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Treating Tobacco Use and Dependence at OHSU Program Modules (click on topic for more detail) 1. The Tobacco Problem 2. Summary information on nicotine dependence and nicotine (tobacco) withdrawal. 3. Medications and behavioral support used to treat nicotine dependence. 4. Dosing issues and special considerations for cessation medications. 5. Patient care at OHSU hospitals and clinics The Tobacco Problem Main Menu Next The Tobacco Problem • Tobacco dependence is a chronic disease. • 21.5% of Oregon men and 18.4% of Oregon women smoke. • Smoking related diseases claim over 7,000 Oregon lives annually. • Smoking costs Oregon over $2 billion each year in healthcare costs and lost productivity. • Smoking is directly responsible for 87% of lung cancer cases and causes most cases of emphysema and chronic bronchitis. Main Menu Next What Can Be Done? • One out of two smokers will die prematurely from a smokingrelated disease. • Every year nearly 45% of smokers try to quit and only about 10% succeed. • Most smokers try to quit smoking by just stopping “cold turkey.” • Effective cessation medications + behavioral treatment (e.g. coaching, counseling, quit lines) can double or triple success rates vs “cold turkey”. • You save lives when you provide cessation treatment. Main Menu Next Why now? • OHSU is completely tobacco free as of September 17, 2007. • Patients coming to OHSU will not be able to smoke. This provides an important opportunity to talk to patients about quitting and help provide assistance to stop. • Evidence-based treatment protocols are widely available and, with your help, are being implemented in OHSU hospitals and clinics. Main Menu Nicotine Dependence And Nicotine (Tobacco) Withdrawal Main Menu Next Nicotine Withdrawal Symptoms • Physical symptoms (can be mistaken for adverse drug experiences.) – Acute physical symptoms resolve significantly in 3-6 weeks. – Some cravings persist for months, but become less frequent. – Medications are generally recommended for up to 12 weeks. • Emotional symptoms (can be mistaken for adverse drug experiences). – Some emotional lability is common e.g. depressed affect and anxiety. (Some risk of Major Depressive Episode in those with recent history of Mood Disorder - refer for follow-up.) – Emotional stress due to life circumstances are risks for later relapse (e.g. death of loved one). Main Menu Next Some Withdrawal Symptoms Following Abrupt Smoking Cessation Or Reduction • Depressed mood • Anxiety • Sleep disturbance • Restlessness • Irritability, frustration or anger • Increased appetite or weight gain • Difficulty concentrating • Decreased heart rate • Cravings SEVERITY OF WITHDRAWAL SYMPTOMS IS A PRIMARY CAUSE OF EARLY RELAPSE. American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.) Washington, DC. Main Menu Next Weight Gain And Smoking Cessation: Results Of A 10 Year Study* Weight gain is a significant barrier. • Weight gain or fear of weight gain after quitting can keep smokers from even trying to make a quit attempt, especially women. • Most smokers & quitters gained weight over 10 years. • Women smokers gained 3.7 lbs. (average). • Women quitters gained 12.1 lbs. (average) • Women quitters gained more than men quitters. • 13.4 % of women quitters gained >29 lbs. vs. 9.8% for men quitters • Most weight gain occurred in the 1st year. • Some will decide to relapse to try to lose weight. *Women and smoking: a report of the Surgeon General; 2001 Main Menu Next Role Of Acetylcholine Nicotinic Receptors • Acetylcholine nicotinic sub receptors are normal structures in the brain and elsewhere of smokers and never smokers (16 nicotinic subtypes identified). • Nicotinic receptors modulate neurotransmitters (e.g. dopamine (α4β2), norepinephrine, serotonin, opioid peptides, etc. in all people. • Nicotine binding excites receptors and disrupts normal activity. Main Menu Next Role Of Acetylcholine Nicotinic Receptors • Chronic nicotine exposure results in permanent receptor upregulation and “nicotine normal” receptor functioning in the brain. • Reduced nicotine binding at receptor sites due to reduced tobacco intake or cessation disrupts “nicotine normal” receptor activity and results in nicotine withdrawal symptoms. • Receptor activity normalizes without nicotine in 3-6 months, but up-regulated receptors remain indefinitely. Main Menu Next Click here for a comprehensive “Review of Tobacco Dependence and Tobacco Dependence Treatment” Main Menu Medications To Treat Withdrawal Main Menu Next Medications Who should receive them? • Nearly all smokers trying to quit, except those with medical contraindications, adolescents and those who smoke fewer than 10 cigarettes per day. • Those who have recently quit (e.g. less than 6 months) who are concerned about relapse may benefit from PRN use of flexible dosed nicotine replacement therapies (NRT) such as nicotine lozenges or gum. Main Menu Next Purpose Of Cessation Medications • Cessation medications are primarily designed to blunt withdrawal symptoms during the acute stages of withdrawal when a smoker quits. • None of the medications cure nicotine dependence or make smokers quit. • A commitment and desire to quit should be present prior to medications being dispensed. • Using an FDA approved cessation medication with counseling doubles the quit rates over counseling alone.1 1. Fiore et al. USDHHS 2000. Main Menu Next Purpose Of Cessation Medications • While the primary purpose of cessation medications is to reduce withdrawal symptoms, some medications such as varenicline and bupropion also reduce smoking satisfaction should the patient smoke while on drug.1 • Varenicline2 and bupropion3 are approved for use beyond usual length of treatment for maintenance of abstinence up to 24 total weeks (relapse prevention). 