to the editor: Dr. Mallin's article, “Smoking Cessation: Integration of Behavioral and Drug Therapies,”¹ drew helpful attention to the importance of the behavioral aspect of addressing tobacco dependence. It is important to include users of smokeless tobacco, as they often have more difficulty quitting because of the sustained high nicotine levels. The recent national tobacco cessation guideline (surgeon general.gov/tobacco) underlined that physicians must focus not simply on smoking cessation, but also on treatment of tobacco dependence.

Tobacco dependence is a chronic relapsing condition that requires consistent efforts by the patient, physician, and the entire health care system. Physicians can help patients quit tobacco by encouraging them during phone calls regarding test results or scheduling, and by adding a notation to faxed prescription refill requests, such as “If still smoking, encourage to quit.” Pharmacists should also encourage patients to quit tobacco, because tobacco use alters the blood levels of many medications.²

The national guidelines listed bupropion, clonidine, and nortriptyline as pharmacotherapies that reliably increase long-term smoking abstinence rates.³ Nicotine replacement therapy (NRT) often needs to be personalized, with many highly addicted tobacco users needing more than the standard dosages approved by the U.S. Food and Drug Administration (FDA). The Mayo Clinic Nicotine Dependence Center (www.mayoclinic.org/ndc-rst) pioneered the use of high-dose NRT, such as more than one 21-mg nicotine patch per day and combining the nicotine patch with nicotine gum, inhaler, and/or nasal spray. Inhaler users need to be advised to puff for mouth absorption rather than inhale to minimize the cough and sore throat that inhalation can cause. The common rhinitis caused by nasal spray usually resolves over several days. Nicotine lozenges and sublingual tablets are available in Europe and may eventually be available in the United States.

Many patients have access to the Internet and can find great support for quitting tobacco. Some helpful sites include the American Lung Association (www.ffsonline.org); the National Spit Tobacco Education Program (www.nstep.org); Nicotine Anonymous (www.nicotine-anonymous.org); the American Cancer Society (www.cancer.org);www.kickbutt.org;www.tobaccofreekids.org; andwww.quitnet.com. Many states have telephone quit-lines that offer tobacco cessation counseling, quit kits, access to medications, information, and referrals, such as Washington state's 877-270-STOP (877-270-7867). The American Legacy Foundation's Great Start (www.americanlegacy.org/greatstart; 866-66-START [866-667-8278]) is a nationwide service designed for pregnant women trying to quit tobacco.

Worldwide efforts include International Quit&Win 2002 (www.quitandwin.org), which is a contest to encourage tobacco users to quit tobacco for the entire month of May with a $10,000 grand prize drawing; however, only four counties in the United States currently participate. World No Tobacco Day (www.worldnotobaccoday.com) is a similar one day promotion held on May 31.

The American Academy of Family Physicians (AAFP) Stop Smoking Kit, developed by family physicians, contains patient materials, a physician/office staff manual, and chart forms for use in a primary care office.