Webcast Frequently Asked Questions

Is there a resource that provides guidelines on using the different management therapies, including side effects, etc?
The AAFP has a pharmocologic product guide (2-page PDF file; About PDFs) in the Ask and Act online toolkit. It includes information on dosing, precautions and side effects of FDA-approved tobacco-cessation medications.

Does Wellbutrin offer the same efficacy as Wellbutrin SR?
I couldn’t find direct comparison data, just one statement that XL “could be marginally more effective than SR,” but without any references.

The Cochrane systematic review on antidepressants and cessation does not mention which dose form of bupropion to use — all the trials I can find have used the sustained-release versions.

There is a debate among smoking cessation experts about whether 150 vs 300 mg/day is best — lower side effects vs slightly higher efficacy.

For CHANTIX — is there a change in dose for patients with renal impairment or for the elderly?
The package insert states there is no dosage adjustment needed for the elderly or hepatic impairment. There is a dosage adjustment to .5 mg bid for “severe renal impairment,” which is clinically defined by a creatinine clearance of less than 30 ml/min. The PI does state that varenicline may be used by renal failure patients on dialysis, but the dose should be reduced to .5 mg daily.

Do you have the percentage quit rate with combination NRT?
The estimated abstinence rate with 2 NRT = 28.6% vs. 1 NRT at 17.4%. This is based on a meta-analysis of 3 different studies.

Is Dianicline available in the U.S.?
No, it is still being evaluated in clinic trials

Have you found anything to minimize nausea side effects with nicotine inhaler?
Patients have told me that emetrol works well but I haven’t seen any evidence to support this.

What is the approximate cost of varenicline?
A: $4.00 - $4.22 per day. (Average wholesale price from 2007 Drug Topics Redbook. Montvale, NJ: Medical Economics Company Inc. June 2007.)

Does the company that makes varenicline provide a drug assistance program for indigent patients?
CHANTIX is included in Pfizer, Inc.’s patient assistance program that offers free medication to people who otherwise cannot afford their medications. Patients must meet financial and other program specific criteria to be eligible for assistance.

For those with anxiety with Wellbutrin, is there some other med to accompany this that will offset that? Is that even a viable option?
I couldn’t find any research on this — some patients do find that it makes them agitated and nervous, part of which may be due to nicotine withdrawal.

How long do you have to wait to switch to another therapy?
Generally after a relapse, one would wait until the patient is ready to “recycle” into another quit date, and begin again with another try at pharmacotherapy — which to use depends on patient preference, side effects of prior use of the meds, reasons for the relapse, etc.

Is ulcerative colitis a good justification for smoking?
Anecdotal reports show nicotine/smoking can lessen the symptoms of ulcerative colitis. However the risks of tobacco use appear to far outweigh the benefits. I found an abstract of one study in NEJM 1994 that showed nicotine patch reduces symptoms: http://content.nejm.org/cgi/content/abstract/330/12/811

A Cochrane review concludes that the patch may be useful with UC symptoms. There is also some investigational use of a nicotine-containing enema. Smoking, of course, is the dirtiest way to introduce nicotine into the system, with all the other 5000 toxins that cause tobacco-related illnesses.

The results of this review provide evidence that transdermal nicotine is superior to placebo for the induction of remission in patients with ulcerative colitis. The review did not identify any significant advantage for transdermal nicotine therapy compared to standard medical therapy. Adverse events associated with transdermal nicotine are significant and limit its use in some
patients.

How do you explain to a patient how CHANTIX works?
Their Web site states: “There are receptors for nicotine in the brain. When smoke is inhaled, nicotine attaches to these receptors. This sends a message to a different part of the brain to release a chemical called dopamine. Dopamine gives a feeling of pleasure. But it only lasts for a short time. The body wants to repeat this feeling. Based on research, it is believed that CHANTIX (varenicline) works by activating these receptors and blocking nicotine from attaching to them. However, CHANTIX does not contain nicotine.”

Do you have to titrate varenicline, or can you start with 1mg qd then 1mg bid?
The goal of titration is to decrease side effects — especially nausea. It is a clinical decision.

How can one help the patient who becomes addicted to Nicotine
Replacement Therapy?
NRT has a low abuse potential compared with the addictiveness of smoking or use of moist snuff products. Products such as the nicotine nasal spray have a higher propensity for continued use beyond the recommended time periods following cessation, and less than 10% do so — most smokers who are in the process of cessation use NRT for much shorter intervals than recommended.

