Eduovisual
Behavioral Health
Tobacco use disorder: pharmacotherapy and counseling
— Mild 2–3, Moderate 4–5, Severe ≥6 criteria
Step 3 management: Document smoking status as a vital sign in the EMR; even a 3-minute physician advice to quit increases cessation rates and is itself a billable, guideline-endorsed intervention (CPT 99406 for 3–10 min, 99407 for >10 min, both covered by Medicare without copay).
Board pearl: A patient who "quit" but uses e-cigarettes is not abstinent for TUD purposes — e-cigarettes deliver nicotine, sustain dependence, and lack FDA approval as cessation aids.
— USPSTF 2021: annual low-dose CT ages 50–80, ≥20 pack-years, current smoker or quit within 15 years
— Precontemplation (no intent in 6 mo) → motivational interviewing, personalized risk
— Contemplation (intent in 6 mo) → decisional balance, address ambivalence
— Preparation (intent in 30 days) → set quit date, prescribe pharmacotherapy
— Action (quit <6 mo) → relapse prevention, intensify support
— Maintenance (≥6 mo abstinent) → continue follow-up, watch for slips
— Age of initiation, prior quit attempts and what worked/failed, longest abstinence
— Triggers (stress, alcohol, coffee, post-meal, driving)
— Household/workplace smokers — strong relapse predictor
— Comorbid psychiatric disease (depression, anxiety, schizophrenia, bipolar) — 2–4× prevalence; affects drug choice
— Comorbid alcohol/cannabis/opioid use — concurrent treatment improves outcomes
— Pregnancy status, breastfeeding, contraception
Key distinction: Nicotine withdrawal (subjective, dysphoric, no autonomic crisis) differs from alcohol or benzodiazepine withdrawal (tachycardia, hypertension, tremor, seizure risk) — nicotine withdrawal is uncomfortable but not dangerous and never requires inpatient detox.
Board pearl: Ask about menthol use — menthol cigarettes are harder to quit, more common in Black smokers, and the FDA has moved to ban them; this is a health equity consideration likely to appear on Step 3.
— Spirometry if any respiratory symptom or ≥40 yo with ≥10 pack-years → FEV1/FVC <0.70 confirms COPD
— Exhaled CO ≥10 ppm confirms recent smoking; <6 ppm is consistent with abstinence — useful in clinic for biofeedback
— BP, weight, BMI (expect 4–5 kg gain post-quit)
Step 3 management: At the preoperative visit, document tobacco status and offer cessation — 4+ weeks of preoperative abstinence reduces wound infection, pulmonary complications, and 30-day mortality; even 24-hour abstinence halves carboxyhemoglobin and improves oxygen delivery.
Board pearl: A 60-year-old male smoker with a pulsatile abdominal mass needs an immediate ultrasound — AAA screening is one of the few times smoking history changes a one-time screening recommendation.
— Serum/plasma >10 ng/mL = active smoker; 3–10 ng/mL = passive exposure or recent quit; <3 ng/mL = nonsmoker
— Urine cotinine cutoff typically >50 ng/mL for active use
— Not affected by NRT at the qualitative level — cotinine is positive in patients on the patch/gum, so use anabasine or nornicotine if you need to distinguish NRT from smoking (e.g., transplant candidates)
— CBC (polycythemia from chronic hypoxia), CMP, lipid panel (smoking lowers HDL), HbA1c (smoking accelerates insulin resistance)
— Spirometry with bronchodilator response if symptomatic or screening
— Low-dose chest CT annually for lung cancer screening per USPSTF criteria (50–80 yo, ≥20 pack-years, quit ≤15 yr)
— Stop screening once 15 years smoke-free or life expectancy/surgical candidacy is limited
— CXR is NOT acceptable for lung cancer screening (NLST showed no mortality benefit)
CCS pearl: On a CCS case, when the patient is a smoker, order smoking-cessation counseling on the very first screen alongside diagnostic studies — counseling is time-sensitive and earns credit; deferring it to "follow-up" loses points.
Key distinction: A positive cotinine with a negative anabasine indicates NRT use without combustible tobacco — the "ideal" intermediate state in a patient transitioning off cigarettes; do not interpret as relapse.
