History and exam
Key diagnostic factors
common
number of cigarettes per day
A simple question that can indicate which people may have more problems with nicotine dependence and guide intensity of nicotine replacement therapy.[76] For those smoking <10 cigarettes/day, an as-needed form of nicotine replacement (gum, lozenge, inhaler, nasal spray) may be preferred rather than using continuous therapies such as the nicotine patch or bupropion.[2]
time to first cigarette (TTFC)
A simple question that can indicate which patients may have more problems with nicotine dependence and guide intensity of nicotine replacement therapy (NRT).[76] If the TTFC is ≤30 minutes, higher doses of NRT may be recommended.
use of alternative tobacco and nicotine delivery products
Although not directly relevant to assisting people with cessation of combustible tobacco smoking, asking about use of alternative tobacco and nicotine delivery products may provide further context about tobacco/nicotine use and dependence. E-cigarettes do not contain tobacco and instead use a liquid made from chemicals that can have different flavours and different amounts of nicotine.[57][58][85][86] Other products include heat-not-burn tobacco devices (e.g., e-hookah), waterpipe ('hookah') use, and smokeless tobacco products (e.g., snuff, ground, or chewing tobacco). Asking about frequency and volume of use, and the time to first use at the start of the day, is useful.
history of substance use disorder (SUD)
uncommon
pregnancy or breastfeeding
Suggests a high risk of tobacco-related harm.[63] Smoking in pregnancy represents a special circumstance with additional considerations. While smoking during pregnancy is a well-established risk factor for adverse pregnancy outcomes including preterm deliveries, low birth weight, and preterm-related deaths, it is still prevalent to varying degrees globally.[7]
Other diagnostic factors
uncommon
history of depression
history of schizophrenia
seizure disorder
Any seizure history, head injury, or other lowered seizure threshold should be noted, and caution exercised in selecting pharmacological agents in smoking cessation.
hypertension
Special considerations may apply when choosing smoking cessation treatments in the context of hypertension.
unstable cardiac disease
Special considerations may apply when choosing smoking cessation treatments in the context of unstable cardiac disease. The relative lack of evidence regarding safety and efficacy of nicotine replacement therapy (NRT) in acute coronary syndrome (ACS) and the theoretical concern for nicotine's vasoconstrictive properties mean that NRT use may be limited during hospitalisation for patients with ACS and life-threatening arrhythmias. The American College of Cardiology notes, however, that given the robust safety profile and efficacy of NRT in the general population, and the clear dangers of smoking, NRT is recommended as first-line therapy in hospitalised patients with ACS.[89]
There is evidence that varenicline, bupropion, and NRT do not increase the risk of cardiovascular events in the general population of smokers.[90]
ventricular arrhythmia
Special considerations may apply when choosing smoking cessation treatments in the context of ventricular arrhythmia.
asthma
Suggests a high risk of tobacco-related harm.[63] Limits use of nicotine replacement delivery by inhaler.
chronic obstructive pulmonary disease (COPD)
temporomandibular joint or dental disorder
May limit appropriateness of nicotine replacement gum.
Risk factors
strong
age <24 years
Smoking usually begins in adolescence or early adulthood (typically before the age of 24 years).[9] Although older teens are more likely to smoke than younger teens, the earlier a person starts smoking or using any addictive substance, the more likely they are to develop an addiction. Males are also more likely to take up smoking in adolescence than females.[56]
low socioeconomic status
Low socioeconomic status is associated with increased smoking rates, with the prevalence among those living below the poverty line in the US at 24.7%, versus 14.8% in those with a high income.[4]
history of mental illness or substance use disorder
history of HIV/AIDS
People with HIV/AIDS have high smoking rates (40% to 75%), and the proportion of deaths among people with HIV/AIDS from diseases related to smoking use is substantial.[46]
use of alternative tobacco and nicotine delivery products
E-cigarettes (vapes) do not contain tobacco and instead use a liquid made from chemicals that can have different flavours and different amounts of nicotine.[57][58] A number of studies have found a strong association between e-cigarette use and subsequent smoking initiation among adolescents and young adults, although it is currently unclear whether this relationship is causal.[37][38][39]
Use of smokeless tobacco products (snuff, ground, or chewing tobacco) may be a risk factor for later development of cigarette smoking, and may increase the risk for nicotine addiction, periodontal disease, and cancer.[58]
weak
genetics
Studies of twins and adoptees suggest that there is a modest genetic influence on regular use of cigarettes that probably interacts with environmental factors.[42]
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