(Clinical Practice Guideline for Treating Smokers in Taiwan) 747( 250 ) ( ) 1. 70% ( ) ( ) 1

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1 ( )...1 ( )...2 ( ) 2 ( ) (Cochrane)..2 ( ) 4 ( ) (Relapse prevention).10 ( ) ( )..13 ( )

2 (Clinical Practice Guideline for Treating Smokers in Taiwan) 747( 250 ) ( ) 1. 70% ( ) ( ) 1

3 % 6. ( ) ( ) % ( ) ( ) (Cochrane) Cochrane Library (Evidence based medicine) Placebo group Placebo group (1) (Physician advice for smoking cessation) 34 minimal counseling 30 3~10 Brief counseling full counseling 130 counseling 2

4 (2) (Nursing interventions for smoking cessation) (3) (Self-help interventions for smoking cessation) 5 8 (4) (Acupuncture for smoking cessation) 18 Placebo group (5) (Aversive smoking for smoking cessation) (6) (Hypnotherapy for smoking cessation) (7) (Exercise interventions for smoking cessation) (8) (Telephone counselling for smoking cessation) (9) (Community interventions for preventing smoking in young people) (10) (Mass media interventions for preventing smoking in young people) (11) (Interventions for preventing tobacco smoking in public places) 22 (12) (Interventions for smoking cessation in hospitalised patients) 1.82 (13) (Training health professionals in smoking cessation) (14) (Group behaviour therapy programmes for smoking cessation) (15) (Individual behavioural counselling for smoking cessation) (16) (Nicotine replacement therapy for smoking cessation) (17) Clonidine (Clonidine for smoking cessation) 1.89 (18) (Anxiolytics for smoking cessation) ( ) 3

5 ) (Institutionalization of documentation) a) (minimal information) 1. ( ) 2. ( ) 3. ( ) b) (additional desirable information) c) ( ) d) e) (HRA) ) (Brief counseling) 5A s in 6 minutes (Ask) ( 2. (Advise) a) b) c) d) 3. (Assess) a) b) c) d) 4. (Assist) a) b) c) d) (withdrawal symptoms) e) f) 5. (Arrange) 4

6 a) b) withdrawal symptoms c) d) (Quit-line) ( ). / 5. 1) 2) 3) 4) ( ) 5) 1. a) b) c) 2. a) b) c) d)

7 e) Patch(Nicotinell TTS) Gum(Nicorette) Patch(Smoke Free) Total (First line Pharmacotherapy) A. cholinergic effect B. (Withdrawal symptoms) (craving) C. (Nicotine Replacement Therapy)( ) CO 1. NRT ( Nicotinell TTS Nicoderm CQ 24 ; Nicotrol 16 ) a) (24 ) (30cm 2 )-52.5mg 20 (20cm 2 )-35mg 20 (10cm 2 )-17.5mg b) (16 ) 15mg 6

8 c) cm cm cm 2 d) e) f) g) h) 1. Nicotinell TTS 24 Nicotrol NRT (Polacrilex) Nicorette a) 4mg (>25 / ) 2mg (<25 / ) 8 12 b) 1/2 c) (Chew and park) d) e) f) g) Bupropion SR (Zyban) a) (dopminergic) (noradrenergic) 7

9 Zyban b) 150 / 7 12 c) d) (seizure) e) Zyban f) MAO inhibitor Zyban g) Zyban 30% 36% NRT Nicotine Inhaler a) b) 6 16 / ( 4mg) 3 6 c) d) e) 5. NRT Nicotine Spray a) )( 40 ) 3 6 b) c) d) 4. (Second line Pharmacotherapy) 1. Clonidine a) b) c) 8

10 d) e) 2. Nortriptyline a) b) c) d) e) 5. (craving) a) b) Bupropion SR c) Bupropion SR 6. a) Bupropion SR 150mg, bid 3. b) Bupropion SR nicotine gum c) Bupropion SR nortriptyline d) 12 FDA Bupropion SR (Cigarette) ( ) (Herb) 9

