Inquire about the smoking status of all patients and determine their willingness to quit, as smoking cessation is associated with a reduction in all-cause mortality, atherosclerotic disease, obstructive lung disease, and some malignancies.

Encourage smoking cessation strongly in patients with coronary artery disease or obstructive lung disease; patients with established coronary artery disease who quit smoking have a large reduction in risk of death compared to patients who continue.

Provide all smokers with a brief counseling intervention to encourage smoking cessation, but especially focus on persons with children because environmental tobacco smoke increases the development of respiratory disease in children.

Recognize that bupropion, nicotine replacement therapy, varenicline, and behavioral counseling all have been shown to be effective aids in smoking cessation and should be offered to all smokers who are interested in quitting.

Encourage smoking cessation before and during pregnancy because cessation reduces the incidence of both preterm labor and low-birth-weight infants.

Recognize that individuals with established obstructive lung disease who are counseled to quit smoking have a slower deterioration of lung function than patients who continue to smoke.

Focus smoking cessation efforts on individuals with children because environmental tobacco smoke increases the development of respiratory disease in children.

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Use specific behavioral modalities for smoking cessation, including physician advice, group behavior therapy, and self-help therapy.

Consider drug treatment modalities for smoking cessation, including nicotine replacement, bupropion, and varenicline.

Know that modalities for which there is limited evidence for effectiveness or evidence against their effectiveness include anxiolytics, clonidine (which, although it has the strongest evidence of benefit, should be considered a second-line therapy due to side effects), mecamylamine, lobeline, naltrexone, and silver acetate.

Recognize that nicotine replacement is safe in most patients, that bupropion carries some risk of adverse effects in some patients with comorbid conditions or on other drugs, varenicline was safe and well-tolerated in clinical trials that enrolled primarily healthy participants, and that the role of these agents is unclear in pregnancy.

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Recognize that among the elderly, smoking cessation has been shown to reduce mortality rates as well as cardiovascular and neoplastic disease after 5 years.

Realize that smoking cessation is associated with dramatic reduction in mortality rates and other adverse outcomes in patients with previous myocardial infarction or documented coronary artery disease.

Know that smoking cessation has been shown to reduce the risk of stroke and myocardial infarction among men within 5 years of smoking cessation.

Understand that smoking cessation has been associated with a significant reduction in malignancies.

Recognize that smoking cessation may lead to weight gain or produce depressive symptoms.

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Recognize newer data suggesting that smoking cessation interventions appear to play a direct role in reducing mortality.

Appreciate that direct evidence exists showing that smoking cessation programs reduce adverse outcomes in pregnancy (low-birth-weight children and preterm birth).

Know that smoking cessation programs have been shown to reduce surrogate outcomes such as decline in FEV1.

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Assess the smoking status in all patients routinely, and encourage each, from adolescents to patients over age 65, to quit smoking.

Encourage patients to set a cessation date within 2 weeks after deciding to quit, and arrange follow-up visits to increase cessation rates and maintain smoking cessation.

Administer bupropion SR, 150 mg po od, for 3 days, followed by 150 mg po bid, for 7 to 12 weeks. Have the patient set a smoking cessation date for about 1 week after starting therapy.

Consider nicotine replacement therapy preparations shown to be effective in smoking cessation including transdermal patch, nicotine gum, nicotine nasal spray, and nicotine inhalers. Choose nicotine replacement therapy according to individual preferences, tolerability of the product, and financial cost.

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Recognize the cost-effectiveness of nicotine replacement therapy and behavioral counseling for smoking cessation and the benefit they provide for a reduction in illness and death associated with smoking.

Appreciate the particular cost-effectiveness of smoking cessation interventions in patients with coronary artery disease because of the probable large reduction in risk of death.

Know that smoking cessation during the first trimester of pregnancy can substantially reduce health costs by contributing to a decrease in preterm births and that smoking cessation throughout pregnancy can reduce costs due to maternal illness.

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This PowerPoint presentation covers the following topics in counseling your patients to change their behaviors.

• The Cycle of Change
• A Brief Intervention Technique: FRAMES
• Reflective Listening
• Counseling Steps: (1) Preparation, (2) Determination to Action, and (3) Maintaining Change

NOTE: This content was excerpted from the ACP Clinical Skills Module, Counseling for Behavior Change.

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This tool provides recommendations based on your current cigarette use.

What type of nicotine replacement will be best for you?

• Your choice of nicotine replacement depends on your personal preference, side effects of the replacement methods, and your past experience with quitting.
• Consider the information provided in this tool when choosing a nicotine replacement method.
• Remember:
  - If you are pregnant or have an unstable heart or blood vessel disease, discuss nicotine replacement options with your physician.
  - It's important to not smoke while using nicotine replacement.
  - Make a follow-up appointment with your health care provider to review progress.
  - Greater success comes when combining nicotine replacement with a behavioral smoking cessation program.

NOTE: This content was excerpted from the ACP Clinical Skills Module, Counseling for Behavior Change.

