Practice guideline for the treatment of patients with nicotine dependence

J. R. Hughes, S. Fiester, M. Goldstein, M. Resnick, N. Rock, D. Ziedonis, J. S. McIntyre, S. C. Charles, D. A. Zarin, H. A. Pincus, K. Z. Altshuler, W. H. Ayres, T. Bittker, B. Blinder, P. J. Clayton, I. Cook, L. Dickstein, H. Egger, G. Flamm

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The following executive summary is not intended to stand by itself. The treatment of smoking cessation requires the consideration of many factors and cannot be adequately reviewed in a brief summary. The reader is encouraged to consult the relevant portions of the guideline when specific treatment recommendations are sought. Recommended psychiatric management strategies that all smokers should receive are listed in table 7 (see page 7). Table 8 lists the recommended treatments and their ratings (see page 7). There are a number of promising treatments for nicotine dependence that may be recommended based on individual circumstances. These include intensive behavior therapy [III], educational/supportive groups [III], exercise [III], hypnosis [III], anorectics [III], antidepressants [III], buspirone [III], higher than-normal dose transdermal nicotine [III], mecamylamine [III], nicotine inhaler [III], and sensory replacement [III]. Treatments that cannot be recommended at this time for the treatment of nicotine dependence (either because data indicating lack of efficacy or lack of sufficient evidence supporting efficacy) include: contingency contracting, cue exposure, hospitalization, nicotine fading, physiological feedback, relaxation, 12- step therapy, ACTH, acupuncture, anticholinergics, benzodiazepines, β blockers, glucose, homeopathics, lobeline, naltrexone, nutritional aids, reduction devices, silver nitrate, sodium bicarbonate, and stimulants. Psychiatrists should assess the smoking status of all their patients on a regular basis. If the patient is a smoker, the psychiatrist discusses interest in quitting and gives explicit advice to motivate the patient to stop smoking, including a personalized reason the patient should stop [I]. When possible, advice may come from multiple sources in addition to the psychiatrist; e.g., from other physicians, nurses, social workers, etc. [I]. Written materials may be used as well as face-to-face interventions [II]. Since many psychiatric patients are not ready to quit, the goal of advice will often be to motivate patients to contemplate cessation by reviewing the benefits of quitting, discussing barriers to quitting, and offering support and treatment [III]. If the patient is interested in stopping smoking, a quit date should be elicited, treatment prescribed, and follow-up arranged [II]. The minimal initial treatment for those who wish to quit includes written materials, brief counseling, and follow-up visit or call 1-3 days after the quit date [II]. If the patient has failed serious attempts without formal treatment, failed with nonpharmacological therapies, had serious withdrawal symptoms, or appears highly nicotine dependent, transdermal nicotine is recommended [I]. If the patient prefers or if ad-lib dosing is needed, nicotine gum can be used instead of transdermal nicotine [I]. If used alone, nicotine gum is to be taken on an every-hour basis [I]. If the patient is a highly nicotine-dependent or heavy smoker, higher-dose nicotine gum should be used [I]. Nicotine gum can also be used on an ad-lib basis to supplement transdermal nicotine therapy [II]. If the patient has had trouble stopping smoking for nonwithdrawal reasons (e.g., due to skills deficits), he or she is a candidate for multicomponent behavior therapy [I]. The more effective components of behavior therapy appear to be skills training/relapse prevention; rapid smoking, in which patients inhale cigarette smoke every few seconds; and stimulus control strategies [III]. Some smokers also appear to benefit from group support [III]. Combined behavior therapy and nicotine replacement improves outcome over either treatment alone and is recommended when available and acceptable to the patient [I]; however, attending behavior therapy should not be prerequisite to receiving nicotine replacement therapy [I]. For the smoker who has failed adequate treatment, as described previously, and who is interested in making another attempt to stop smoking, the psychiatrist should assess the adequacy of prior treatments and evaluate the patient for ongoing or residual alcohol, drug, or psychiatric problems that need treatment [II]. If the patient has previously failed an adequate trial of transdermal nicotine and relapse appeared to be withdrawal related, three options are reasonable: a) ad-lib nicotine gum added to transdermal nicotine [II], b) oral or transdermal clonidine [II], or c) nicotine nasal spray [II]. If relapse was due to reasons other than withdrawal (e.g., stress), multicomponent behavior therapy should be considered [I]. If the patient has previously attended such therapy, more intensive individual behavior therapy (e.g., 1-2 times/week for 2-3 weeks) should be considered [III]. Psychiatric and general medical patients who smoke and are on smoke- free wards should receive clear instructions about the no smoking policy, advice to stop smoking, and education about the symptoms and time course of nicotine withdrawal [III]. Those patients who wish to use the smoke free ward to initiate a stop smoking attempt may receive the therapies outlined previously [I]. Patients who do not wish to stop smoking permanently and who evidence nicotine withdrawal may be instructed in behavioral strategies to decrease withdrawal symptoms [III] and provided nicotine replacement (patch or gum) [II]. There is a possibility that smoking cessation might modify psychiatric symptoms (see table 6, page 5) such that it interferes with the diagnosis and treatment of psychiatric disorders (8). Cessation can also dramatically alter blood levels of some psychiatric medications (see table 5, page 5) (8) [II].

Original languageEnglish (US)
Pages (from-to)1-31
Number of pages31
JournalAmerican Journal of Psychiatry
Issue number10 SUPPL.
StatePublished - Oct 1996

ASJC Scopus subject areas

  • Psychiatry and Mental health


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