Tobacco use

and
Dependence
Based on Malaysian CPG 2003

Assessment of tobacco use

Screen for tobacco use

Uses tobacco and now willing to make a quit attempt

Uses tobacco but not now willing to make a quit attempt
Once used tobacco but has since quit
Never regularly used tobacco

Assess for
Level of addiction using Fagerstrom Questionnaire + number
of cigarettes smoked
Readiness for quitting

Brief clinical intervention (if willing to

quit)
Ask about tobacco use at every visit
Advise to quit in a clear, strong personalized manner
Assess willingness to make a quit attempt this time
If patient is willing, provide assistance
If patient will participate in intensive treatment, refer to
intensive intervention
If patient clearly states unwillingness, provide motivational
intervention
If patient is a member of special population
(adolescent/pregnant), consider providing additional
information

 Assist in quit attempt

Set a quit date (ideally within 2 weeks). Reduce the number of
cigarettes gradually before set date
Tell family, friends, co-workers about quitting and request
understanding and support
Encourage other smokers in household to quit with them or
not smoke in their presence to minimize risk of treatment
failure
Advice patient to remove tobacco products from their
environment
Anticipate nicotine withdrawal symptoms and ways to
overcome them

 Arrange follow-up
Follow-up contact should occur soon after the quit date
(ideally first week)
Subsequent follow-ups are recommended weekly within first
month, two weekly for 2nd and 3rd month and monthly for 6
months.
If tobacco use has occurred, review circumstances and elicit
recommitment to total abstinence. Remind patient that a
lapse can be used as a learning experience. Assess
pharmacotherapy use and problems

Motivational intervention (if

unwilling to quit)
Relevance
Encourage patient to identify eg relevance to own disease
status, family, etc

Risks
Ask patient to identify potential negative consequences of
tobacco use
Short-term risks: SOB, AEBA, impotence, infertility
Long-term risks: CVA, IHD, COPD, cancers (larynx, oral cavity,
pharynx, oesophagus, pancreas, bladder, cervix)
Environmental risks: cancer in spouse, smoking in children,
increased risk for low birth weight

 Rewards
Ask patient to identify potential benefits of stopping tobacco
use
Eg improved health, food tastes better, save money, healthier
children

Roadblocks
Ask patient to identify barriers to quitting and address each
Eg withdrawal symptoms, fear of failure, lack of support

Repetition
Repeat the motivational intervention every time an
unmotivated patient visits clinic setting

Relapse prevention (if recently quit)

Congratulate patient
Reinforce patients decision to quit
Review with patient benefits of quitting
Assist patient in resolving any residual problems arising
from quitting
Most relapse occurs within the first 3 months of the
quitting process but some may occur months or years
after the quit date

Pharmacological intervention
Special consideration should be given before using
pharmacotherapy in
Patients with medical contraindications (recent MI, lifethreatening arrhythmia, unstable or worsening angina, recent
cerebrovascular accident or hypersensitivity to nicotine)
Pregnant/breastfeeding women
Adolescent smokers

Nicotine gum
Nicorette 2mg for patients smoking <20 cigarettes a
day, 4mg for patients smoking >20 cigarettes a day
Gum should be used up to 12 weeks with no more than
24 pieces/day
Side effects: mouth soreness, dyspepsia, jaw ache
Avoid in patients with serious arrhythmias, within 2
weeks post-MI, patients with serious or worsening
angina pectoris

Nicotine patch
Nicotinell TTS 30 (21mg), 20 (14mg), 10 (7mg)
At the start of each day, place a new patch on a
relatively hairless location between neck and waist
Side effects: local skin reactions, insomnia
Avoid in patients with serious arrhythmias, within 2
weeks post-MI, patients with serious or worsening
angina pectoris

Nicotine inhaler
4mg/cartridge (80 inhalations) at 6-16 cartridges/day
for total 6 months with tapering in final 3 months of
treatment
Avoid eating and drinking anything except water for 15
minutes before and during inhalation
Side effects: coughing, rhinitis
Avoid in patients with serious arrhythmias, within 2
weeks post-MI, patients with serious or worsening
angina pectoris

Bupoprion SR
150mg OM x 3/7 then increase to 150mg BD for 7-12
weeks
Side effects: insomnia, dry mouth
Avoid in patients with a history of seizure disorder,
eating disorder, on another form of bupropion or who
have used an MAOI within last 14 days