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Remaining smokers need aggressive intervention.

PHILADELPHIA -- American smokers have, on average, become significantly more nicotine dependent since 1989--which means that more aggressive interventions are needed to help them quit.

That's because most of the smokers who could more easily quit have already done so. "The less-addicted smokers are out of the pool. We're left with people who are more dependent," Dr. David P.L. Sachs said at the annual meeting of the American College of Chest Physicians.

"The vast majority of patients we see now in actual clinical practice are more highly nicotine dependent," said Dr. Sachs, director of the Palo Alto (Calif.) Center for Pulmonary Disease Prevention. Dr. Sachs documented this shift by comparing the average level of nicotine dependence in patients who participated in three smoking-cessation studies that he collaborated on during 1989-2006.

In all three studies, nicotine dependence at baseline was quantified with the Fagerstrom Tolerance Questionnaire (FTQ), a brief, self-report survey that measures nicotine dependence on a scale of 0-10, with 10 being the highest level of dependence (see box).

Among 220 U.S. smokers enrolled in 1989 and 1990 in a study of a nicotine patch, the average FTO score was 6.62. The next study enrolled 206 patients in 1994 in a study of sustained-release bupropion; their average FTQ score was 7.02, significantly higher than in the prior study.

The third study group cited by Dr. Sachs included 2004 patients who were enrolled in 2005-2006 to assess an individualized treatment regimen. These people has an average FTQ score of 7.44, a significant jump above the 1994 average.

Looked at a different way, the percentage of patients rated as highly nicotine dependent, with an FTQ score of 7 or higher, was 56% in 1989-1990, 66% in 1994, and 73% in 2005-2006.

The consequence of this trend is that physicians should expect a challenge with most patients whom they try to help quit smoking, Dr. Sachs said. He suggested that physicians start by measuring the FTQ score for each prospective quitter. Otherwise, "You can't know how physically dependent a person is," he said.

If the smoker is highly dependent, with an FTQ score of 9 or 10, then the physician will most likely need to prescribe several agents to help the patient quit. "The higher the FTQ score, the more withdrawal symptoms and the less effective is treatment," he said.

For a highly dependent person, three or more standard OTC nicotine patches worn simultaneously will probably be necessary, as well as an additional nicotine source for times of stress, such as nicotine gum, nasal spray, inhaler, or lozenges, In addition, highly dependent patients will likely need treatment with sustained-or extended-release bupropion (Zyban) or varenicline (Chantix), Experts are still testing the best ways to combine these agents, Dr. Sachs said, and it is possible that some highly dependent patients may need treatment with all four agents.

Dr. Sachs has received research grants from, has been a consultant to, and has been a speaker for, Pfizer, which markets Chantix, and GlaxoSmithKline, which markets Zyban, as well as for several other drug companies.

Dr. Sachs discusses his research in a video interview available at

RELATED ARTICLE: Fagerstrom Tolerance Questionnaire

1. How soon after you wake up do you smoke your first cigarette?

* Within 5 minutes: 3 points.

* 6-30 minutes: 2 points.

* 31-60 minutes: 1 points.

* After 60 minutes: 0 points.

2. Do you find it difficult to refrain from smoking in places where it is forbidden, e.g., in church, at the library, in cinemas?

* Yes: 1 point.

* No: 0 points.

3. Which cigarette would you hate most to give up?

* The first in the morning: 1 point.

* Any other: 0 points.

4. How many cigarettes per day do you smoke?

* 31 or more: 3 Points.

* 21-30: 2 Points.

* 11-20: 1 Points.

* 10 pr less: 0 Points.

5. Do you smoke more frequently during the first hours after awakening than during the rest of the day?

* Yes: 1 Points.

* No: 0 Points.

6. Do you smoke when you are so ill that you are in bed most of the day? (If you never get sick, give the most likely response.)

* Yes: 1 Points.

* No: 0 Points.

Source: Br. J. Addict. 1991; 86: 1119-27


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Title Annotation:CLINICAL ROUNDS
Author:Zoler, Mitchel L.
Publication:OB GYN News
Geographic Code:1USA
Date:Jan 1, 2009
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