Appendix 1. Fagerstrom
Nicotine Tolerance Questionnaire
| How Addicted To Nicotine Are You? | ||||
|
Question |
A=0 Points |
B=1 |
C=2 Points |
Score |
|
1. How soon after you wake up do you smoke your first cigarette? |
After 30 minutes |
Within 30 minutes |
----- |
|
|
2. Do you find it difficult to refrain from smoking in places where it is forbidden, such as at the library, theater, or doctor’s office? |
No |
Yes |
||
|
3. Which of the cigarettes you smoke in a day is the most satisfying? |
Any other than the first one in the morning |
The first one in the morning |
----- |
|
|
4. How many cigarettes a day do you smoke? |
1-15 |
16-25 |
More than 25 |
|
|
5. Do you smoke more during the morning than during the rest of the day? |
No |
Yes |
----- |
|
|
6. Do you smoke when you are so ill that you are in bed most of the day? |
No |
Yes |
----- |
|
|
7. Does the brand you smoke have a low, medium, or high nicotine content? |
Low 0.4 mg |
Medium 0.5 to 0.9 mg |
High 1.0 mg or more |
|
|
8. How often do you inhale the smoke from your cigarette? |
Never |
Sometimes |
Always |
|
|
If you scored 4 points or more, you may be addicted
to nicotine. Total ___
|
||||
Appendix 2. Pharmacology
|
Nicotine replacement products1, 2, 3 |
||
|
Transdermal nicotine4, 5, 6, 7, 8 |
||
|
Dosage |
Heavy dependence |
> 24 cigarettes/day¾ High dose (21 mg) for 6 weeks, then intermediate dose (14 mg) for 2 weeks, then low dose (7 mg) for 2 weeks |
|
Mild dependence |
< 24 cigarettes/day¾ Intermediate dose (14 mg) for 6 weeks, then low dose (7 mg ) for 2 Taper over 2 weeks |
|
|
Contraindications |
Allergy, pregnancy (Risk Category D) |
|
|
Adverse reactions |
Sleep disturbances, skin irritations |
|
|
Drug Interactions |
No direct interactions; smoking cessation may alter the pharmacokinetics of some drugs |
|
|
Efficacy |
One year abstinence vs placebo - Odds Ratio (O.R.) =2.1 |
|
|
Polacrilex nicotine9, 10, 11, 12, 13 |
||
|
Dosage |
> 25 cigarettes/day; 4mg strength < 25 cigarettes/day; 2 mg strength One piece of gum q 1 to 2 hr for 6 weeks Taper over 6 weeks |
|
|
Contraindications |
Allergy; pregnancy (Risk Category X) |
|
|
Adverse Reactions |
Nausea, dyspepsia, jaw fatigue, dependency |
|
|
Drug Interactions |
No direct interactions; smoking cessation may alter the pharmacokinetics of some drugs |
|
|
Efficacy |
One year abstinence vs placebo - O.R. = 1.4 to 1.6 |
|
|
Nasal spray nicotine14, 15 |
||
|
Dosage |
8 to 40 mg/day (average 15 mg) for 8 weeks Taper over 6 weeks |
|
|
Contraindications |
Allergy, pregnancy (Risk Category D) |
|
|
Adverse reactions |
Nasal and /or throat irritation, dependence |
|
|
Drug interactions |
No direct interactions; smoking cessation may alter the pharmacokinetics of some drugs |
|
|
Efficacy |
One year abstinence vs placebo - O.R. = 1.8 |
|
|
Oral vapor nicotine-inhaler16 |
||
|
Dosage |
6 to 16 cartridges/day for 12 weeks (each cartridge is 4 mg) Taper over 6 to 2 weeks |
|
|
Contraindications |
Allergy; pregnancy (Pregnancy Category D) |
|
|
Adverse reactions |
