Interventions for smokeless tobacco use cessation.

BACKGROUND: Use of smokeless tobacco (ST) can lead to nicotine addiction and long-term use can lead to health problems including periodontal disease and cancer. OBJECTIVES: To assess the effects of behavioural and pharmacologic interventions for the treatment of ST use. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, Web of Science, PsycINFO, Dissertation Abstracts Online, and Scopus. Date of last search: March, 2007. SELECTION CRITERIA: Randomized trials of behavioural or pharmacological interventions to help users of ST to quit with follow up of at least six months. DATA COLLECTION AND ANALYSIS: Two authors independently extracted data. MAIN RESULTS: Two trials of bupropion SR did not detect a benefit of treatment at six months or longer (Odds Ratio (OR) 0.86, 95% Confidence Interval (CI): 0.47 to 1.57). Four trials of nicotine patch did not detect a benefit (OR 1.16, 95% CI: 0.88 to 1.54), nor did two trials of nicotine gum (OR 0.98, 95% CI: 0.59 to 1.63). There was statistical heterogeneity among the results of 12 behavioural interventions included in the meta-analyses. Six trials showed significant benefits of intervention. In post-hoc subgroup analyses, behavioural interventions which include telephone counselling or an oral examination may increase abstinence rates more than interventions without these components. AUTHORS' CONCLUSIONS: Behavioural interventions should be used to help ST users to quit and telephone counselling or an oral examination may increase abstinence rates. Pharmacotherapies have not been shown to affect long-term abstinence.

Smoking characteristics and cessation in patients with thromboangiitis obliterans.

AIM: Describe the smoking characteristics and the results of a smoking intervention programme involving 27 cigarette smokers with Thromboangiitis Obliterans (TAO). METHODS: Clinical records of all cigarette smokers with TAO that attended our smoking treatment clinic from 1990 to 2004 were reviewed. Demographic and smoking characteristics, the type of smoking treatment received and its efficacy and safety up to 12 months was abstracted. Treatment consisted of the combination of behavioural and pharmacological treatment. The behavioural treatment was delivered in eight individual visits: one baseline visit and seven follow-up visits. Pharmacological treatment consisted of combinations of nicotine patches and nicotine gum (NRT) and/or bupropion. This is an 'intent to treat' analysis. A descriptive analysis of the variables was performed. Qualitative variable relationships were tested using the chi-square test for independence, or Fisher's Exact Test when expected values were less than five. Statistical significance was accepted at a level of p < 0.05. RESULTS: 27 cigarette smokers (23 male and 4 female), mean (SD) age 36.07 (7.23), mean FTND-score 8.4 (1.4), smoked a mean of 29.6 (7.71) cigarettes daily. They attended our clinic a mean of 45.48 (8.63) months after onset of TAO. Their mean number of attempts to stop was 3.22 (2.75). The continuous abstinence rate decreased from 29% at the end of treatment to 18.5% at 12-month follow up. The seven day point prevalence abstinence rate at the 12th month of follow up was 40.7%. We found that continuous abstinence at 6 and 12 months was more frequent among those with multiple previous stop attempts (p = 0.003 and p = 0.001, respectively). There were no significant differences in abstinence outcomes between groups. Incidence of adverse effects was similar to other smokers seeking treatment. All the smokers who achieved continuous tobacco abstinence had improvement in their disease and none of them underwent amputation, compared to 50% of those who resumed smoking and later required an amputation. CONCLUSIONS: Continuous abstinence rates among treated cigarette smokers with TAO are relatively low, but abstinence does improve symptoms and reduce the likelihood of amputation. More aggressive treatment programmes need to be developed for this high risk, highly tobacco dependent population.

Serum nicotine and cotinine levels during nicotine-patch therapy.

We related serum nicotine and cotinine levels while subjects were smoking their usual numbers of cigarettes to levels while wearing a nicotine patch under carefully controlled, smoke-free conditions in a clinical research center. Twenty-four volunteers who needed intensive treatment for severe nicotine dependence were admitted to the clinical research center and were treated with a 22 mg transdermal nicotine patch each day and an intensive smoking-cessation program. Serum nicotine and cotinine levels, withdrawal symptoms, and hours and quality of sleep were noted. The steady-state serum nicotine and cotinine levels produced with the nicotine patch were lower than those observed when the subjects were smoking. Mean nicotine and cotinine levels were inversely related to mean withdrawal scores for the first 6 days. A fixed dose of transdermal nicotine will not be effective for all smokers. Individualization of therapy should be based on objective biologic measures such as serum cotinine and subjective assessment of withdrawal relief.