The use of NRT among nonsmokers is almost unknown. NRT is not associated with longterm health risks. Patients who continue to use NRT for long periods of time after cessation can be weaned from the products, or may stop them “cold turkey” but must not resume cigarettes (even one), as relapse to former levels of smoking is likely.

Does imipramine work as well as nortripline?
The most recent Cochrane review of antidepressant therapy concludes that only nortriptyline and bupropion are useful.

Hughes J, Stead L, Lancaster T. Antidepressants for smoking cessation. Cochrane Database Syst Rev. 2004 Oct 18;(4):CD000031

What are some combination treatments you have tried and found to be effective?
NRT and bupropion have been shown to be synergistic; the Mayo Clinic and others support the use of high-dose NRT, including patch plus gum/lozenge/nasal spray for highly addicted smokers, although the literature reviews are mixed in their findings.

If I decide to use Wellbutin and nicotine patch together, how often do I have to see the patient to check blood pressure?
I can't find any literature that warns of hypertension as a side effect of the therapy — the manufacturer's warnings for bupropion note that it had a 6.1% incidence of hypertension among users in one trial. The usual care approach for cessation counseling and follow-up should be sufficient (see patient about the time of the quit date, a week later, a month later).

What dose of nortriptyline have you found most helpful?
75-100 mg once daily is the recommended dose. You might want to review the article, “Nortriptyline for smoking cessation: a review” by Hughes JR, Stead LF, Lancaster T in the August 2005 issue of Nicotine Tob Res.

What is the success rate for varenicline?
Based on summary of package insert (PI) data:

How many insurances cover Chantix (varenicline) or Dianicline?
Many commercial insurances cover cessation medication, but it is variable from plan-to-plan and region-to-region. Dianicline is not yet available in USA.

You mentioned that Missouri Medicaid did not allow any compensation for NRT, but do they reimburse for counseling, group therapy, etc?
Not that I have been able to discover. However, Medicaid benefits vary widely from state-to-state.

I heard that Wellbutrin would not be covered for smoking cessation, that only Zyban without substitution would be paid for. Comments?
Coverage varies by insurance plan. Some will not cover any cessation medications; others have preferred medications. Some plans will not cover buproprion for any patient, regardless of if it is being used for smoking cessation or depression.

I've had one Medicare visit so far, which I billed with the new Medicare tobacco cessation coverage. Any experience w/ Medicare actually paying
these, and how much? Any advice, experience?
The AAFP has not received any feedback from members that they are not being paid. As for the Medicare allowance, 99406 ranges between $12-15, while 99407 ranges between $24-30; the actual allowance will vary by Medicare locality. You can look up the allowance in your specific locality online at http://www.cms.hhs.gov/apps/pfslookup/Step1.asp

What is the reimbursement by Medicare for Smoking Cessation counseling
for an in-patient acute care facility? If Medicare does reimburse an acute care facility, what is the code for billing?
The Medicare National Coverage Decision on tobacco cessation counseling says that counseling is covered for both outpatient and hospitalized beneficiaries. It also says that inpatient hospital stays with the principal diagnosis of Tobacco Use Disorder are not reasonable and necessary for the effective delivery of tobacco cessation counseling services. Therefore, CMS will not cover tobacco cessation services if tobacco cessation is the primary reason for the patient's hospital stay.

Medicare will pay an acute care facility for smoking cessation counseling. For billing instructions, facilities should consult the Medicare transmittals at http://www.cms.hhs.gov/transmittals/downloads/R562CP.pdf (14-page PDF file; About PDFs) and http://www.cms.hhs.gov/transmittals/downloads/R605CP.pdf (7-page PDF file; About PDFs)

On a Medicare patient, can I use a CPT code for tobacco cessation counseling along with the E&M code for the visit, i.e. for hypertension?
According to section 12.2 of Chapter 32 of the Medicare Claims Processing Manual, "Carriers shall allow payment for a medically necessary E/M service on the same day as the smoking and tobacco-use cessation counseling service when it is clinically appropriate. Physicians and qualified non-physician practitioners shall use HCPCS 99201– 99215 to report an E/M service with modifier 25 to indicate that the E/M service is a separately identifiable service from 99406 or 99407." See the transmittal at http://www.cms.hhs.gov/transmittals/downloads/R562CP.pdf (14-page PDF file; About PDFs)

Who qualifies as a Medicare qualified provider in order to get reimbursement for smoking cessation interventions?
The definition of "qualified provider" is pretty broad and includes, among others, physicians, clinical social workers, psychologists, hospitals, and rural health clinics.

