TOBACCO CESSATION ORDERS DATE/TIME
1) Identify Tobacco Status Ready to quit NOW or within 30 days → Set QUIT date, initiate counseling and determine if pharmacotherapy appropriate Not ready to quit → Advise about health effects and provide motivational counseling for tobacco cessation Recently quit (within last year) → Initiate relapse prevention counseling and determine if pharmacotherapy appropriate 2) Pharmacotherapy Bupropion SR (Zyban) 150 mg PO daily x 3 days then 150mg PO twice daily (8 am & 3pm) (Contraindications include: history of seizure disorders, eating disorders, use of MAO inhibitors, concommitant use of Bupropion, and abrubt discontinuation of alcohol or sedatives) NOTE: nicotine replacement therapy should be used with caution in pregnancy (Category D), recent MI (within 2 weeks), unstable angina, and serious underlying arrhythmias Nicotine Patch (may use with Zyban; may use with Nicotine Gum OR Lozenge; may use as monotherapy) 21 mg transdermal q 24 hrs (16 hrs if sleep disturbance) 14 mg transdermal q 24 hrs (16 hrs if sleep disturbance) 7 mg transdermal q 24 hrs (16 hrs if sleep disturbance) Nicotine Gum (may use with Zyban and Patch; may use as monotherapy) 2 mg q 2 hrs PRN (no food or beverage 15 minutes prior to use, during use, and 15 minutes after use) – if using monotherapy recommend to use at least 5 per day 4 mg q 2 hrs PRN (no food or beverage 15 minutes prior to use, during use, and 15 minutes after use) – if using as monotherapy recommend to use at least 5 per day Chew slow and park in cheek every few minutes until taste / tingling subsidesusually 20-30 min; MAX per day = 20 Nicotine Lozenge (may use with Zyban and Patch; may use as monotherapy) 2 mg q 2 hrs PRN (no food or beverage 15 minutes prior to use, during use, and 15 minutes after use) - if using monotherapy recommend to use at least 5 per day 4 mg q 2 hrs PRN (no food or beverage 15 minutes prior to use, during use, and 15 minutes after use) - if using monotherapy recommend to use at least 5 per day Dissolve (do not bite) and rotate in mouth until taste / tingling subsidesusually 20-30 min; MAX per day = 20 3) Patient declines Pharmacotherapy 4) Provide tobacco cessation education materials 5) Make referral to out-patient tobacco cessation program Georgetown’s School of Nursing & Health Studies Tobacco Cessation Program 1-202-784-WELL (1-202-784-9355) 1-800-QUIT-NOW (1-800-784-8669) for free telephone tobacco cessation counseling Patient will follow up with PCP on:_____________________________________
SIGNATURE / TITLE MD PAGER NO.