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This document provides information on both Varenicline (Chantix) and Bupropion (Zyban), including contraindications, patient selection, a guide for use, side effects, and precautions.

NOTE: This content was excerpted from the ACP Clinical Skills Module, The Diabetic Foot.

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Short-term tobacco dependence treatment is effective, and every tobacco user should be offered counseling and nicotine replacement (patch, gum, inhaler, and nasal spray) at every visit. Counseling should focus on establishing a quit date, emphasizing abstinence, using other family members, and avoiding alcohol and other drugs. Several effective pharmacotherapies for tobacco dependency are available and at least one of these medications should be added to counseling unless contraindicated. Data from the NIH Lung Health Study revealed that more participants in Smoking Intervention Group quit compared with usual and customary therapy (year 1: 34.4% vs. 9.0%; year 5: 37.4% vs. 21.9%). The annual rate of decline in FEV1 over 4 years for quitters was half that for continuing smokers. Additional findings from this study include: women who quit had a larger improvement in first year than men; women who continued to smoke had a greater loss of function than men with comparative smoking rate; and heavy smokers benefit more from quitting than lighter smokers (8). Strategies to help patients willing to quit smoking include the 5 A's...

Note: Subscription to MKSAP 14 is required to view this material. For more information, visit www.acponline.org.

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The second issue of In the Clinic provides a clinical overview of the health consequences of smoking as well as a comprehensive discussion on prevention of smoking-related disease, treatment, and practice improvement.

NOTE: Only ACP members and individual subscribers can access the electronic features of In the Clinic. Non-subscribers who wish to access this issue of In the Clinic can elect "Pay for View."

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How does someone decide whether to have a salad or ice cream with lunch? How do cancer patients choose between different courses of chemotherapy? While these questions vary greatly in their difficulty and significance, the key to understanding how people answer them lies in a still-developing field called behavioral economics.

"Behavioral economics brings together psychology and economics to better understand how people make decisions," said Kevin Volpp, ACP Member, assistant professor of medicine and health care systems at the University of Pennsylvania School of Medicine and the Wharton School in Philadelphia. The field grew out of some economists' recent realization that, contrary to traditional economic theory, people do not always make rational decisions or choose the course of action that is in their long-term interests.

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Question
Does describing to patients how smoking has accelerated their age-related decline in lung function (“lung age”) increase smoking cessation rates?

Conclusion
Telling smokers their lung age after spirometry increased the likelihood of successful smoking cessation a year later.

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Question
In high-risk smokers hospitalized for cardiovascular disease, does an intensive behavioral plus pharmacotherapy smoking cessation intervention after discharge plus usual care reduce mortality and hospital admissions more than usual care alone?

Conclusion
In high-risk smokers hospitalized with cardiovascular disease, an intensive smoking cessation intervention reduced hospital admissions and all-cause mortality more than usual care only.

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Question
In patients with coronary artery disease (CAD), do lifestyle and dietary changes reduce mortality?

Conclusion
In patients with coronary artery disease, evidence from randomized controlled trials supports increased physical activity and combined dietary changes for reducing mortality.

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Question
Do antidepressants increase long-term abstinence from smoking?

Conclusions
In smokers, bupropion and nortriptyline increase smoking cessation at 6 months. Selective serotonin-reuptake inhibitors do not increase abstinence.

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Question
Is oral or transdermal clonidine more effective than placebo for achieving long-term smoking cessation?

Conclusion
Oral or transdermal clonidine is more effective than placebo for achieving long-term smoking cessation but is associated with side effects including dry mouth and sedation.

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Background:

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the United States. Fewer than half of the estimated 24 million Americans with airflow obstruction have received a COPD diagnosis, and diagnosis often occurs in advanced stages of the disease.

Purpose:

To summarize the evidence on screening for COPD using spirometry for the U.S. Preventive Services Task Force (USPSTF).

Data Sources:

English-language articles identified in PubMed and the Cochrane Library through January 2007, recent systematic reviews, expert suggestions, and reference lists of retrieved articles.

Study Selection:

Explicit inclusion and exclusion criteria were used for each of the 8 key questions on benefits and harms of screening. Eligible study types varied by question.

Data Extraction:

Studies were reviewed, abstracted, and rated for quality by using predefined USPSTF criteria.

Data Synthesis:

Pharmacologic treatments for COPD reduce acute exacerbations in patients with severe disease. However, severe COPD is uncommon in the general U.S. population. Spirometry has not been shown to independently increase smoking cessation rates. Potential harms from screening include false-positive results and adverse effects from subsequent unnecessary therapy. Data on the prevalence of airflow obstruction in the U.S. population were used to calculate projected outcomes from screening groups defined by age and smoking status.

Limitation:

No studies provide direct evidence on health outcomes associated with screening for COPD.

Conclusion:

Screening for COPD using spirometry is likely to identify a predominance of patients with mild to moderate airflow obstruction who would not experience additional health benefits if labeled as having COPD. Hundreds of patients would need to undergo spirometry to defer a single exacerbation.

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