nicotine patch with NRT gum or spray (Fiore et al., 2008). The guideline also recommends two second-line medications, defined as medications that FDA has not approved for tobacco-dependence treatment and about which there are more concerns for potential side effects than in the case of first-line medications: clonidine and nortriptyline.

Interactions between tobacco smoke and various medications have been identified (Zevin and Benowitz, 1999), and clinicians should not only be aware of their patients’ smoking status but also should monitor patients to ensure that their medications are acting as prescribed. Because former smokers may relapse and current smokers may decide to quit smoking, it is important to ascertain smoking status at each office visit and to inform patients of the need to be aware of possible changes in their response to any medication, whether prescription or over the counter and whether used for tobacco cessation or for other conditions.

Combined Behavioral Interventions and Medications

The guideline concludes that “the combination of counseling and medication is more effective for smoking cessation than either intervention alone. Therefore, whenever feasible and appropriate, both counseling and medication should be provided to patients trying to quit smoking” (Fiore et al., 2008). A meta-analysis of 9 studies showed a 70% increase in the likelihood of quitting when medication was added to counseling alone, and a meta-analysis of 18 studies showed a 40% increase in the likelihood of quitting when counseling was added to medication alone (Fiore et al., 2008). With behavioral counseling alone, there was a dose–response relationship between the number of counseling sessions and rates of cessation. Two or more sessions significantly increased cessation rates; the highest abstinence rates were observed with more than eight counseling sessions (32.5% abstinence rate at 6 months). Furthermore, among patients who used multiple tobacco-cessation medications in combination with individual or group counseling, the cessation rates at 6 months increased with the number of medications. Patients who continued to use medications at 6 months had a greater abstinence rate than those who quit using them in less than 6 months (82% vs. 52%) (Steinberg et al., 2006).

Other Individual Interventions

Although other tobacco-cessation interventions are available—such as self-help materials, rapid smoking, acupuncture, and hypnosis—results are inconclusive with regard to their effectiveness in helping tobacco users achieve long-term abstinence. The 2008 PHS guideline states that rapid smoking (also called aversive smoking) was more



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