Mouth and throat irritation; dependence |
|
|
Drug interactions |
No direct interactions; smoking cessation may alter the pharmacokinetics of some drugs |
|
|
Efficacy |
One year abstinence vs placebo ¾ O.R. = 1.3 |
|
|
Non-nicotine tobacco cessation product17, 18, 19 |
||
|
Bupropion SR 20, 21 |
||
|
Dosage |
150 mg qd for 3 days, then 150 mg bid for 7 to 12 weeks |
|
|
Contraindications |
Seizure disorders, predisposition to seizures, MAOIs, allergy (Pregnancy Category B) |
|
|
Adverse reactions |
Sleep disturbances, dry mouth |
|
|
Drug interactions |
Selected antidepressants (MAOIs, norepinephrine re-uptake inhibitors), drugs metabolized by CYP2B6 and CYP2D6 |
|
|
Efficacy |
One year abstinence vs placebo - O.R. = 1.4 to 2.35 |
|
|
Pregnancy Categories Rate:
|
||
|
EVIDENCE AND REFERENCES
| ||
|
1 PDR 1999 2 Fiore 1996 3 Drug Facts and Comparisons 1998 4 Henningfield 1995 LE=A, SR=I 5 Setter 1998 6 Dale 1995 7 Greenland 1998 LE=A, SR=I 8 Fiore 1994 LE=A, SR=I 9 Lam 1987 10 Henningfield 1995 LE=A, SR=I 11Thompson 1998 | 12 Murray 1996 13 Hughes 1998 14 Hjalmarson 1994 LE=A, SR=I 15 Hurt 1998 LE=A, SR=I 16 Tonneson 1993 LE=A, SR=I 17 PDR 1999 18 Fiore, 1996 19 Drug Facts and Comparisons 1998 20 Hurt 1997 LE=A, SR=I 21 Jorenby 1999 |
|
|
Drug and dose |
Cost/unit1 |
Cost/month |
Rank/Cost2 |
|
Nicotine patch |
$2.24-$2.96 per patch Dose 1 patch/day(varied mg) |
Average price for initial therapy-30 days = $67.34-90.00/month |
$$$ |
|
Nicotine gum |
2mg = $0.33 each 4mg = $0.37 each |
12/day x 30 days = $118.80 first month 12/day x 30 days = $133.00 first month |
$$ |
|
Nicotine spray |
$0.22 per mg Dose 15 mg/day |
$100.53-400.00/first month |
$$$$$ |
|
Nicotine inhaler |
$0.60-0.66 each cartridge Dose 8-16 pieces/day |
$144.00-300.00/month |
$$$$ |
|
Bupropion 150 mg (Zyban) |
$0.69-.95 each tablet Dose 2 tablets/day |
BID = $41.40-57.78/month |
$ |
| 1 These are acquisition costs of
drug alone, not intended to represent a "full blown" cost-effectiveness
hierarchy combine DoD and VHA (12/98).
2 Drugs are estimated for cost per range of dosing over the therapeutic time unless specified per specific time period. |
|||
Self-help brochures:
National Institutes of Health, National Cancer Institute Publications Ordering Service
PO Box 24128
Baltimore, MD 21227
800-422-6237
1. National Cancer Institute. Clearing the Air: How to Quit Smoking ... and Quit for Keeps. NIH Publication No. 95-1647 (Order # P133)
2. Why Do You Smoke? (brochure). NIH Publication No. 94-1822, Revised July 1993 (Order # P145)
American Cancer Society.
When Smokers Quit.
DHHS Publication No. (CDC) 90-8416 1990
(Call 1-800-ACS-2345)1. Smart Move! (Order #2515)
2. Quitting Spitting (Order #2090)
3. When Smokers Quit (Order #5602)
4. Helping Smokers Quit (Order #2099)American Heart Association
1-800-AHA-USA-1 or 242-87211. Quitting Smoking for Good (Order #50-1097)
Agency for Health Care Policy and Research (AHCPR)
Ordering Phone # is 1-800-358-9295For the primary care provider:
How to Help Your Patients Stop Smoking: Manual for Physicians, NIH Publication.