— Full PFTs with DLCO if spirometry abnormal — DLCO drops early in emphysema before FEV1
— 6-minute walk test for functional baseline in COPD
— Alpha-1 antitrypsin level once in every COPD patient (GOLD recommendation)
— Sleep study if obesity, snoring, or daytime sleepiness — OSA and smoking commonly coexist
— Calculate 10-year ASCVD risk; smoking roughly doubles risk
— Coronary calcium score can refine intermediate-risk decisions
— Stress testing only if symptomatic or preoperative for high-risk surgery — not routine
— Annual LDCT as above
— Oral exam every visit; refer to ENT for suspicious lesions
— Urinalysis has no role for routine bladder cancer screening, but gross hematuria in a smoker mandates cystoscopy and upper-tract imaging
— Cervical cancer screening per usual schedule (smoking is a cofactor with HPV)
Board pearl: EAGLES trial (2016) — varenicline, bupropion, NRT patch, and placebo in ~8,000 smokers with and without psychiatric disorders showed no significant increase in serious neuropsychiatric events; this removed the FDA black-box warning on varenicline in 2016. High-yield biostats/safety point.
Step 3 management: A new diagnosis of COPD, MI, stroke, or cancer is a teachable moment — quit rates are 2–3× higher when cessation is initiated during hospitalization for a smoking-related illness; always prescribe pharmacotherapy at discharge.
— Willing to quit now → set quit date within 2 weeks, prescribe first-line pharmacotherapy + behavioral counseling
— Not ready → brief motivational interviewing using the 5 R's: Relevance, Risks, Rewards, Roadblocks, Repetition
— Recently quit → relapse prevention counseling, continue/extend pharmacotherapy
— Varenicline — highest efficacy as monotherapy (OR ~2.9 vs. placebo)
— Combination NRT (long-acting patch + short-acting gum/lozenge/inhaler/spray) — comparable to varenicline in some trials
— Bupropion SR — modest efficacy; preferred when depression or weight-gain concern dominates
— Single-agent NRT — modest, useful when other options contraindicated
— Severe dependence (>30 cpd, time-to-first-cigarette <5 min) → varenicline or combo NRT
— Comorbid depression → bupropion ± NRT
— Cardiovascular disease → varenicline and NRT both safe; bupropion lowers seizure threshold and can raise BP
— Seizure disorder, eating disorder, recent benzo/alcohol withdrawal → avoid bupropion
— Pregnancy → behavioral first; NRT if needed; avoid varenicline/bupropion (limited data)
— Renal failure (CrCl <30) → reduce varenicline dose
Step 3 management: Always offer pharmacotherapy unless contraindicated — "willpower alone" has a 12-month abstinence rate of only 3–5%; combined therapy reaches 25–35%. Document the offer even if the patient declines.
— Dosing: Days 1–3: 0.5 mg daily; Days 4–7: 0.5 mg BID; Day 8+: 1 mg BID × 12 weeks; extend to 24 weeks if successful
— Quit date: set for day 8, OR use flexible quit (anytime within first month), OR reduce-to-quit approach
— Side effects: nausea (~30%) — take with food/water; vivid dreams, insomnia (dose in afternoon vs bedtime), headache, constipation
— Renal: CrCl <30 → max 0.5 mg BID; ESRD on HD → 0.5 mg daily
— No longer carries black-box for neuropsychiatric effects (removed 2016 post-EAGLES)
— Most effective monotherapy; can be combined with NRT patch for greater efficacy
— Patch (long-acting): ≥10 cpd → 21 mg/24 hr × 6 wk, then 14 mg × 2 wk, then 7 mg × 2 wk; <10 cpd → start at 14 mg
— Gum/lozenge (short-acting): 4 mg if time-to-first-cigarette <30 min, else 2 mg; park-and-chew technique; max 24/day
— Inhaler/nasal spray — Rx only; useful for hand-to-mouth ritual
— Combination NRT = patch + PRN short-acting — equivalent to varenicline efficacy
— Adverse: local irritation, vivid dreams (remove patch overnight), hiccups/dyspepsia (gum)
— Dosing: 150 mg daily × 3 days, then 150 mg BID × 7–12 weeks; start 1–2 weeks before quit date
— Contraindications: seizure disorder, eating disorder, abrupt alcohol/benzo cessation, MAOI use
— Side effects: insomnia (avoid bedtime dose), dry mouth, lowers seizure threshold (~0.1%), hypertension
— Bonus: blunts post-quit weight gain; treats comorbid depression
Board pearl: A patient on bupropion for depression who wants to quit smoking — do not add a second bupropion; the antidepressant dose (300–450 mg/day of bupropion XL) already provides cessation effect. Add NRT or switch to varenicline.
