What is the recommended plan of care for a patient seeking to quit smoking?

Plan of Care for Smoking Cessation

Initiate combination pharmacotherapy immediately with varenicline (preferred) or combination nicotine replacement therapy (NRT) plus structured behavioral counseling, as this approach achieves the highest quit rates and should not be delayed when the patient is motivated. 1, 2

Immediate Assessment and Documentation

• Document smoking status at every visit as a vital sign, including pack-years, current daily consumption, previous quit attempts, and readiness to change 3, 4
• Assess for psychiatric comorbidities (depression, anxiety) and substance use, as these increase relapse risk and may influence medication selection 3, 1
• Set a firm quit date within 1-2 weeks of the initial consultation, emphasizing complete abstinence as the goal 3, 4

First-Line Pharmacotherapy Options

Varenicline (Most Effective Single Agent)

• Start varenicline one week before the quit date with the following FDA-approved titration schedule 5:
  • Days 1-3: 0.5 mg once daily
  • Days 4-7: 0.5 mg twice daily
  • Day 8 onward: 1 mg twice daily
• Continue for 12 weeks minimum, with an additional 12 weeks recommended for successful quitters to prevent relapse 5
• Varenicline achieves 21.8% quit rates at 6 months versus 9.4% with placebo, making it the most effective single agent 2
• Avoid varenicline in patients with active psychiatric disorders (psychosis, severe depression, bipolar disorder) due to neuropsychiatric adverse event warnings 5, 6

Combination NRT (Preferred Alternative)

• Combine nicotine patch (steady-state delivery) with short-acting NRT (gum, lozenge, or inhaler for breakthrough cravings) 1, 4
• This combination is more effective than single NRT and achieves 15.7% quit rates at 6 months 2, 1
• NRT is the safest option for patients with psychiatric comorbidities, as it has no psychiatric contraindications 6
• Provide clear instructions on proper use, including potential side effects and realistic expectations 3, 4

Bupropion SR (Second-Line)

• Bupropion achieves 16.2% quit rates at 6 months versus 9.4% with placebo 2
• Use cautiously in patients with seizure history or factors that lower seizure threshold 5

Structured Behavioral Counseling (Mandatory Component)

The 5 A's Framework at Every Visit

• Ask about tobacco use status at every encounter 1, 4
• Advise to quit in a clear, strong, personalized manner linked to current health concerns 1, 4
• Assess willingness to make a quit attempt now 3, 1
• Assist with practical counseling, pharmacotherapy, and quit plan development 1, 4
• Arrange intensive follow-up support 1, 4

Counseling Intensity and Content

• Deliver at least 4 sessions of 10-30 minutes each over 12 weeks, with the first session within 2-3 weeks of starting pharmacotherapy 3, 1
• Longer, more frequent sessions achieve higher success rates, with high-intensity counseling (>10 minutes) nearly doubling abstinence rates compared to minimal counseling 3
• Focus on specific problem-solving strategies 3, 1:
  • Removing all tobacco products from home and work before quit date
  • Identifying high-risk situations and smoking triggers
  • Developing coping strategies for stress and cravings
  • Reviewing what worked or didn't work in previous quit attempts
  • Planning for nicotine withdrawal symptoms (peak at 1-2 weeks)

Delivery Formats

• Provide individual or group counseling in-person, by telephone, or via quitline if face-to-face sessions are unavailable 3, 4
• Coordinate counseling with scheduled medical visits to minimize additional appointments 3
• Refer to specialized smoking cessation programs for patients with significant psychiatric comorbidity 3, 1

Follow-Up Schedule

• First follow-up within 2-3 weeks of quit date to assess medication adherence, withdrawal symptoms, and early relapse risk 1, 4
• Continue weekly follow-up for at least 4 weeks, then monthly for the first 3 months 3, 1
• Verify abstinence with expired carbon monoxide measurement when possible 3
• Monitor for mood changes, depression, or anxiety throughout the cessation attempt, especially in the first 6 months 3, 1

Alternative Approach for Patients Unable to Quit Abruptly

• Consider a gradual reduction approach for patients who are certain they cannot quit abruptly 5:
  • Start varenicline and reduce smoking by 50% within first 4 weeks
  • Reduce by another 50% in the next 4 weeks
  • Achieve complete abstinence by week 12
  • Continue treatment for additional 12 weeks (total 24 weeks)
• Encourage patients to quit sooner if they feel ready during the reduction period 5

Common Pitfalls to Avoid

• Never provide advice without offering practical assistance and pharmacotherapy, as medication significantly increases success rates 4, 7
• Do not delay pharmacotherapy initiation when the patient is motivated, as this misses a critical window 1
• Avoid inadequate follow-up support, which is a major cause of relapse 4
• Do not prescribe varenicline without behavioral counseling, as combination therapy is substantially more effective than either alone 3, 7
• Never underestimate the importance of addressing psychiatric comorbidities, particularly depression and anxiety, which are common relapse triggers 3, 1

Special Populations

Patients with Severe Renal Impairment

• For creatinine clearance <30 mL/min: Start varenicline at 0.5 mg once daily, titrate to maximum 0.5 mg twice daily 5
• For hemodialysis patients: Maximum dose 0.5 mg once daily if tolerated 5

Patients with Cardiovascular Disease

• Balance cardiovascular event concerns with substantial health benefits of smoking cessation 5
• Instruct patients to report new or worsening cardiovascular symptoms and seek immediate care for signs of MI or stroke 5

Hospitalized Patients

• Provide NRT to inpatients who smoke and continue support beyond hospitalization 4
• Ensure smoke-free hospital policies and inform patients before admission 4

Treatment of Relapse

• Encourage another quit attempt when factors contributing to relapse have been identified and addressed 5
• Most smokers require 6 or more quit attempts before achieving long-term abstinence 2
• Resume cessation plan as quickly as possible after any slip 3