Too many of our patients smoke, especially those with schizophrenia. Amazingly, the best estimate is that 85% of patients with schizophrenia are regular smokers (Am J Psychiatry 1986; 143:993-997). While we may not have a whole lot of time during our sessions to discuss smoking, it’s still helpful to tuck away some smoking cessation tools in your arsenal.

Here are the top three things you can do in the context of medication visits to help your patients quit.

1. Counsel them through the quitting process. Medicare recently announced that it would start covering counseling sessions to help people quit smoking. This decision was the culmination of a long process of persuasion, because even though the data that smoking cessation counseling helps is robust, adding this coverage is expected to cost Medicare a lot of money, at least an extra $11 million per year according to a New York Times report.

Even a few minutes of chatting with a patient about not smoking is more effective than nothing at all, increasing quit rates to about 15% from the 10 % quit rate of those receiving no counseling (Agency for Healthcare Research and Quality, http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.chapter.7644). The more counseling you provide, the more the benefit, up to a point. Thus,in one meta-analysis, the efficacy of the number of sessions yielded these numbers:

No. of Sessions	Quit Rate (%)
0-1	12.4
2-3	16.3
4-8	20.9
>8	24.7

According to the AHRQ guidelines, the basic intervention is composed of the following five steps, termed the “5A’s:”

•  Ask about tobacco use


•  Advise users to quit


•  Assess their willingness to quite


•  Assist patients to quit by setting a quit date and by providing counseling and pharmacotherapy


•  Arrange follow-up contact within the first week after the quit date

Of course, these are only the bare bones outline of a treatment approach. Counseling sessions should go deeper, going into issues such as developing a detailed quite plan, enlisting family and friends to support the patient in quitting, developing concrete plans to deal with urges to relapse, and making sure to remove all cigarettes and associated paraphernalia from the patient’s home or work environments.

2. Prescribe nicotine replacement therapy. Unlike smoking cessation counseling, nicotine replacement therapy (NRT) is not covered by Medicare or almost any insurance companies. However, Medicare has announced that it will start covering NRT in 2006, and TCR expects other insurers to follow suit.

There are now four methods of NRT available: the patch, the gum, the inhaler, and the nasal spray. According to the latest Cochrane review (The Cochrane Database of Systematic Reviews 2004, Issue 3), they all work about equally, yielding double the quit rates of placebo at 6-12 months. The quit percentages aren’t huge however, ranging from 14-20% on NRT vs. 8-13% on placebo.

There’s a possibility that the nicotine nasal spray works a little better than the others, because its dose of nicotine gets into the brain very quickly and delivers more of a nicotine high to that ex-smoker who’s really craving a cigarette. The downside of the spray is that compliance is not as good as with other techniques, especially the patch.

3. Prescribe Zyban or Nortriptyline. Of these two antidepressants, Zyban (also known as Wellbutrin SR, or bupropion) has the most robust supportive data, with 24 studies to its credit and data consistently showing that it doubles quit rates vs. placebo (The Cochrane Database of Systematic Reviews 2004, Issue 4). The recommended dose is 150 mg BID, and patients are told to wait four weeks after starting the medication before trying to quit. Only one study has compared Zyban with the Nicoderm Patch, and in this study Zyban was the winner, yielding a 33% one year quit rate vs. 16% on patch alone (NEJM 1999; 340:685-691). However, the validity of this finding is suspect, because the patch inexplicably did not outperform placebo, contradicting dozens of prior studies showing it to be effective (The Cochrane Database of Systematic Reviews 2004, Issue 3). And yes, the study was funded by Glaxo Wellcome (now called “GlaxoSmithKline”), makers of Zyban.

Nortriptyline, dosed up to about 100 mg QD, also doubles quit rates relative to placebo (Arch Gen Psychiatry 2002; 59:930-936) and for this reason many might wonder whether all antidepressants are effective for smoking cessation. Apparently not, because the Cochrane reviewers pooled results of five SSRI trials (three of Prozac, one of Zoloft, and one of Paxil) and could find no overall benefit.

Interestingly, many of the studies cited above excluded patents with depression, and these antidepressants appear to help patients kick the habit regardless of their moods.

TCR VERDICT: Tools for quitting abound; learn how to use them!