ABC | Volume 112, Nº4, April 2019

FSCLP Statement Oliveira et al 2019: Recommendations for reducing tobacco consumption in Portuguese-Speaking countries Arq Bras Cardiol. 2019; 112(4):477-486 Table 4 – Initial assessment in the approach to smoking ANAMNESIS • Scales: Fagerström (for nicotine dependence) 22 - Table 5. • Prochaska and DiClementi (for motivation) 23 - check the counseling techniques per patient - Table 6. • Clinical and/or psychiatric comorbidities (diabetes, hypertension, depression, alcoholism, stroke, convulsion, cancer). • Medications for continuous use. • Risk factors for CVD (dyslipidemia, use of oral contraceptives or estrogen). • Gestation or breastfeeding. • Issues related to smoking: - How long have you been smoking? - How many cigarettes do you smoke a day? - Did you try to stop smoking and what was the result? - Are you interested (or thinking) about quitting smoking? • Issues related to smoking cessation: - If planned to set a date to stop smoking and if would like help with that; - If ever tried to quit smoking, if was successful, if used any medication, and for long did not smoke. PHYSICAL EXAM • Monitor BP, especially if using bupropion. • Monitor body weight: weight gain may be a barrier to starting smoking cessation and a predictor of relapse. COMPLEMENTARY TESTS • Cell blood count, liver function tests, and serum glucose, lipids and electrolytes. • Chest x-ray • Electrocardiogram. • Spirometry (not always readily available). • Measurement of exhaled carbon monoxide (COex), if possible. This measure is directly related to the carboxyhemoglobin and cigarettes smoked per day. The cut-off value is 6 ppm. CVD: cardiovascular disease. Inhaled nicotine binds to specific neuronal receptors that lead to the release of excessive dopamine and endorphins, whose effects are perceived by the smoker as stimulating and pleasurable. With the dopamine reuptake, such effects dissipate and the receptors signal the need for a new stimulus (that is, they want more nicotine), which is perceived as an unpleasant sensation (limbic system, reward circuit). Regular smokers live daily with withdrawal; for withdrawal to occur, all is required is smoking to be interrupted for a short time. 15 Craving is a typical symptom of the physical dependence of nicotine, defined as a strong desire or urge to smoke. Nicotine deprivation produces variable physical effects that last between 7 to 30 days and are more intense in the first 3 days after quitting smoking. However, the craving may persist for many months because the environmental stimuli that have been associated with smoking throughout life continue, and these associations are difficult to erase. In order to face these situations, the former smoker needs to develop skills and strategize to avoid triggering factors leading to lapse and relapse. 15 Pharmacotherapy should be used to supplement CBT and alleviate withdrawal symptoms. The medications are recommended to be used for 3 months, extending to 6 months in cases with greater difficulty in smoking cessation. 13 With pharmacological therapy, one person is estimated to successfully quit smoking (defined as smoking abstinence for 6 months) for each 6 to 23 people treated. 11 Table 10 summarizes the criteria for the initiation of pharmacological therapy, which should always take into account the patient’s comfort, safety, and preference, as well as the absence of contraindications for the use of a particular drug. The medications are divided into two basic categories: 1. Nicotine replacement therapies (NRTs); 2. Non-nicotine replacement therapies (NNRTs). NRTs are considered the first-line treatment approach for smokers and is indicated for patients with moderate to high dependence levels according to the Fagerström test. NRTs should not be combined with tobacco use. The patients should be instructed to stop smoking after initiating an NRT. The numbers needed to treat (NNT) for definitive cessation is 23 and for premature death is 46. 11 Available NRTs are 24-hour release patches, chewing gum (2 mg and 4 mg), and nicotine tablet (2 mg and 4 mg). Table 11 describes the approach with NRTs for smoking cessation. 11-15 481