Nicotine-replacement therapy with use of a transdermal nicotine patch--a randomized double-blind placebo-controlled trial.

The rate of smoking was significantly reduced in volunteer subjects by providing effective nicotine replacement, self-help material, and weekly visits with a nurse for 6 weeks. Nicotine-replacement therapy with a transdermal nicotine patch (Nicolan) almost doubled the 6-week smoking-cessation rate in comparison with that in a placebo group (77% versus 39%; P = 0.002) among subjects who were smoking at least 20 cigarettes per day at baseline. Although most subjects who used the active nicotine patches had skin reactions, the reactions were primarily mild. For use of both active and placebo patches, the level of patient compliance was high. Among subjects who continued to smoke, the use of cigarettes was decreased to less than 50% of the baseline smoking level in 7 of 7 with active nicotine patches and in 15 of 19 with placebo patches. Outcomes beyond 6 weeks showed a substantial relapse rate in both groups. Thus, when nicotine-replacement therapy is provided, a need exists for concurrent behavioral intervention and training for prevention of a relapse, neither of which was part of this protocol.

A free smoking intervention clinic initiated by medical students.

OBJECTIVE: To describe a medical student-run smoking intervention clinic, report initial outcomes, and assess medical student competence in smoking intervention counseling. PATIENTS AND METHODS: Volunteer medical students of Mayo Medical School in Rochester, Minn, staffed a free smoking intervention clinic in conjunction with the Salvation Army Free Acute Care Clinic between December 1997 and January 1999. Patients received a comprehensive intervention for smoking that comprised counseling, frequent follow-up contact, and pharmacologic therapy, including bupropion and nicotine replacement. Eighty-eight patients seen during the first 13 months of the clinic's operation and 30 medical student volunteer counselors were included in the study. Patients were contacted via telephone to assess 6-month self-reported smoking abstinence. Medical student counselors completed a self-assessment questionnaire surveying competence before and after working in the clinic. RESULTS: The 6-month self-reported smoking abstinence rate was 18% (95% confidence interval, 11%-28%). Twelve of 14 medical students completing the survey reported improved competence in smoking intervention counseling. CONCLUSIONS: A comprehensive smoking intervention program provided by medical students yielded smoking abstinence rates comparable to other treatment programs. Medical students believed they improved their smoking cessation counseling skills.

Treatment of nicotine dependence.

Nicotine dependence is characterized by periods of relapse and remission. Health care workers can have a pivotal role in the treatment of nicotine dependence. Smokers should be identified and categorized based on their readiness to change. Smokers who are preparing to stop smoking should be given multicomponent therapy in a step-care approach using behavioral treatment, addiction treatment, pharmacotherapy, and techniques of relapse prevention. Pharmacotherapies approved by the Food and Drug Administration for smoking interventions include sustained-release bupropion, nicotine gum, the nicotine inhaler, nicotine nasal spray, and nicotine patches.

Cholesterol-lowering effect of stanol ester in a US population of mildly hypercholesterolemic men and women: a randomized controlled trial.

OBJECTIVE: To determine the efficacy of stanol esters in lowering cholesterol in a US population. SUBJECTS AND METHODS: After a run-in phase, 318 subjects were randomized to receive one of the following margarine-like spreads containing stanol ester or placebo for 8 weeks: EU 3 G: 1 g of stanol (ester form) per 8-g serving of a European formula 3 times a day; US 3 G: 1 g of stanol (ester form) per 8-g serving of a US reformulation 3 times a day; US 2 G: 0.67 g of stanol (ester form) per 8-g serving of a US reformulation 3 times a day; or placebo spread. RESULTS: Mean +/- SD baseline total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) levels were 233+/-20 and 153+21 mg+/-dL, respectively. In the US 3 G group, 3 g daily of stanol esters lowered TC and LDL-C levels by 6.4% and 10.1%, respectively. There was a dose-dependent response compared with 2 g daily (US 2 G). Triglyceride and high-density lipoprotein cholesterol levels were unchanged. The incidence of adverse effects was not different from placebo. Serum vitamin A and 25-hydroxyvitamin D levels were not affected. CONCLUSIONS: Stanol esters lowered TC and LDL-C levels in a mildly hypercholesterolemic US population without evidence of adverse effects. It may be a useful dietary adjunct to lower cholesterol.