In Georgia, the State Employees Plan added a $50 per month surcharge for beneficiaries who smoke. This has been effective in goading some patients to try and quit. Are there other states or insurers that are placing some of these penalties?
Yes.

Please address the common objection of post cessation weight gain.
According to the CDC Office on Smoking and Health website: “Many smokers will gain some weight when they quit, usually less than 10 pounds. Eat a healthy diet and stay active. Don't let weight gain distract you from your main goal—quitting smoking. Some quit-smoking medications [NRT and bupropion] may help delay weight gain.”

Any recommended treatment for patients who state that they would get fat if they quit smoking?
Nothing more than helping them understand that the health consequences of limited weight gain most experience pales by comparison to continued smoking, and that exercise and sensible efforts at weight control help (ie, cutting back on sweets, increasing fruits/veggies, etc). This concern, primarily among women, needs to be met up front in counseling, as it seems a major impediment to many. Some of the pharmacotherapeutic agents (bupropion, NRT, possibly varenicline) seem to retard weight gain during their use.

Is weight gain less on varenicline?
From July 4, 2006 JAMA article: "Varenicline, an alpha 4 beta 2 Nicotine Acetylcholine Receptor Partial Agonist, vs Sustained-Release Buproprion and Placebo for Smoking Cessation":
Chantix wt gain in kg 2.37
Buproprion 2.12
Placebo 2.92

Do you have a difficult time getting your patients to return for follow up? If so, how do you deal with that?
Yes. Providing the patient with a structured follow up plan can increase compliance. While there is no direct replacement for a follow up visit to the health care provider, encourage the patient to utilize other methods of follow up including quitlines, group visits, and online support groups.

How do you feel about counseling with a psychologist as an adjunct to smoking cessation?
The US Public Health Service Guidelines (2004) did a meta-analysis on the
matter —physician advice was reported to have a 2.2 increased odds ratio for cessation compared with 1.7 for non-physician clinicians. However, the document calls for increased research on the subject.

How do you know for sure that a patient has quit?
Commonly used approaches include monitoring the expired breath CO or urine cotinine — the latter being considerably more expensive and usually confined to clinical trials.

Do you find that the season, ie winter vs summer makes a difference in the cessation success?
I have not noticed any seasonal pattern.

Is there any evidence of increased success when replacing a nicotine habit with a healthful habit such as exercise?
A recent study, “The acute effects of exercise on cigarette cravings, withdrawal symptoms, affect and smoking behaviour: a systematic review,” in the journal Addiction Volume 102 Issue 4 Page 534 - April 2007 shows promise of exercise as an adjunct. The authors’ conclusion: “Relatively small doses of exercise should be recommended as an aid to managing cigarette cravings and withdrawal symptoms. Further research to understand the mechanisms involved, such as stress reduction or neurobiological mechanisms, could lead to development of more effective and practical methods to reduce withdrawal phenomena.”

There is limited evidence from the Cochrane reviews. Authors’ conclusions: Only one of the 11 trials offered evidence for exercise aiding smoking cessation at a 12-month follow up. All but one of the other trials were too small to exclude reliably an effect of intervention, or included an exercise intervention which was insufficiently intense to achieve the desired level of exercise. Trials are needed with larger sample sizes, sufficiently intense exercise interventions, equal contact control conditions and measures of exercise adherence.

Do you need parents to talk to minors about quitting?
My practice is to visit with adolescents and pre-teens to prevent smoking initiation or to get them to stop. This should not need parental consent unless treatment is involved.

Do you have any comments on non-compliant patients (ie CAD, hx MI, COPD, etc) whom you are treating for their medical problems but they absolutely refuse to even consider quitting smoking?
Denial is very strongly associated with most addictive behavior. The “stages of change” concept puts these patients in “pre-contemplation.” The Public Health Service guidelines recommendation is to continue to work with them over time, try to help them understand the health risks at a personal level, puncture myths they may have about smoking or cessation, and let them know you’ll be there to help when they’re ready. A tough group.