11 ( ) (Relapse prevention) 2~4 Triggers Triggers Triggers Trigger 1. support (withdrawal symptoms) ( 5 ) (Quit line) 4. support support 10

12 Triggers Triggers Withdrawal symptoms Bupropion SR --NRT 4mg

13 ( ) 1. a. b. c. d. 2. XXX XXXX 3. / a. b. c. d. e. ( ) 4. a. b. c. ( ) d. 5. a. b. c. d. 12

14 . ( ) (Guideline for Smokers. Freedom from smoking)

15 .. 1. ( ) 2. (Cold Turkey) 3. ( XX ) ,460,000 Triggers Triggers Triggers Trigger Trigger 14

16 ? (Trigger) ( )

17 1. (1) (2)

18 (3) = =108~ /10= /10= ( ) 2. (1) (2) (3) 3. ( )( ) (1) (2) (3) (4) (5) 17

19 ( ) (Guideline for smokers Π. You can quit 5 keys for successful quitting )

20 Bupropion SR

21 1) U.S. Public Health Services: Treating Tobacco Use and Dependence Clinical Practice Guideline Agency for Health Care Policy and Research. 2) Health Education Authority of U.K.: Cochrane Collaboratio s Tobacco Addiction Review Group 3) Preventive Services Task Force 1996 Guideline for Clinical Preventive Services Second Edition. 4) Recommendations regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke. Am J Prev Med 2001;20:Suppl:10-5(Also available at: 5) Task Force on Community Preventive services of the Centers for Disease Control and Prevention. communityguide.org 6) Anonymous. Nicotine replacement therapy for patients with coronary artery disease. Working Group for the Study of Transdermal Nicotine in Patients with Coronary artery disease. Archives of Internal Medicine. 1994;154(9): ) Henningfield JE. Nicotine medications for smoking cessation. N Engl J Med 1995;333: ) Joseph AM. Norman SM. Ferry LH. Prochazka AV. Westman EC. Steele BG. Sherman SE. Cleveland M. Antonnucio DO. Hartman N. McGovern PG. The safety of transdermal nicotine as an aid to smoking cessation in patients with cardiac disease. New England Journal of Medicine.1996; 335(24): ) Fiore MC. Jorenby DE. Baker TB. Smoking cessation: principles and practice based upon the AHCPR Guideline, Agency for Health Care Policy and Research. Annals of Behavioral Medicine. 1997;19(3): ) Hurt RD. Sachs DP. Glover ED. Offord KP. Johnston JA. Dale LC. Khayrallah MA. Schroeder DR. Glover PN. Sullivan CR. Croghan IT. Sullivan PM. A comparison of sustained-release bupropion and placebo for smoking cessation. [see comments]. New England Journal of Medicine. 1997;337(17): ) Benowitz NL. Gourlay SG. Cardiovascular toxicity of nicotine: implications for nicotine replacement therapy. [Review] [123 refs] Journal of the American College of Cardiology. 1997;29(7): ) Cromwell J, Bartosch WJ, Fiore MC, Hasselblad V, Baker T. Cost-effectiveness of the Clinical Practice Recommendations in the AHCPR Guideline for Smoking Cessation. JAMA 1997;278: ) Prochazka AV. Weaver MJ. Keller RT. Fryer GE. Licari PA. Lofaso D. A randomized trial of nortriptyline for smoking cessation. [see comments]. Archives of Internal Medicine. 1998;158(18):

