Snapshot A 69-year-old male presents with concerns about his declining health. His brother recently died of renal cell carcinoma and he is now concerned about his own health. The patient has a history of type II diabete mellitus, HTN and a 50 pack-year smoking history. He asks you what he can do to improve his health. Introduction Smoking is considered the most important modifiable risk factor in the US for cancer and cardiovascular and pulmonary disease All adults should be screened regularly for tobacco use Smoking cessation should be discussed with all smokers at EVERY clinical contact most likely to reduce mortality Therapies for smoking cessation include: nicotine replacement bupropion varenicline cognitive behavioral therapy (CBT) Nicotine Replacement Comes in many forms including: gum inhaler lozenge patch spray Many forms can be purchased over the counter Gums, inhalers, lozenges are excellent for combatting acute cravings Patches ideal for delivering a basal rate of nicotine Bupropion (Zyban) The mechanism of action is believed to involve blockage of the nicotine receptor Prescription only theray should begin 1-2 weeks prior to quit date and then continued 4-6 months after quit date Can be combined with nicotine replacement therapy for increased effectiveness Thought to be especially beneficial in patients with history of depression Side effects: insomnia dry mouth Warnings/contraindications seizure disorder eating disorder recent use of a monamine oxidase inhibitor Varenicline (Chantix) Nicotinic receptor partial agnoist Prescription only Therapy should begin 1 week prior to quit date and then continued 4 months after quit date Very effective when combined with nicotine therapy (older sources say NOT to combine them) Side effects: headache nausea insomnia Warnings: may cause neuropsychiatric symptoms or increased suicidality avoid in patients with history of unstable psychiatric symptoms or suicidality Cognitive Behavioral Therapy (CBT) CBT is a form of psychotherapy that targets changing maladaptive thinking patterns and the negative behaviors associated with them not been found to be highly effective when used alone for smoking cessation may be helpful when employed with some of the therapies listed above