Is there an effective questionnaire available to address the physical and psychological aspects of quitting vs not quitting?
Having quit myself after 10 years of NRT my personal recommendation is to emphasize replacement pleasures and to teach the expectations and reality of withdrawal.

Alternative therapy: Cold laser, acupuncture, acupressure, hypnosis or laser therapy? Any comments?
The Cochrane review of acupuncture, laser, etc is not supportive of their use. I found only one controlled study on laser therapy, reported in a Chinese CAM journal — not superior to placebo among the adolescent subjects in the trial. A Pub Med abstract from a CAM journal says this about acupuncture: “For smoking cessation, tinnitus, and weight loss the evidence is usually regarded as negative.”

J Altern Complement Med. 2004 Jun;10(3):468-80 Clinical research on acupuncture. Part 1. What have reviews of the efficacy and safety of acupuncture told us so far?

I have been practicing medical acupuncture for about 3 years. There are anecdotal reports of successful treatment with acupuncture, typically using protocols similar to drug withdrawal (heroin/cocaine) acupuncture treatment developed by a Dr. Michael Smith at a large clinic outside NY City. In my own acupuncture practice I’ve been underwhelmed by its success for smoking cessation and no longer encourage patients to consider it.

How effective is acupuncture?
There is no current evidence that acupuncture is effective as a tool for tobacco cessation.

White AR, Rampes H, Campbell JL. Acupuncture and related interventions for smoking cessation. Cochrane Database Syst Rev. 2006 Jan 25;(1):CD000009

What about ear stapling?
Not effective -- an acupuncture variant.

Tell us about injections available to patients. Where are they administered? Patients state "in the neck."
I haven't heard of this one...I did find an abstract in Chest concerning an anticholinergic cocktail injection used in a cessation clinic in Florida, claiming good results: http://meeting.chestjournal.org/cgi/content/abstract/126/4/713S-a.
Some have questioned the results of this study, stating, “The N is far too small and there is no control.”

Any study yet addressed cold turkey?
Here is a web site that advocates for this approach: http://whyquit.com.

The 2004 Clinical Practice Guideline “Treating Tobacco Use and Dependence” estimates about a 10% efficacy rate for self-help/no clinician intervention attempts to quit smoking. A recent published report from Australia reports as high as a 40% quit rate for “cold turkey.”

Doran CM, Valenti L, Robinson M, Britt H, Mattick RP. Smoking status of Australian general practice patients and their attempts to quit. Addict Behav. 2006 May;31(5):758-66.

Is nicotine fading a useful technique?
Nicotine fading refers to gradual reduction in nicotine consumption, usually by switching to brands with lower nicotine content than the patient’s usual brand. While a few studies have reported reasonable success from this method, many patients will compensate for lower nicotine by inhaling more deeply, smoking the new cigarette closer to the filter, or even smoking more per day in order to maintain a constant level of nicotine in the body. It is not a recommended method in the Clinical Practice Guidelines.

Can you give information on success rates of approved medications vs, unapproved methods: 1) hypnosis 2) anticholinergic blockade 1 visit to a clinic (I hear there are many in California followed by behavior mod/counseling).
Anecdotally, I can tell you that hypnosis can be effective in helping patients quit. I don’t know of evidence basis. It would be hard to do a controlled study so all we might have is comparison to “usual” treatment. I can’t find any reputable trials on anticholinergic blockade treatments — a couple of reports by the clinics using their own proprietary versions of this treatment claim very high success rates.

There’s at least one report in the literature of acute psychosis as a side effect. These are not FDA approved treatments, and I personally discourage their use. Hypnosis has not been found by Cochrane review to be effective. Some individuals may benefit, however.

What approach do you recommend for the pregnant smoker?
While nonpharmacologic intensive counseling is best, most tobacco cessation experts believe that exposure to one component of smoke (nicotine) is much less hazardous than 4000-plus toxins in smoke, including CO. Intermittent dose forms are best (lozenge, gum) as recent reports show a possible link between the patch and fetal limb malformations. Bupropion and varenicline are Category C for pregnancy.

Any laws against smoking by pregnant women in any state that you know?
No, although some states have laws now on smoking in cars while kids are inside.