No. 95-3064 July 1998 (Order # P138)How to Help Your Patients Stop Using Tobacco: Manual for Oral Health Team NIH Publication
No. 93-3191 August 1993 (Order # T137)Agency for Health Care Policy and Research (AHCPR)
Clinical Practice Guideline: Helping SmokersQuit AHCPR Publication. No. 96-0694 April 1996 www.ahcpr.crov/clinic/quitsmok/htm
Agency for Health Care Policy and Research (AHCPR) You Can Quit Smoking.
Publication No. 96- 0695 April 1996 www.ahcpr.crov/clinic/quitsmok/htmNational Technical Information Service
5285 Port Royal Road
Springfield, VA 22161Established stop smoking programs commercially available:
1. Quit Smart¾ self contained behavior modification program 1-888-737-6278; www.quitsmart.com
2. American Lung Association (ALA).
Freedom from Smoking¾ self contained behavior modification program (call local ALA)3. Group Health of Puget Sound.
Free and Clear¾ behavior modification and telephone support counselors for pharmacotherapy 1-800-292-2336Carbon Monoxide Testing Machines:
Medford Scientific
30 Jackson Road
Jackson Commons, Suite B-3
Medford, NJ 08055
800-457-5804
Price: about $1,300Vitalograph, Inc.
8347 Quivira Drive
Lanexa, KS 66215
(913) 888-4221
Cost of monitor: $1,050
ACC/AHA American College of Cardiology/American Heart Association
AHCPR Agency for Health Care Policy and Research
CDC Centers for Disease Control and Prevention
CNS Central nervous system
DoD Department of Defense
DSM-IVR Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Revised
FDA U. S. Food and Drug Administration
LE= Level of evidence
MAOI Monoamine oxidase inhibitor
NIH National Institutes of Health
NRT Nicotine replacement therapy
O.R. Odds ratio
OTC over-the-counter
PCM Primary care managers
PCP Primary care providers
PTSD Post-traumatic stress disorder
SIDS Sudden infant death syndrome
SR= Strength of recommendation
TMJ Temporomandibular joint syndrome
US DHHS U.S. Department of Health and Human Services
VHA Veterans Health Administration
Addicted to Nicotine: A National Research Forum, Program Book. National Institutes on Drug Abuse, NIH and Robert Wood Johnson Foundation. Bethesda, MD, July 27-28, 1998
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth edition. Washington, D.C.: APA 1994
Brandon SL; Tiffany ST; Baker TB. The process of smoking relapse. In: Tims F. Leukfeld C. (Eds.). Relapse and recovery in drug abuse. National Institute on Drug Abuse Research Monograph 72. Rockville, MD: National Institute on Drug Abuse. 1986
Brownell KD; Lichtenstein G; Marlatt GA; et al. Understanding and preventing relapse. In: Biological Barriers in Behavior Medicine. Linen W. (Ed.). Plenum Press, NY: 1998
Chisick MC; Poindexter FR; York AK. Comparing tobacco use among incoming recruits and military personnel on active duty in the United States. Tobacco Control 1998;7:241-46
Cigarette Smoking Among Adults United States, 1995. MMWR 1997;46:1217-20
Clearing the Air. U.S. Department of Health and Human Services 1993; NIH Publication No. 95-1647:24
Cromwell J; Bartosch WJ; Fiore MC; et al. Cost-effectiveness of the clinical practice recommendations in the AHCPR Guideline for smoking cessation. JAMA 1997;278:1759-66
Dale LC; Hurt RD; Offord KP; et al. High dose nicotine patch therapy. JAMA 1995;274:1353-58
Davis WM. Tobacco/nicotine dependence and cessation therapies. Drug Topics 1998;142(18):60-67
Drug Facts and Comparisons. Facts and comparisons publications (1999 ed.) Wolter Kluwers Co: St. Louis, MO 1999
Ferry LH; Burchette R. Efficacy of Bupropion for smoking cessation in non-depressed smokers. Journal of Addictive Diseases, 13(4);1994,9a
Fiore MC; Bailey WC; Cohen SJ; et al. Smoking Cessation. Clinical Practice Guideline No. 18. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and research, AHCPR Publication No. 96-0692. April 1996
