide tailored self-help materials to their patients who want to quit. (Strength of Evidence = B)

Formats of psychological intervention (Intervention type)

Telephone support
Telephone support is a great method for encouraging smokers to stop. It can be reactive (where the smoker calls a helpline for information and advice) or proactive (where the smoker receives calls from a telephone counsellor at set times). The strongest evidence for efficacy exists for the proactive form of telephone support. In part because most smokers do not make the call to quit-line after enough to get the full benefit, they ready accept and appreciate proactive calls. Telephone cessation services are cost effective and have a very wide reach (that is, there can be delivered to many people over a large geographical area).
Key Points
Proactive telephone support for smoking cessation enhances long-term abstinence rates.
There is evidence that adding telephone support to medication increases short and long-term abstinence rates more than that of medications alone. There is no advantage in adding telephone support to face-to-face support. However, when the intensity of face-to-face counselling is low, such as providing a single counselling session for hospital in-patients, additional follow-up with telephone counselling has been shown to have a positive effect.
Also, there is no evidence that telephone follow-up after intensive support reduces relapse rates.
Self-help Materials
Self-help materials, such as in written (leaflets and books and booklets) or electronic (CDs, online), are an inexpensive means of communicating cessation advice to a potentially big number of tobacco users. However, the content of these materials is of variable quality.
Key Points
- Self-help materials have only a small effect on long-term cessation rates in comparison with no intervention (that is, to assist 'cold turkey' quit attempts).
- Approximately 1 out of 100 people who would not otherwise have stopped smoking will do so for at least 6 months after receiving written self-help materials (and no other form of assistance).
- Adding self-help materials to other effective interventions, such as brief advice, face-to-face or telephone support and medications, does not appear to increase the effectiveness of those interventions.

- Self-help materials that are tailored to the individual are likely to be more effective than non-tailored materials.
- There are 15 studies have found evidence of effectiveness of text message mobile phone support programs both in the short and long-term. Combined internet/mobile telephone programs together can be effective for up to 12 months for assisting tobacco users to quit.
- Online smoking cessation interventions are low cost and have the potential to reach a large number of smokers. An important advantage of the internet over printed materials is that of its interactivity and the ability to tailor information to individual needs. Web-based programs are a promising delivery system for assisting tobacco users to quite especially if it is interactive, but further research is needed to identify their most effective use.
Hypnotherapy (without counseling)
Hypnotherapy is widely promoted as an innovative way to stop smoking. It is said to assist smoking cessation by weakling the desire to smoke, or enforcing the will to stop. In spite of being in use for some decades, there are only a few well-designed studies to evaluate its use. A Cochrane meta-analysis was not able to show that hypnotherapy was better than no treatment and there is insufficient evidence to compare hypnotherapy with alternative treatments.
Acupuncture
Sometimes people have acupuncture for tobacco cessation with the aim of decreasing withdrawal symptoms. Related therapies include acupressure, laser therapy and electrical stimulation. At present, there is no consistent evidence that acupuncture, or any related therapy, is better than doing nothing. The acupuncture meta-analysis comparing “active” acupuncture with “control” acupuncture revealed no difference in results between the two types of procedures. These outcomes suggest that any effect of acupuncture might be produced by other factors such as positive expectations about the procedure.
Types of Counseling and Behavioral Therapies
Recommendation: Two types of counseling and behavioral therapies result in higher abstinence rates: (1) providing smokers with practical counseling (problem-solving skills/skills training), and (2) providing support and encouragement as part of treatment. These types of counseling elements should be included in smoking cessation interventions. (Strength of Evidence = B)
Combining Counseling and Medication
Recommendation:
- The combination of counseling and medication is more effective for smoking cessation than either medication or counseling alone. Therefore, whenever

feasible and appropriate, both counseling and medication should be provided to patients trying to quit smoking. (Strength of Evidence = A)
- There is a strong relation between the number of sessions of counseling, when it is combined with medication, and the likelihood of successful smoking cessation. Therefore, to the extent possible, clinicians should provide multiple counseling sessions, in addition to medication, to their patients who are trying to quit smoking. (Strength of Evidence = A)
Self-Management
- It involves cognitive-behavioral strategies that rearrange environmental cues or triggers
- Trigger — situation, behavior, thought or mood related with smoking or dipping
- Goal of self-management: For patients to train systematically using coping strategies to not smoke or dip in trigger situations.

