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 5 – Fagerström test for nicotine dependence 22 1. How soon after you wake up do you smoke your first cigarette? [3] Within 5 minutes [2] 6 to 30 minutes [1] 31 to 60 minutes [0] After 60 minutes 2. Do you find it difficult to refrain from smoking in places where it is forbidden? [1] Yes [0] No 3. Which cigarettes would you hate most to give up? [1] The first one in the morning [0] Any other 4. How many cigarettes per day do you smoke? [0] 10 or less [1] 11 to 20 [2] 21 to 30 [3] 31 or more 5. Do you smoke more frequently during the first hours after waking than during the rest of the day? [1] Yes [0] No 6. Do you smoke when you are so ill that you are in bed most of the day? [1] Yes [0] No →Total: [0-2] Very low; [3-4] Low; [5] Moderate; [6-7] High; [8-10] Very high. Table 6 – Motivation stages and counseling techniques 23 • Pre-contemplative: not yet worried; not ready for behavioral change → inform the risks of continuing smoking and encourage the patient to think ↓ • Contemplative: recognizes the need for and wants to change, but still wants to smoke (ambivalence) → ponder about the pros and cons of cessation and keep yourself available to talk ↓ • Determined: wants to quit smoking and is ready to take the necessary steps→ choose a date to quit smoking ↓ • Action: engaged in attitudes intended to promote changes and quit → follow-up to prevent relapse and relieve withdrawal symptoms ↓ • Maintenance: maintains the behavioral change achieved and remains abstinent → reinforce the benefits of quitting smoking and identify risk situations for relapse and coping skills ↓ • Relapse: unable to maintain the abstinence achieved and returns to the smoker’s behavior → offer support, review, and resume the entire process. Table 7 – Follow-up of smoking cessation • Set a date to stop smoking. • Get to know the social environment of the smoker in such a way that his family, friends, and coworkers are able to help him. • If other family members smoke, it will be important to encourage them to quit or to smoke outside their home. • Elaborate the action plan with nonpharmacologic and pharmacologic strategies. • Follow-up the attempts to stop smoking. • Inform about possible abstinence syndrome and craving on smoking cessation. • The patient, along with the physician, should choose the cessation method to be used: – Abrupt cessation: is usually the method of choice among smokers, and the abstinence syndrome is the main obstacle. – Gradual cessation: the smoker can continue to smoke a small number of cigarettes indefinitely and ends up returning to the previous consumption pattern. Table 8 – Cognitive-behavioral therapy • Explain the mechanisms of dependence and ambivalence. • Discuss the advantages of quitting smoking and the disadvantages of continuing to do so. • Increase the motivation of the smoker before starting the cessation program, moving from the contemplative posture to a stage of action. • Structured sessions with booklet support discussing the main aspects of addiction, withdrawal symptoms, and obstacles to overcome. • Four to six weekly 90-minute sessions (cessation sessions) and three to four biweekly 90-minute sessions (maintenance sessions) in the first 3 months of treatment. • Guide patients to set a smoking cessation date between the second and third therapy sessions, regardless of the therapeutic protocol chosen. • The maintenance phase is focused on preventing episodes of lapse or relapse. This phase lasts 12 months, with monthly follow-up (in person or by phone). • The first 6 months after smoking cessation are considered the most critical period for lapses or relapses. 482