Key distinction: Set quit date with bupropion = after 1–2 weeks of medication; with varenicline = day 8 (or flexible); with NRT = day 1.
— Nortriptyline 25–75 mg/day — TCA, modest efficacy; anticholinergic side effects; useful with comorbid depression when bupropion contraindicated
— Clonidine 0.1–0.3 mg/day — α2 agonist; sedation, hypotension, rebound HTN on withdrawal — taper
— Both off-label in the US; reserved for refractory cases
— Not FDA-approved for cessation; mixed evidence (some RCTs show benefit vs. NRT, but at the cost of continued nicotine dependence)
— 2024 USPHS and AAFP: do not recommend e-cigarettes as first-line; if a patient uses them, encourage transition to FDA-approved products and eventual abstinence
— Associated with EVALI (e-cigarette/vaping-associated lung injury) — bilateral infiltrates, often with vitamin E acetate in THC-containing products
— Youth/adolescent vaping is a public health emergency — screen all teens
— Patch + lozenge/gum — gold standard combo NRT
— Varenicline + patch — superior to varenicline alone in some trials
— Bupropion + NRT — synergistic; addresses different pathways
Step 3 management: Failure on one regimen is not failure of cessation — average smoker makes 6–30 quit attempts before sustained abstinence. Re-engage, switch agents, intensify counseling, never give up on the patient.
Board pearl: A patient develops bilateral ground-glass opacities, dyspnea, fever, and GI symptoms after recent vaping — think EVALI; obtain CT, exclude infection, admit if hypoxic, treat with corticosteroids, and counsel cessation of all vaping products.
— Quitting at any age improves survival, lung function decline, CV events, and dementia risk
— 65-year-old quitter gains ~2 years of life expectancy; 80-year-old quitter still gains months and improves quality
— All first-line agents safe — varenicline and NRT both well-tolerated
— Watch for polypharmacy interactions: smoking induces CYP1A2 → quitting raises levels of theophylline, clozapine, olanzapine, caffeine, warfarin, propranolol — recheck levels/INR within 1–2 weeks of cessation
— Adjust clozapine and olanzapine doses down by ~25–50% after smoking cessation to avoid toxicity
— Varenicline: CrCl 30–50 → no adjustment; CrCl <30 → max 0.5 mg BID; ESRD on HD → 0.5 mg daily (dialyzed)
— Bupropion: reduce dose/frequency in CKD and ESRD; metabolites accumulate
— NRT: no renal dose adjustment needed
— Bupropion: reduce to 150 mg every other day in severe hepatic impairment (Child-Pugh C)
— Varenicline: no hepatic adjustment (primarily renal excretion)
— NRT: no hepatic adjustment
— Smoking cessation reduces post-MI mortality by ~36% within 2 years — single most effective secondary prevention
— Varenicline is safe post-MI/stroke (CATS trial); start in-hospital
— NRT is safe even in unstable CAD — risk of continued smoking >> theoretical NRT risk; AHA endorses use
— Bupropion: monitor BP; avoid in uncontrolled HTN
— EAGLES: all agents safe in stable mental illness; schizophrenia patients benefit dramatically — smoking prevalence ~60% in this population
— Coordinate with psychiatry; expect psychotropic dose adjustments post-quit (CYP1A2 again)
Step 3 management: A 70-year-old on warfarin quits smoking — recheck INR in 5–7 days; loss of CYP1A2 induction can raise INR, increasing bleed risk. Same logic for theophylline (toxicity) and clozapine (seizure, sedation).