Self-Management Process
1- Think ahead : patients use information from self-monitoring to develop list of triggers / high risk situation
2- Prepare for the urge : how will smokers actually handle the situation
3- Cope with the urge : coping skills are :
• Cognitive coping.
- Behavioral coping When you have an urge to smoke
Cognitive coping skills:
Things you can think about
Psychoeducation:
- Urges are time-limited, not continuous urge
- Urges are stronger and more frequent upon initial quitting, but gradually diminish in intensity
For example:
Tell yourself "smoking isn't an option"
Remind yourself of the reasons (Why?) you wanted to quit
Think of how long you have been tobacco-free
Think of how you got through this situation in the past

Behavioral copingskills:
Actions that you can take
• Patients intervene to break up behavior chain
(Situation #rge Smoke) using one (or more) of 3 general strategies:
- Avoid the trigger situation
• Alter or change the trigger situation
- Use an alternative or substitute in place of the cigarette or smokeless tobacco:
- Drink water.
- Delay the desire.
- Deep breathing.
- Do something else.
- Make your mouth and hand busy as much as you can.
Stress and smoking
What causes stress?
Major life events and daily hassles can cause stress
Major life events
- Death of family member
- Fired from a job
- Divorce
- Serious illness
- Child leave home
- Move to a new place
- Pregnancy
- Birth of a child
- Marriage
- retirement
Daily hassles
- Minor money problems
- Car trouble
- Rude people
-Fights with partner
- Traffic jams
- Bad weather
- Home repairs
- Arranging child care
- Housework
- Loud children
- Stress is often stated as the main reason for smoking. What types of triggers or situations provoke stress-related tobacco use?
- Smokers occasionally confuse the relief of their nicotine withdrawal with the feeling of relaxation. The main goal is to help patients to realize that tobacco is the problem, not the solution.
In the long run, the daily hassles causes more stress than the major life events do. Possible ways to live with stress and bad mood include:

- Deal with the problem directly (problem solving).
- Do other stress-relieving activities (reading, sports, family gatherings).
- Talk to someone to help solve the problem (support).
- Accept temporary stress (stress management).
- Decision making.
- Assertiveness.
Deep breathing
It is a very great way to deal with a stressful situation. You can breathe deeply while sitting, standing or lying down – even while working, sitting around at a game or waiting for something.
Pharmacotherapy
Nicotine addiction
1. Nicotine is the main substance in tobacco that results in addiction, but it is not responsible for the harmful effects of smoking, which are caused mainly by tar, oxidizing chemicals, carbon monoxide, polycyclic aromatic hydrocarbons and other contents of tobacco smoke.
2. Dependence on nicotine develops fast. Studies have shown that non-daily tobacco use triggers emergent nicotine dependence – in the Second Development and Assessment of Nicotine Dependence in Youth study the source, where subjects had smoked at least one cigarette, 62% smoked at least once per month, 53% experienced withdrawal symptoms and 40% experienced the need for daily smoking.
3. Dependence on smoking is a complex process. It requires a close link in time between the context, in which smoking occurs, its rituals, the sensory stimuli of touch, taste and smell, and the extremely rapid delivery of nicotine to the brain that occurs when smoking a modern cigarette. Evidence suggests that psychosocial, biological and genetic factors all play a role in nicotine addiction.
4. When cigarette smoke is inhaled, the large surface area of the lungs means that nicotine is rapidly absorbed into the pulmonary venous circulation and travels quickly to the brain through the bloodstream. Nicotine in tobacco smoke reaches the brain reward system within seconds of inhalation. This nicotine targets multiple nicotine receptors in the brain including, but not confined to, the α4β2 nicotinic acetylcholine receptor. Activation of this and other receptors triggers the release of dopamine and other neurotransmitters. This reward system is the common pathway for the experience of pleasure from many different social, physical and chemical stimulants.

Recommendation:
Physicians have to advise all patients attempting to quit to use effective medications for tobacco dependence treatment, except where contraindicated or for specific populations for which there is insufficient evidence of effectiveness (i.e., pregnant women, smokeless tobacco users, light smokers, and adolescents). (Strength of Evidence = A)
As with other chronic diseases, the most effective treatment of tobacco dependence requires the use of multiple clinical modalities. Medications are a vital element of a multicomponent approach. The clinician should encourage all patients initiating a quit attempt to use one or a combination of effective medications, although medication use may not be appropriate with some patient groups (see the pervious recommendations).
First-line (FDA-approved) medications:
- Nicotine Replacement Therapy (NRT) (nicotine patch*, nicotine lozenge*, nico tine gum, nicotine nasal spray, and nicotine inhaler).
● Bupropion SR ((Zyban / Wellbutrin)
• Varenicline* (Champix)
Second-line (non-FDA-approved):
- Clonidine
- Nortriptyline.
Each has been documented to increase significantly rates of long-term smoking abstinence.
First-Line Medications
First-line medications are safe and effective for tobacco dependence treatment and have been approved by the FDA for this use, except in the presence of contraindications or with specific populations for which there is insufficient evidence of effectiveness. These first-line medications have an established empirical record of successfulness, and physicians have to consider them first in choosing a medication.
Clinical assessment, con

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