The various products differ in the kinetics of nicotine release. Nicotine patches yield a constant serum nicotine concentration and thus prevent nicotine-withdrawal phenomena. Nicotine chewing gum, tablets, or inhalers yield a rapid increase in nicotine concentration and give the user a feeling of control over nicotine intake, but they do not adequately mimic the rapid nicotine release from a cigarette. Nicotine nasal spray approved, but not marketed, in Germany comes closest to doing so but, for this very reason, is the most likely of all smoking cessation aids to create dependence itself.
Patients with severe withdrawal symptoms can be treated with a combination of products, e. Nicotine replacement should be provided for eight to twelve weeks and gradually reduced during this time. Supportive pharmacotherapy helps the patient get through the short-term symptoms of withdrawal. The side effects of nicotine administration are well known to smokers from their previous long-term consumption of nicotine via cigarettes. The individual nicotine replacement products can also have specific local side effects that are not produced by cigarette smoking e.
Bupropion is a monocyclic, activating antidepressant that is structurally related to amphetamine. It mimics the effect of cigarette-derived nicotine by inhibiting the reuptake of noradrenaline and dopamine, and it is thought to reduce nicotine-withdrawal manifestations by this mechanism as well. Sleep disturbances are a very common side effect; common ones include among others tremor, headache, difficulty concentrating, dizziness, dry mouth, and gastrointestinal complaints.
Epileptic seizures arise occasionally, and the drug is therefore contraindicated for patients who are at elevated risk of a seizure. The physician must also be aware of possible interactions with various other medications including antipsychotic agents, other antidepressants, and theophylline. The goal of nicotine replacment is to give the smoker, for a limited time only, a steadily diminishing dose of nicotine without the toxic substances that accompany nicotine derived from cigarette smoke.
Varenicline exerts its effect at the nicotinergic alpha4beta2-acetylcholine receptor, leading to saturation of the craving for smoking and preventing a subjectively positive effect of any additional nicotine taken up from cigarettes. Users report abnormal dreams, sleep disturbances, headache, and nausea as very common side effects; the common ones are dizziness, fatigue, and gastrointestinal complaints. Varenicline is contraindicated for use by pregnant women, children, and adolescents, as well as by smokers with mental illnesses in view of a few reported cases of suicidal thoughts and behavior.
Varenicline can interact with cimetidine, warfarin, and nicotine replacement drugs. The indication for either bupropion or varenicline should be considered carefully in view of the substantial likelihood of side effects. The patient can continue to smoke in the first few weeks of administration of either drug, while the dose is still rising. In this phase, most users already perceive cigarettes as less satisfying than before, and accordingly smoke less. The recommended duration of treatment is eight weeks for bupropion and twelve weeks for varenicline.
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Nicotine replacement should be provided for 8 to 12 weeks and gradually reduced during this time. If the treatment succeeds, but the patient remains in danger of taking up smoking again, all of the approved products can be given for a longer time. Nicotine replacement therapy is always better than cigarette smoking! The efficacy of these drugs has been repeatedly studied and evaluated in meta-analyses. Even though the latter two drugs seem to be more effective than nicotine replacement therapy, they are recommended less highly in the guidleines of the Drug Commission of the German Medical Association 7 because of their more severe side effects and risks.
Other treatments such as acupuncture and hypnosis are popular but are not recommended in the current treatment guidelines. The data on hypnosis and hypnotherapy are so inconsistent that their use cannot be recommended 6.
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Nor is there any recognized proof of efficacy for other methods such as electrical or electronic cigarettes, various naturopathic and homeopathic medications, some medications that have already been mentioned above, and many other techniques that are of an esoteric nature or rely principally on the power of suggestion. Treatments such as acupuncture and hypnosis are popular but are not recommended in the current treatment guidelines.
Even though tobacco consumption is a major direct or contributory cause of many diseases, the communication of information for the counseling of smokers and the treatment of dependent smokers who are willing to quit have long been neglected topics in medical school and in continuing medical education.
The topics covered include the tobacco problem in its societal context, strategies for tobacco-control policy and medical intervention, the consequences of smoking and smoking cessation for health, the psychological and neurobiological basis of tobacco dependence, methods of diagnostic evaluation, counseling, and smoking cessation in the individual-treatment setting, and aids to the implementation of smoking cessation in clinical practice.
Further training in how to conduct group therapy for smokers, e. Trained therapists can register with a provider database www.
This database helps counselors and smokers find the support they need. Smoking cessation courses can cost 80 to euros, depending on the type of course and on the provider; supportive pharmacotherapy for smoking cessation, in accordance with the guidelines, can cost up to euros.
The long-term efficacy of smoking cessation is higher when medical and psychological support for it are reimbursed e4. Recently, there have been calls for smoking cessation treatment to be regarded as part of the treatment of COPD, which would imply that its costs must be covered by statutory health insurance. An analogous classification would also be justifiable for smokers with other physical illnesses whose course would be positively influenced by smoking cessation, as well as for pregnant women who smoke and for persons diagnosed as tobacco-dependent.
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Instruments such as the FTND are useful aids to motivational work; motivational interviewing techniques,. If the patient cannot participate successfully in a smoking cessation program, and if telephone counseling, internet-based cessation programs, and self-help literature are not available, then weekly contacts with a physician to discuss progress and any difficulties in combination with supportive medication might be an appropriate alternative.
Persons who quit smoking can expect a long-term weight gain of 4 to 7 kg e5 , e6. Bupropion, varenicline, nicotine-replacement therapy, and medications such as dexfenfluramine or fluoxetine can counteract weight gain in the short term, but their long-term efficacy is uncertain. Weight can possibly be reduced over the long term by increased exercise e6.