Key distinction: NRT post-MI is safe; old teaching to avoid NRT in CV disease is outdated — continued smoking is far more dangerous than transdermal nicotine.
— Screen at every prenatal visit; offer cessation at the first visit (USPSTF Grade A)
— First-line: behavioral counseling (CBT, motivational interviewing, incentive-based programs — strongest evidence)
— Pharmacotherapy in pregnancy is controversial:
— NRT: ACOG considers it reasonable when behavioral therapy fails — use intermittent (gum/lozenge) over patch when possible to avoid continuous nicotine exposure; if patch used, remove at night
— Varenicline and bupropion: insufficient data; generally avoided in pregnancy though emerging data on bupropion is reassuring
— E-cigarettes: avoid — nicotine harms fetal brain development regardless of delivery
— Cotinine or exhaled CO verification at prenatal visits is appropriate
— Smoking reduces milk supply; nicotine passes into milk
— NRT compatible with breastfeeding — far safer than continued smoking; time short-acting NRT after feeds
— Bupropion: present in milk, generally considered compatible
— Varenicline: limited data, generally avoid
— USPSTF: counseling/educational interventions to prevent initiation (Grade B)
— Insufficient evidence for pharmacotherapy in adolescents — behavioral is first-line
— E-cigarettes are the dominant nicotine product in US teens; screen for vaping at every visit
— Parental smoking is the strongest predictor — address whole household
Board pearl: Financial incentive programs ("contingency management") have the strongest evidence for cessation in pregnant women — exam-favorite when the question highlights a pregnant patient struggling to quit despite counseling.
Step 3 management: A pregnant smoker at 10 weeks who fails 2 weeks of counseling → shared decision-making for intermittent NRT (gum 2 mg PRN), prefer over varenicline/bupropion; continue counseling, document risks/benefits of treatment vs. continued smoking.
— Accelerated atherosclerosis, MI (2–4× risk), stroke, PAD (smoking is the strongest modifiable risk factor), AAA, sudden cardiac death
— Doubles risk of recurrent MI; quitting reduces it by half within 1 year
— COPD (chronic bronchitis, emphysema) — 80% attributable to smoking
— Lung cancer — 80–90% attributable; small cell and squamous cell most tightly linked
— Increased pneumonia, influenza, TB reactivation, pneumothorax (especially in young thin smokers)
— Interstitial lung diseases: RB-ILD, DIP, pulmonary Langerhans cell histiocytosis — smoking-related ILDs
— Lung, larynx, oral cavity, pharynx, esophagus (squamous), stomach, pancreas, liver, kidney, bladder, ureter, cervix, AML
— Bladder cancer: smoking is #1 risk factor; gross painless hematuria → cystoscopy
Board pearl: Smoking lowers serum levels of estrogen, leading to earlier menopause and worsening osteoporosis — also why oral contraceptives + smoking >35 yo is contraindicated (VTE/MI risk).
Key distinction: Smoking and ulcerative colitis — UC is the rare disease where smoking decreases risk and severity; nevertheless, never advise smoking — risks vastly outweigh benefits. Use this as a UWorld-style trick-question setup.
— New COPD with frequent exacerbations, oxygen needs, FEV1 <50% predicted
— Suspicious LDCT findings (Lung-RADS 3 or 4) — need bronchoscopy, biopsy, multidisciplinary thoracic oncology
— Suspected ILD, alpha-1 antitrypsin deficiency
— Multiple failed quit attempts despite optimal first-line therapy
— Severe psychiatric comorbidity destabilizing cessation
— Concurrent alcohol, opioid, or stimulant use disorder (treat together — concurrent treatment improves all outcomes)
— Every hospitalized smoker should receive: nicotine withdrawal management (NRT patch within hours of admission), brief counseling, and discharge pharmacotherapy + outpatient follow-up
— Joint Commission tobacco performance measures track these elements
— Smoke-free hospital campuses are standard; NRT prevents AMA discharges
— EVALI with hypoxia, respiratory failure → ICU, steroids, supportive care
— Acute MI/stroke/CO poisoning from smoking-related events → standard emergency protocols
— Severe agitation from nicotine withdrawal in restrained or ICU patient → NRT patch + short-acting gum
CCS pearl: On any CCS hospital case with a smoker — order "nicotine patch" and "tobacco cessation counseling" on admission orders, then discharge with varenicline or combo NRT + 1-week follow-up + quitline referral. These actions earn process-of-care credit.