22 14) Thorndike AN. Rigotti NA. Stafford RS. Singer DE. National patterns in the treatment of smokers by physicians. JAMA. 1998;279(8): ) Raw M. McNeill A. West R. Smoking cessation guidelines for health professionals. A guide to effective smoking cessation interventions for the health care system. Health Education Authority. Thorax. 1998;53 Suppl 5 Pt 1:S ) Thorndike AN, Rigotti NA, Stafford RS, Singer DE. National Pattern in the Treatment of Smokers by Physicians. JAMA 1998;279: ) Hughes JR. Goldstein MG. Hurt RD. Shiffman S. Recent advances in the pharmacotherapy of smoking. JAMA. 1999;281(1): ) Rigotti NA. Treatment options for the weight-conscious smoker. [letter; comment]. Archives of Internal Medicine. 1999;159(11): ) Marcus BH. Albrecht AE. King TK. Parisi AF. Pinto BM. Roberts M. Niaura RS. Abrams DB. The efficacy of exercise as an aid for smoking cessation in women: a randomized controlled trial. [see comments]. Archives of Internal Medicine. 1999;159(11): ) Pauwels RA, Lofdahl CG, Latitinen LA, Schouten JP, Postma DS, Pride NB, Ohlsson SV. Long-Term Treatment with Inhaled Budesonide in Persons with Mild Chronic Obstructive Pulmonary Disease Who Continue Smoking. N Engl J Med 1999;340: ) Hajek P. West R. Foulds J. Nilsson F. Burrows S. Meadow A. Randomized comparative trial of nicotine polacrilex, a transdermal patch, nasal spray, and an inhaler. Archives of Internal Medicine. 1999; 159(17): ) Raw M, Ncneill A, West R. Smoking cessation : evidence based recommendations for the healthcare system. BMJ 1999;318: ) Rigotti NA. Lee JE. Wechsler H. US college students' use of tobacco products: results of a national survey. JAMA. 2000;284(6): ) Lasser K. Boyd JW. Woolhandler S. Himmelstein DU. McCormick D. Bor DH. Smoking and mental illness: A population-based prevalence study. JAMA.2000;284(20): ) Bohadana A. Nilsson F. Rasmussen T. Martinet Y. Nicotine inhaler and nicotine patch as a combination therapy for smoking cessation: a randomized, double-blind, placebo-controlled trial. Archives of Internal Medicine. 2000;160(20): ) West R. McNeill A. Raw M. Smoking cessation guidelines for health professionals: an update. Health Education Authority. Thorax. 2000; 55(12): ) Rigotti NY. A 36-Year-old Woman Who Smokes Cigarettes. JAMA 2000;184: ) Lancaster T. Stead L. Silagy C. Sowden A. Effectiveness of interventions to help people stop smoking: findings from the Cochrane Library. BMJ. 2000;321(7257): ) West R, MacNeill A, Raw M. Smoking cessation guidelines for health 21

23 professionals : an update. Thoax 2000;55: ) Henningfield JE. Rose CA. How US airlines became smoke free. Tobacco Control. 2001;10(3): ) Hiatt WR. Medical Treatment of Peripheral Arterial Disease and Claudication. N Engl J Med 2001;344: ) Rigotti NA. Treatment of Tobacoo Use and Dependence. N Engl J Med 2002;346: ( ) ( ) 40-60% 25%--30% (clinical effectiveness) 2 10% 20% ( ) (Pre-contemplation phase) ( ) (Contemplation phase) ( ) (Preparation phase) (Action phase) (Maintenance phase) 5R s Relevance (Risk) / ( 22

24 ) (Reward) (Roadblock) (Repetition) 23

25 $ ,14,25 8 (Nicoderm CQ) 16 (Nicotrol) (>25 / ($6.25); 10 ) 4- (<25 / ($6.87) ) 6 16 / ( ($10.94) ) ($5.40) 1 ( 40 ) 25

26 Bupropion SR (Zyban) 7 12 ; 3.33 MAO inhibitor 150 ( Zyban ( 0.1%) 1~2 6 ), 150 mg Clonidine Nortriptyline, / ( $0.24) ($0.74) : 1.Fiore MC, Bailey WC, Cohen SJ, et, al. Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians. Rockville, Md: US Department of Health and Human Services, Agency for Health Care Research and Quality; AHRQ publication Nancy A. Rigotti,M.D.:Treatment of Tobacoo Use and Dependence. The New England Journal of Medicine 2002;346:

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