Fiore MC; et al. The effectiveness of the nicotine patch for smoking cessation: a meta-analysis. JAMA 1994;271:1940-7
Fiore MC; Jorenby DE; Baker TB. Smoking cessation: Principles and practice based upon the AHCPR guideline 1996. Ann Behav Med 1997;19(3):213-19
Geboy MJ (Ed.). Smoking cessation for primary care. Fed Practitioner Supp 1996;13(125):31
Gourlay SG; Benowitz NL. Is clonidine an effective smoking cessation therapy? Drugs 1995; 50(2):197-207
Greenland S; et al. A meta-analysis to assess the incidence of adverse effects associated with the transdermal nicotine patch. Drug Safety 1998;18(4):297-308
Haddock C K; Klesges RC; Talcott GW; et at. Smoking prevalence and risk factors for smoking in a population of United States Air Force basic trainees. Tobacco Control 1998;7:232-35
Hatziandreu EJ; Pierce JP; Lefkopoulou M. Quitting smoking in the United States in 1986. J Natl Cancer Inst 1990;82(17):402-6
Henningfield JE. Drug therapy, nicotine medications for smoking cessation. NEJM 1995; 333(18):1196-203
Hjalmarson A; et al. Effect of nicotine nasal spray on smoking cessation: a randomized, placebo-controlled, double-blind study. Arch Intern Med 1994; 154:2567-72
Hughes JR; Goldstein MG; Hurt RD et al. Recent advances in the pharmacotherapy of smoking. JAMA 1998;281(1):72-6
Hurt RD; et al. A comparison of sustained release bupropion and placebo for smoking cessation. NEJM 1997; 337(17):1195-202
Hurt RD; et al. Nicotine nasal spray for smoking cessation: pattern of use, side effects, relief of withdrawal symptoms, and cotinine levels. Mayo Clin Proc 1998;73:118-25
Jorenby DE; Leischow SJ; Nides MA; et al. A Controlled trial of sustained-release bupropion, a nicotine patch, or both for smoking cessation. NEJM 1999;340(9):685-91
Kenford SL; Firore MC; Jorenby DE. Predicting smoking cessation: who will quit with and without the nicotine patch. JAMA 1994;:271:589-94
Lam W; et al. Meta-analysis of randomized controlled trials of nicotine gum. Lancet 1987;2:27-30
Law M; Tang JL. An analysis of the effectiveness of interventions intended to help people stop smoking. Arch Intern Med 1995;155:1933-41
Legoretta AP; et al. Results of a smoking-cessation program in a managed care setting. Am J Man Care 1996;2:831-36
Measuring Nicotine Dependence: A review of the Fagerstrom nicotine tolerance questionnaire. Jour Behav Med 1989;12(2):159-82
Miller MJ; Draugalis JR. A retrospective analysis of the costs and consequences of a tobacco cessation program for active duty service members. Mil Med 1996; 161:420-24
Murray RP; et al. Safety of nicotine polacrilex gum used by 3,094 participants in the lung health study. Chest 1996;109:438-45
Physicians Desk Reference, (53rd ed.) Medical Economics Company, Inc. Montvale, NJ:1999
Rohren CL; et al. Predicting smoking cessation outcome in a medical center from stage of readiness: contemplation versus action. Prev Med 1994;23:335-44
Schwartz J. Method of smoking cessation. Med Clin North Am 1992;76(2):451-76
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Tonnesen P; et al. A double-blind trial of a nicotine inhaler for smoking cessation. JAMA 1993;269(10):1268-71
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U.S. Department of Health and Human Services, Preventing tobacco use among young people: a report of the Surgeon General. Atlanta (GA): U.S. Department of Health and Human Services. Public Health Service. Center for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion Office on Smoking and Health. 1994
U.S. Public Health Service. Smoking cessation in adults. Putting prevention into practice. Am Fam Phys 1995 June;51(8):1914-18
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