Step 3 management: A hospitalized patient with COPD exacerbation, MI, or stroke is in the highest-yield teachable moment of their life — initiate pharmacotherapy before discharge, not "at follow-up."
— Frequently coexists (~25% comorbidity); alcohol is the #1 smoking-relapse trigger
— Withdrawal is medically dangerous (seizures, DTs) — opposite of nicotine
— Use AUDIT-C alongside tobacco screening; if positive, treat both — naltrexone treats AUD and may reduce smoking
— Often co-smoked with tobacco ("blunts," "spliffs")
— Each substance independently harms lungs; co-use accelerates COPD
— Cessation strategies differ — no FDA-approved pharmacotherapy for cannabis
— ~85% of patients on MAT smoke — highest comorbidity of any substance
— Address tobacco alongside opioid treatment; methadone smokers benefit from varenicline and combo NRT
— Failure to address tobacco contributes to higher mortality than overdose in long-term recovery
— Smokeless tobacco (chew, snuff, dip) — oral cancer, leukoplakia, periodontal disease; varenicline has data; NRT helps
— E-cigarettes — nicotine dependence without combustion; not a "diagnosis" but a sustained dependence state
— Heated tobacco products (IQOS, etc.) — emerging; treat similarly to combustible
— Smoking induces CYP1A2 → smokers metabolize caffeine faster; quitting raises caffeine levels → jitters, insomnia, anxiety that can be misattributed to nicotine withdrawal — advise halving caffeine intake at quit date
Board pearl: A patient quits smoking and develops worsening anxiety, insomnia, and palpitations at day 3 — consider caffeine toxicity from loss of CYP1A2 induction, not just nicotine withdrawal. Halve caffeine, reassess.
Key distinction: Nicotine withdrawal never requires inpatient detox; alcohol or benzodiazepine withdrawal can be life-threatening — never confuse the two when a question describes autonomic instability.
— Differentials: major depressive episode unmasked or precipitated; generalized anxiety disorder; bipolar mixed state
— Use PHQ-9 and GAD-7 at quit visit and 2-week follow-up; treat persisting depression with SSRI or bupropion (bonus cessation effect)
— Withdrawal insomnia resolves in 1–2 weeks
— Persistent → consider OSA (common in ex-smokers due to weight gain), bupropion if dosed late, varenicline vivid dreams
— Expected (~4–5 kg average, more in women and heavy smokers)
— Differentials: hypothyroidism (TSH), depression (atypical), medication-induced (bupropion decreases appetite, mirtazapine increases)
— Counsel on diet/exercise; bupropion mitigates weight gain
— Loss of nicotine's prokinetic effect; resolves in weeks
— Watch for varenicline-induced constipation
— Paradoxical worsening in first weeks of cessation as cilia recover and clear retained mucus — reassure, not failure or infection
— Persistent productive cough → CXR, consider pneumonia or new lung cancer
— Mild withdrawal symptoms; consider caffeine excess (see chunk 13)
— New severe headache → standard workup
— Resolves in 2–4 weeks
— Persistent → screen for depression, OSA, hypothyroidism
— Common at 1–2 weeks; harmless, self-limited
— Persistent ulcer >2 weeks → ENT (always rule out oral cancer in former smokers)
Step 3 management: New depressive symptoms after quitting smoking are common but not normal — screen with PHQ-9, treat actively, and do not restart smoking as "self-medication"; switch or add bupropion which treats both.
Board pearl: Worsening cough in the first 2 weeks post-quit is mucociliary recovery — reassure; worsening cough at 2 months with weight loss in an ex-smoker is lung cancer until proven otherwise.