Inpatient treatment of severe nicotine dependence.

The most severely nicotine-dependent patients who have tried traditional treatment programs without success may require maximal intervention to achieve abstinence. In the Clinical Research Center at the Mayo Clinic, we assessed the feasibility of an inpatient treatment program for 24 such subjects, who were hospitalized (in groups of 6) for 2 consecutive weeks. A combination of behavioral, chemical-dependence, and transdermal nicotine-replacement therapy was provided in a smoke-free, protected milieu. Components of the program included group therapy, management of stress, exercise, daily lectures, and supervised activities. The mean age of the 18 women and 6 men was 51.3 years (range, 29 to 69 years). The mean duration of smoking was 33.7 years, and the number of cigarettes smoked per day at the time of admission averaged 33.2. The most frequent tobacco-related medical illnesses were chronic obstructive pulmonary disease, arteriosclerosis obliterans, and coronary artery disease. All subjects but two--each smoked part of a cigarette--remained abstinent from the use of cigarettes while in the Clinical Research Center, and all completed the 2-week inpatient program. The subjects underwent follow-up for 10 weeks after dismissal and were contacted periodically thereafter. At 1 year, 7 of the 24 subjects (29%) had maintained continuous abstinence from smoking, and their self-reported status at 1 year was verified biochemically.

Rheumatoid vasculitis manifesting as intra-abdominal hemorrhage.

Rheumatoid vasculitis, an extra-articular component of rheumatoid arthritis, causes a wide spectrum of manifestations that range from clinically insignificant to life-threatening disease. As a systemic necrotizing arteritis, rheumatoid vasculitis is usually characterized by end-organ ischemia. Herein we describe a patient with abdominal pain and syncope due to intra-abdominal hemorrhage from a ruptured aneurysm of the inferior pancreaticoduodenal artery in the setting of rheumatoid vasculitis. Although the intra-abdominal hemorrhage was the unusual manifestation of rheumatoid vasculitis in this patient, he had a history of prior extra-articular rheumatoid disease, including pulmonary fibrosis and Sjögren's syndrome with associated parotid lymphoproliferative disease. In patients with rheumatoid arthritis who have abdominal pain and an unexplained rapidly decreasing hemoglobin concentration, the diagnosis of intra-abdominal hemorrhage from a ruptured visceral aneurysm due to rheumatoid vasculitis should be considered, even in the absence of other indications of systemic vasculitis.

Nicotine nasal spray for smoking cessation: pattern of use, side effects, relief of withdrawal symptoms, and cotinine levels.

OBJECTIVE: To determine the extent of side effects during the initial use of nicotine nasal spray for smoking cessation. DESIGN: We performed a one-sample, noncomparative, open-label evaluation of the pattern of use, side effects, relief of withdrawal symptoms, and cotinine levels with nicotine nasal spray. MATERIAL AND METHODS: Adult smokers were recruited to use the nicotine nasal spray for smoking cessation at a dosage of 1 to 2 mg/h. Subjects completed daily diaries, which included an assessment of nicotine withdrawal symptoms, previously reported irritant effects of the nicotine nasal spray, and symptoms of nicotine toxicity. A plasma cotinine level was measured at baseline and at day 7 for calculation of percentage replacement. RESULTS: The mean age of the 50 study subjects was 43.7 years, 46% were women, and the mean baseline smoking rate was 28.5 cigarettes per day. We found an increase in five symptoms (runny nose, nasal irritation, throat irritation, watering eyes, and sneezing) that had been essentially absent before initiation of use of the nicotine nasal spray. All but throat irritation decreased significantly during days 0 through 7 of the study. The mean daily frequency of nicotine nasal spray use for the first week was 15.0 doses. Use of the nasal spray decreased significantly (P<0.001) during the initial 8 weeks of treatment. The mean percentage cotinine replacement for those subjects who were abstinent at day 7 was 38.6%. CONCLUSION: Although nicotine nasal spray causes substantial irritant side effects during the first few days of use, these adverse effects decrease significantly within the first week. Despite these side effects, subjects continued to use the nicotine nasal spray and experienced a high rate of initial abstinence from smoking.

The CardioVision 2020 baseline community report card.