The potential adverse effects of moderate weight gain are far outweighed by the benefits of tobacco abstinence e5. Physicians should take a smoking history daily cigarette consumption, attempts to quit from every smoker and inquire about his or her current motivation to quit. Persons who quit smoking can expect a long-term weight gain of 4 to 7 kg. Weight can possibly be reduced over the long term by increased exercise. CME points of the Medical Associations can be acquired only through the Internet, not by mail or fax, by the use of the German version of the CME questionnaire within 6 weeks of publication of the article.
See the following website: The EFN must be entered in the appropriate field in the cme. Because of an error in the German version of Question 9, all answers receive full credit. Please answer the following questions to participate in our certified Continuing Medical Education program.
Only one answer is possible per question.
Treatment of Tobacco Dependence
Please select the answer that is most appropriate. In the opinion of many authors, what percentage of smokers meet the ICD definition of tobacco dependence? Which of the following pieces of information is a proper and useful part of the diagnostic evaluation of a smoker? Which of the following medications is approved in Germany for the supportive treatment of smokers at the start of smoking abstinence?
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Which of the following can be a symptom of tobacco withdrawal in a tobacco-dependent person? Which of the following interventions is a recommended behavioral-therapeutic element of smoking cessation treatment? According to the German Federal Statistical Office, what percentage of the German population age 15 and above were smokers in ? Which of the following is recommended by the Drug Commission of the German Medical Association as an aid to smoking cessation? A year-old man was admitted to the hospital with an acute coronary syndrome. He had smoked cigarettes since age 17, a total of 45 pack-years, recently about 40 cigarettes per day.
His FTND score was 8. His reasons for smoking included what he perceived to be stress reduction, increased concentration, and relaxation attributable to smoking. Despite concern for his health and dissatisfaction with his own dependence on cigarettes, he had made no further attempts to quit, because he feared any such attempt would fail.
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Smoking cessation conseling began with detailed patient education about the available types of support. The patient decided to stop smoking and agreed to come for regular follow-up visits over the ensuing weeks. Nevertheless, he could not quit as desired because of marked nervousness, agitation, irritability, and sleep disturbances, and nicotine replacement therapy was recommended. In view of his high daily cigarette consumption and his marked nicotine dependence, combined treatment with a nicotine patch and nicotine chewing gum 4 mg was prescribed, and this indeed reduced his craving for cigarettes.
He succeeded in giving up cigarettes entirely by his chosen target date. In a subsequent six-week phase with weekly follow-up visits, he considered alternative means of stress reduction and relaxation, as well as ways to deal with situations that might lead him to take up smoking again. The nicotine replacement therapy was successfully tapered over the course of eight weeks of treatment, and then discontinued.
Treatment of tobacco dependance: Dtsch Arztebl Int ; Conflict of interest statement. National Center for Biotechnology Information , U. Journal List Dtsch Arztebl Int v. Published online Aug Anil Batra , Prof. Author information Article notes Copyright and License information Disclaimer.
Received May 2; Accepted Jul 4. See the reply " Correspondence letter to the editor: See the letter " Correspondence reply: This article has been cited by other articles in PMC. Abstract Background to people die in Germany each year of tobacco-related diseases. Method We present recommendations for the diagnostic evaluation, counseling, psychotherapy, and pharmacotherapy of smokers, derived from the findings of current Cochrane meta-analyses and from the pertinent German-language and American guidelines.
Learning objectives The learning objectives for readers of this article are: Open in a separate window. Mortality as a function of smoking status among British physicians from [1]. The main tobacco-associated diseases. Diagnostic evaluation Important information for the physician guiding a patient through outpatient smoking cessation includes: Withdrawal phenomena on reduction or cessation of consumption insomnia, nervousness, irritability, increased appetite, depressed mood ; consumption to alleviate withdrawal phenomena. Within 5 minutes 3 points 6 to 30 minutes 2 points 31 to 60 minutes 1 point After 60 minutes 0 points.
Yes 1 point No 0 points. The first one in the morning 1 point All others 0 points. Motivational strategies for smoking cessation Motivation. The smoker should understand and appreciate the potential personal advantages of quitting smoking. Smokers who are willing to quit smoking but never actually make an attempt usually do so out of fear: At every contact with the physician, the smoker should be asked about his or her current motivation to quit.
Repetition gradually reinforces the motivation to quit. The severity of nicotine dependence. The duration of nicotine replacement therapy. BOX 4 Available medications for smoking cessation.
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Treatments with no evidence of efficacy Other treatments such as acupuncture and hypnosis are popular but are not recommended in the current treatment guidelines. Treatments with no evidence of efficacy. Certified training programs and the reimbursement of smoking cessation counseling and treatment Even though tobacco consumption is a major direct or contributory cause of many diseases, the communication of information for the counseling of smokers and the treatment of dependent smokers who are willing to quit have long been neglected topics in medical school and in continuing medical education.
Techniques for the counseling of smokers. Reimbursement of smoking cessation therapy. Sun Oct 19, 8: Tue Nov 20, 9: Sun Oct 19, 9: Mon Dec 22, 6: No nowadays shit ripped from mp-fucking-3 nor burnt on CDr! Trade or buy, ask for my collection list with items. Fri Jan 16, 7: Thu Jan 22, 8: Tue Jan 27, 4: Mon Feb 02, 4: Fri Feb 06, 8: Tue Feb 10, 8: Wed Feb 11, 4: Thu Feb 12, 9: Fri Feb 13, 5: Thu Feb 26, 3: Tue Mar 03, 6: Tue Mar 03, 9: Mon Mar 23, 8: Tue Mar 24, 4: I need items from my list below in tape or CD-R format.
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