— Standard 12 weeks; extend to 24+ weeks for high-dependence patients or those with prior relapses
— No firm upper limit on NRT — long-term NRT use is far safer than smoking
— Varenicline 24-week extension trials show sustained benefit
— Identify and rehearse responses to triggers (alcohol, stress, social settings, post-meal, coffee)
— Avoid alcohol in early abstinence
— Behavioral substitution — sugar-free gum, cinnamon sticks, exercise
— Stress management — CBT, mindfulness, exercise
— Social support — quitline (1-800-QUIT-NOW), text programs (SmokefreeTXT), apps, support groups
— Slip ≠ relapse — a single cigarette is not failure; problem-solve and continue pharmacotherapy
— Statin per ASCVD risk (smoking removed from calculator at 5 years abstinence — but vascular benefit accrues continuously)
— Aspirin per indication
— Continue antihypertensives, antidiabetics with awareness that BP and HbA1c may shift after quitting
— FEV1 decline slows to near-normal rate after cessation — emphasize this
— Continue LDCT until 15 years smoke-free or USPSTF age cutoff
— Pneumococcal vaccines (PCV20 or PCV15+PPSV23) and annual influenza are indicated in current and former smokers
Step 3 management: At each follow-up: ask about tobacco use (current vs abstinent), reinforce abstinence, review medications, screen for depression/weight gain, update LDCT and cancer screening — make this a structured visit template.
Board pearl: Pneumococcal vaccination is recommended for all adult smokers age 19–64 under ACIP — high-yield vaccine-eligibility question.
— Set firm quit date (within 2 weeks)
— Prescribe pharmacotherapy with clear dosing instructions
— Provide written quit plan; refer to quitline and text-message program
— Schedule follow-up within 1–2 weeks
— Confirm quit; if not quit, identify barriers, intensify pharmacotherapy, reschedule quit date
— Assess side effects (nausea on varenicline, skin irritation on patch, insomnia on bupropion)
— Screen for depression/anxiety with PHQ-9, GAD-7
— Recheck INR if on warfarin, drug levels if on theophylline/clozapine
— Confirm continued abstinence; exhaled CO if available
— Address weight gain, cravings, social triggers
— Adjust pharmacotherapy if needed
— Plan for extension vs taper of pharmacotherapy
— Reinforce non-pharmacologic supports
— Continue to ask at every visit
— Annual LDCT if eligible
— Cancer screening per usual schedule
— Practical counseling: problem-solving, skill-building, anticipate high-risk situations
— Intratreatment social support: encouragement, empathy, validate effort
— Extratreatment social support: enlist family/friends as quit-allies
— Minimal advice (<3 min): OR ~1.3 vs no intervention
— Low intensity (3–10 min): OR ~1.6
— High intensity (>10 min, multiple sessions): OR ~2.3
— Group counseling and individual counseling equally effective; telephone counseling (quitlines) equivalent to in-person
— CPT 99406 — intermediate counseling 3–10 min
— CPT 99407 — intensive counseling >10 min
— Up to 8 sessions/year covered without cost-share
Step 3 management: Document start date, drug, dose, duration, follow-up plan, and counseling time at every cessation visit — both for clinical continuity and for billing/quality measure capture (HEDIS, MIPS, Joint Commission TOB measures).
Board pearl: Quitlines (1-800-QUIT-NOW) are free, evidence-based, and available in every state — referring a patient is a guideline-endorsed action and a common Step 3 "best next step."