OBJECTIVE: To establish baseline data for the CardioVision 2020 program, a collaborative project in Olmsted County, Minnesota, organized to reduce cardiovascular disease rates by altering 5 health-related items: (1) eliminating tobacco use and exposure, (2) improving nutrition, (3) increasing physical activity, (4) lowering serum cholesterol level, and (5) controlling blood pressure. SUBJECTS AND METHODS: Data about tobacco use, diet, and physical activity were collected by random digit dial interview and follow-up questionnaire from a sample of the population. Blood pressure data were collected from medical records at Mayo Clinic, and serum cholesterol data were derived from the Mayo Clinic laboratory database. Data were stratified into 6 age groups. RESULTS: A total of 624 women and 608 men responded to the questionnaire. Population blood pressure data were available for 1,956 women and 1,084 men. Population serum cholesterol data were available for 17,042 women and 12,511 men. Except for women in the 30- to 39-year-old age group, less than 10% of the population sampled met 4 or 5 goals. Conversely, about 90% of the population met at least 1 goal, and about 80% met 1, 2, or 3 of the goals. CONCLUSION: The data from the Olmsted County population indicate considerable opportunity to reduce this population's burden of cardiovascular disease.

Bupropion for smoking cessation : predictors of successful outcome.

OBJECTIVES: To identify predictors of smoking abstinence at the end of medication use that could assist in the optimal use of a sustained-release (SR) form of bupropion for treating cigarette smokers. DESIGN: A double-blind, placebo-controlled, dose-response trial. SETTING: Multicenter (three sites) study conducted in the United States. PARTICIPANTS: Six hundred fifteen healthy men and women (> or = 18 years of age) who were smoking > or = 15 cigarettes per day and who were motivated to stop smoking. INTERVENTION: Random assignment of patients to placebo or SR bupropion treatment, 100, 150, or 300 mg/d, for 7 weeks (total duration of study was 52 weeks: 7 weeks of treatment and 45 weeks of follow-up). MEASUREMENTS AND RESULTS: Logistic regression was used to identify predictors of abstinence at the end of the medication phase. Univariate predictors included the following: bupropion dose (p < 0.001); older age (p = 0.024); lower number of cigarettes smoked per day (cpd) (p < 0.001); lower Fagerström Tolerance Questionnaire score (p = 0.011); longest time previously abstinent that was < 24 h or > 4 weeks (p < 0.001); absence of other smokers in the household (p = 0.021); greater number of previous stop attempts (p = 0.019); and study site (p = 0.004). Multivariate predictors of abstinence at the end of the medication phase were the following: higher bupropion dose (p < 0.001); lower number of cpd (p < 0.001); longest time previously abstinent from smoking (p = 0.002); male gender (p = 0.014); and study site (p = 0.021). CONCLUSION: Bupropion SR therapy was effective in treating cigarette smokers independently of all other characteristics studied. Lower smoking rate, brief periods (ie, < 24 h) or long periods (ie, > 4 weeks) of abstinence with previous attempts to stop smoking, and male gender were predictive of better outcomes, independent of the dose of bupropion that was used.

Temporal effects of nicotine nasal spray and gum on nicotine withdrawal symptoms.

Nicotine nasal spray and nicotine gum have been found to be effective in relieving nicotine withdrawal symptoms. In this randomized single-blind study, 91 cigarette smokers were randomly assigned to a single 1 mg dose of active nicotine nasal spray (n=29), active 4 mg nicotine gum (n=31), saline placebo nasal spray (n=16) or placebo gum (n=15). Following overnight abstinence, subjects repeatedly completed visual analog scales for assessing nicotine withdrawal symptoms over 30 min preceding (time -30 min to time 0) and 120 min following a single dose of study medication. This sequence was performed 3 times during the day. Nicotine withdrawal symptoms were assessed on a 41-point visual analog scale (1=no withdrawal, 41=extreme withdrawal). At the initial session only, blood samples for serum nicotine levels were taken at baseline, then at 5, 10, 30 and 120 min following study drug administration. The mean (+/-SD) age of the subjects was 38.6 (+/-10.1) years, 48% were females, smoking rate was 24.5 (+/-7.8) cigarettes per day, and years of smoking was 19.9 (+/-10.0). A single 1 mg dose of nicotine nasal spray provided more immediate relief for craving for a cigarette compared to a single 4 mg dose of nicotine gum. Serum venous nicotine levels for the active nicotine nasal spray and nicotine gum were comparable at 5 and 10 min while the levels were higher for nicotine gum at 30 and 120 min. Changes in withdrawal symptoms were not found to be related to serum venous nicotine levels. Our findings provide a rationale for the as needed use of nicotine nasal spray to control withdrawal symptoms, possibly in combination with other medications with longer acting effects.

Application of serum nicotine and plasma cotinine concentrations to assessment of nicotine replacement in light, moderate, and heavy smokers undergoing transdermal therapy.

As part of a clinical trial investigating the level of nicotine replacement with different doses of transdermal therapy for smoking cessation, peak and trough serum nicotine and plasma cotinine concentrations were measured in 70 subjects while they were actively smoking (baseline) and daily for 6 consecutive inpatient days while they were receiving transdermal nicotine. Subjects were randomly assigned to a daily 24-hour patch delivering a transdermal nicotine dose of 0, 11, 22, or 44 mg and stratified by self-reported smoking rate as either light (10-15 cigarettes per day), moderate (16-30 cigarettes per day), or heavy (>30 cigarettes per day). Steady-state concentrations of nicotine and cotinine were attained in 1 and 3 days, respectively, at all doses and were independent of baseline smoking rate. Mean percentage replacement of nicotine was calculated by dividing steady-state peak nicotine or cotinine concentrations by their respective baseline concentrations. Significant underreplacement occurred in subjects receiving the 11 mg/day patch regardless of baseline smoking rate. Underreplacement also occurred in moderate and heavy smokers receiving 22 mg/day and in light smokers at this same dose. Complete replacement occurred only in subjects receiving the 44 mg/day patch. These results have several implications for transdermal nicotine therapy. First, with the higher nicotine and cotinine levels observed with heavier smoking, it is inherent that one size does not fit all, and there is a need to consider more individualization of dosage for nicotine patch therapy. Second, there is substantial underreplacement with the 22 mg/day dose in moderate to heavy smokers and in some light smokers. Third, even with twice the usual dose (i.e., 44 mg/day), there was no accumulation of either nicotine or cotinine. Plasma cotinine levels after achievement of steady state (i.e., after 3 days of patch therapy) can be collected at any time and used to calculate percent replacement using baseline levels.

Application of urine nicotine and cotinine excretion rates to assessment of nicotine replacement in light, moderate, and heavy smokers undergoing transdermal therapy.

As part of a clinical trial investigating the level of nicotine replacement with different doses of transdermal therapy for smoking cessation, urine excretion rates of nicotine and cotinine were measured in 70 subjects while they were actively smoking (baseline) and for 6 consecutive inpatient days while they were receiving transdermal nicotine therapy. Subjects were stratified according to baseline smoking rate as light (10-15 cigarettes per day), moderate (16-30 cigarettes per day), or heavy (>30 cigarettes per day) smokers and randomly assigned to a daily 24-hour patch delivering a transdermal nicotine dose of 0, 11, 22, or 44 mg. Steady-state excretion rates of nicotine and cotinine were attained in 2 and 3 days, respectively, at all doses and were independent of smoking rate. Percentage replacement of nicotine was calculated by dividing steady-state nicotine or cotinine excretion rates by their respective baseline excretion rates. Significant underreplacement occurred with the 11-mg/day dose, particularly in moderate and heavy smokers (<50%). At a dose of 22 mg/day, nicotine replacement was still <100% in the majority of subjects. Only at a dose of 44 mg/day did mean replacement exceed 100% regardless of baseline smoking rate.

Nicotine patch therapy for smoking cessation in recovering alcoholics.

In a post hoc analysis of prior nicotine patch studies, we analysed findings in 357 subjects (43 recovering alcoholics, 314 non-alcoholics) to determine if recovering alcoholic smokers were more nicotine dependent than non-alcoholics and whether the efficacy of nicotine patch therapy was comparable. The Self-Administered Alcoholism Screening Test was used to identify recovering alcoholics. Recovering alcoholics had significantly higher mean smoking rates (cigarettes per day), Fagerström scores and baseline serum nicotine and cotinine than non-alcoholics. Among a subset of 240 subjects with a comparable treatment protocol, smoking cessation rates at the end of nicotine patch therapy were similar in recovering alcoholics (46%) and non-alcoholics (47%) receiving active 22 mg patches but higher than the respective placebo groups (17% and 19%). The 1-year rate was significantly (p = 0.005) higher in the non-alcoholic group assigned to an active patch (31%) compared to placebo (14%). For recovering alcoholics, the rates were lower and not significantly different (active 0%, placebo 11%). Recovering alcoholic smokers are likely to be more nicotine dependent than non-alcoholic smokers but can achieve comparable short-term cessation rates with nicotine patch therapy. Use of an objective, validated measure of alcohol dependence is indicated in clinical trials when it is desirable to know whether the subjects are active or recovering alcoholics.