— Repeated brief advice at each visit is ethical and effective; moralizing or shaming is unethical and counterproductive
— Discuss varenicline's historical neuropsychiatric warnings (now removed) — patients may have outdated concerns
— Bupropion seizure risk must be disclosed, especially in eating-disorder or alcohol-withdrawal contexts
— NRT in pregnancy — document shared decision-making (risks of medication vs. continued smoking)
— Tobacco status is not subject to special protections like 42 CFR Part 2 (which covers SUD treatment records in federally assisted programs — applies to formal addiction treatment programs but generally not routine primary care tobacco counseling)
— Disclosure to employers (e.g., for tobacco surcharges on health plans) requires patient consent
— Discharge from hospital without cessation pharmacotherapy is a documented safety gap — relapse rates exceed 70% if not bridged
— Update medication reconciliation to flag CYP1A2 substrates (warfarin, theophylline, clozapine, olanzapine) when smoking status changes
— Communicate quit status to PCP, mental health, and pharmacy
— Secondhand smoke exposure alone is not reportable to CPS in most states, but caregiver smoking in the presence of a child with severe asthma or on home oxygen may rise to neglect — know your state law
— Document counseling and safety planning; offer caregiver cessation
— Tobacco surcharges on ACA plans (up to 50%) may not apply if patient enrolls in a cessation program — counsel patients on this benefit
— Life insurance requires honest tobacco disclosure; fraud is a legal issue
— Higher smoking rates in low-income, rural, Indigenous, LGBTQ+, and Black communities (menthol)
— Cessation services must be culturally tailored and financially accessible
Step 3 management: A hospitalized smoker discharged on clopidogrel for new MI — confirm cessation pharmacotherapy is prescribed, schedule PCP follow-up within 7 days, communicate to PCP that smoking cessation may alter levels of warfarin and other CYP1A2 substrates if applicable. This is the kind of transition-of-care detail Step 3 rewards.
Board pearl: Three exam triggers for immediate cessation pharmacotherapy: (1) hospitalization for any smoking-related illness, (2) pregnancy diagnosis, (3) new cancer diagnosis — these are the highest-yield teachable moments and the right answer is almost always "start pharmacotherapy + counseling now."
— 50-year-old smoker, 1 ppd × 30 years, asymptomatic, here for physical → best next step?
— Answer: Advise to quit + offer pharmacotherapy + LDCT screening (eligible by USPSTF) + AAA US (if male 65–75)
— Smoker with depression → bupropion ± NRT
— Smoker with seizure disorder → varenicline or NRT, not bupropion
— Smoker with CKD stage 4 → reduced-dose varenicline (0.5 mg BID) or NRT
— Smoker post-MI day 3 in hospital → NRT patch now, varenicline before discharge
— Pregnant smoker failing counseling → intermittent NRT (gum/lozenge)
— Patient on clozapine quits smoking → expect rising levels, sedation, seizure risk → reduce dose 25–50%, monitor
— Patient on warfarin quits → INR rises, recheck in 5–7 days
— Patient on theophylline quits → toxicity risk, recheck level
— Day 3 post-quit, irritable, restless, increased appetite, craving → nicotine withdrawal, reassure, continue/intensify pharmacotherapy — not depression yet
— Persistent low mood, anhedonia, hopelessness 4 weeks post-quit → screen for MDD, start SSRI/bupropion
— Young vaper, bilateral GGOs, hypoxia, GI symptoms → EVALI; rule out infection, corticosteroids, cease vaping
— 15-year-old using e-cigarettes daily → behavioral counseling, parental involvement, school-based programs, no pharmacotherapy first-line in adolescents
— Smoker scheduled for elective hip replacement in 6 weeks → advise cessation now, prescribe NRT/varenicline, counseling — 4-week abstinence reduces complications
— Patient on bupropion for depression wants to quit smoking → do not add second bupropion; use NRT or varenicline
— 7-minute cessation counseling visit → CPT 99406
— 15-minute visit → 99407
Board pearl: When the question gives you a smoker in a teachable moment (MI, COPD exacerbation, new cancer, pregnancy), the answer is almost always pharmacotherapy + counseling now, not "follow up in clinic" or "willpower."
Step 3 management: The exam rewards action, not deferral — choose the option that initiates evidence-based therapy at the current visit.
Tobacco use disorder is a chronic relapsing disease for which the standard of care at every visit is the 5 A's: ask about use, advise quitting, assess readiness, assist with combination pharmacotherapy (varenicline, combo NRT, or bupropion) plus behavioral counseling, and arrange close follow-up — because pharmacotherapy plus counseling roughly triples sustained quit rates and is the single most powerful preventive intervention in medicine.
Board pearl: If the question features a smoker, the highest-yield answer is almost always combination pharmacotherapy plus behavioral counseling initiated at this visit, with documented follow-up — Step 3 rewards the clinician who acts, not the one who defers.