A comprehensive model for the treatment of nicotine dependence in a medical setting.

We have summarized the basic components of a comprehensive model for the treatment of nicotine addiction in a medical setting. It is a labor-intensive program with emphasis on individual assessment and the development of individual treatment programs adaptable to all levels of nicotine dependence. We anticipate that this model will be increasingly used by medical centers in the future. As more traditional programs successfully treat the less severely nicotine-dependent patients, more severely dependent smokers are left in need of more intensive services. We have already begun to see this trend in our practice, requiring more counselor time for individual follow-up and referral into our group therapy programs. Adjunctive pharmacologic therapy is an exciting and promising area, but best results include associated behavioral intervention. Reimbursement remains a major impediment to patient involvement in many of these programs. This impediment will be overcome when third-party payers begin to cover these services as endorsed by the Surgeon General and the United States Department of Health and Human Services.

Interventions for smokeless tobacco use cessation.

BACKGROUND: Use of smokeless tobacco (ST) can lead to nicotine addiction and health problems including periodontal disease and oral cancer OBJECTIVES: To assess the effects of behavioural and pharmacotherapeutic interventions to treat ST use. SEARCH STRATEGY: We searched the Cochrane Tobacco Addiction Group trials register (February 2004), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2004), MEDLINE (January 1966-February 2004), EMBASE (1988-January 2004), CINAHL (1982-February 2004), PsycINFO (1984-February 2004), Database of Abstract of Reviews of Effectiveness (DARE, The Cochrane Library, Issue 1, 2004). SELECTION CRITERIA: Randomized trials of behavioural or pharmacological interventions to help users of ST to quit, with follow-up of at least six months. DATA COLLECTION AND ANALYSIS: Two authors independently extracted data. MAIN RESULTS: One trial of bupropion did not detect a benefit of treatment after six months (Odds Ratio (OR) 1.00, 95% Confidence Interval (CI): 0.23 to 4.37). Three trials of nicotine patch did not detect a benefit (OR 1.16, 95% CI: 0.88 to 1.54), nor did two trials of nicotine gum (OR 0.98, 95% CI: 0.59 to 1.63). There was statistical heterogeneity among the results of eight trials of behavioural interventions included in the meta-analysis. Three trials showed significant benefits of intervention. In a post-hoc analysis the trials of interventions which included an oral examination and feedback about ST-induced mucosal changes had homogeneous results and when pooled showed a significant benefit (OR 2.41 95% CI: 1.79 to 3.24). REVIEWERS' CONCLUSIONS: Behavioural interventions should be used to help ST users to quit. Pharmacotherapies have not been shown to affect long-term abstinence but larger trials are needed.

Drug therapy to aid in smoking cessation. Tips on maximizing patients' chances for success.

The arsenal of pharmacologic agents available for smoking cessation has expanded in the last few years, and it is likely to continue to do so. It is important that practicing physicians keep abreast of new methods as they become available and encourage patients who smoke to undertake cessation measures. Nicotine-replacement therapy is available in gum, patch, nasal spray, or inhaler form, and bupropion therapy aids in smoking cessation through dopaminergic activity. The foundation of effective intervention is likely to remain unchanged: an individualized plan addressing behavioral, addictive, pharmacologic, and relapse-prevention components. In addition to the necessary information about treatment choices, physicians should offer motivation, support, and follow-up to their patients who wish to quit smoking.

Counseling patients to quit smoking. What to say, when to say it, and how to use your time to advantage.

Helping patients stop smoking is one of the most important--and frustrating--services primary care physicians can provide. Many physicians are reluctant to spend time talking about tobacco use with patients who show little or no interest in changing their habits. Fortunately, specific technique have been identified that can make the task easier. This article from the distinguished Nicotine Dependence Center of the Mayo Clinic looks at the "best practices" for dealing with nicotine dependence.