1. Gonzales et al. JAMA 2006;206:47-55. 2. Tonstad et al. JAMA. 2006;296:64-71. 3. Hurt et al. Addict Behav 2002;27:493-507 Main Menu Next Compliance With Medications • The brain takes many weeks to adjust to low or no nicotine binding at nicotinic receptors. • “Failure” of medications is often due to patients using less medication than recommended (underdosing) or discontinuing medication too early (similar to compliance issues with antibiotics). • Ask about medication use; encourage proper daily dosing/technique and following recommended length of time for dosing to increase likelihood of success in quitting and relapse prevention. Main Menu Next FDA Approved First-Line Cessation Medications • Nicotine replacement therapies (NRT) – – – – – Nicotine patch Nicotine lozenge Nicotine gum Nicotine inhaler Nicotine nasal spray • Varenicline (Chantix®): non-nicotinic • Bupropion SR (Zyban®, Welbutrin®): nonnicotinic Main Menu Next Recommended Medications • Varenicline: Most efficacious of meds (to date); no known drugdrug interactions, no contraindications, moderate cost, nonnicotinic. • Nicotine patch: Average efficacy, well accepted, easy to use, few contraindications, lower cost. • Nicotine patch + flexible dosing NRT (lozenge – also gum or inhaler): Combining increases efficacy for more dependent smokers (4 mg lozenge is more efficacious than gum or inhaler). • Bupropion:, Average efficacy, lower cost, some contraindications, non-nicotinic Main Menu Next Varenicline (Chantix ®) • Rx • Is as effective for women as for men.1 • No significant effect on weight gain. 1,2 • Nausea, usually mild to moderate, occurs in up to 30% of patients. 1,2 • Dose may be reduced by half if nausea persists with less than a 10% decrease in efficacy.3 1. Gonzales et al. JAMA 2006;296:47-55. 2.Jorenby et al JAMA 2006;296:56-63. 3. Chantix prescribing instructions. Pfizer, Inc. 2006. Main Menu Next Varenicline • No “black box” in labeling. 3 • No known drug/drug interactions. 3 • Not been tested in pregnant women or children. 3 • Combination therapy has not been tested. • Dose adjustment (reduced) is recommended for patients with severe renal impairment. 3 3. Chantix prescribing instructions. Pfizer, Inc. 2006. Main Menu Next Varenicline • Usual “target quit day” is 8th day of treatment. Start with 0.5 mg daily for 3 days. Increase to 0.5 mg twice daily for 4 days. Increase to 1.0 mg twice daily on day 8 until the end of treatment (no need to taper at end of Tx). • Smoking while taking the medication does not increase health risk over smoking alone. • Common adverse events: nausea, sleep disturbance, abnormal dreams, flatulence. • Average cost/day is $4.00. Main Menu Next Nicotine Transdermal Patch • OTC – fixed dose. Actual nicotine bioavailability is approximately 50% of dose listed on patch. • Less effective for women* • NicodermTM, NicotrolTM, HabitrolTM, ProstepTM, generics. • Quit rates are similar for all patches. • Time to peak nicotine levels in brain range from 2 hrs (Nicoderm) to 8 hrs. (a consideration if patches are taken off at night) • May delay post cessation weight gain. *Wetter et al. J Consul Clin Psychol; 1999 Main Menu Next Nicotine Transdermal Patch • For patients who smoke 10-20 cigarettes/day: 21mg once daily for 6-8 wks. For those who smoke >20 cigarettes/day consider adding lozenge, gum, or second patch. • Step down to 14mg for 2 - 4 wks, then step down to 7 mg for 24 wks. • Common adverse events are patch site skin irritation, vivid dreams and sleep disturbance. • Can be combined with other NRT or bupropion. • Average cost/day is $4.00 for 21mg, $3.40 for 14mg or 7mg. Main Menu Next Nicotine Lozenge (nicotine polacrilex) • OTC - flexible dosing (2 mg & 4 mg). Actual nicotine bioavailability is somewhat greater than 50% of dose listed on packaging. • 10-15 minutes to reach the brain. • May be less effective for women but little gender data available. • Reduces post cessation weight gain (4 mg)1 • Only NRT shown to be effective for re-treatment.1 • Can be combined with a patch or used for relapse prevention. 1Shiffman et al. Efficacy of a nicotine lozenge for smoking cessation. Arch Intern Med 2002;162:1267-1276 Main Menu Next Nicotine Lozenge • Start one lozenge every 1–2 hours for first 6 wks; then one every 2-4 hours for 3 weeks, then one every 4-8 hours. • Use 4 mg for patients who smoke their 1st cigarette within 30 minutes of awakening, others use 2 mg dose. • Common adverse events: mouth soreness and dyspepsia. • Average cost/day is $8.88. Main Menu Next Bupropion Hydrochloride SR (Zyban® , WellbutrinSR®, generic) • Is as effective for women as for men1; reduces/delays post cessation weight gain; effect is greater in women.2 • Reduces post cessation negative affect. 3 • Not for those with seizure Hx, taking meds that lower seizure threshold, significant head trauma, anorexia or bulimia or who currently drink heavily or binge. Seizure risk is 1/1000 for SR. • Efficacious for re-treatment. 4 1.Gonzales et al. Am J Prev Med 2002;22:234-39. 2.Rigotti et al. SRNT 5th Annual Meeting, Arlington, VA. 1999. 3.Shiffman et al. Psychopharmacologia 2000;148:33-40. 4.Gonzales et al. Clin Parmacol Ther 2001;69:438-44. Main Menu Next Bupropion SR • Start 150 mg once daily for 3 days, then twice daily for 7-12 weeks. • Usual target quit day is day 8 of treatment. • Common adverse events: insomnia, sleep disturbance and headache. • Not recommended for those with any Hx of abuse of stimulants. Can cause agitation. • SR-average cost/day is $4.33. Main Menu Next Other Nicotine Replacement Therapies Main Menu Next Nicotine Gum (nicotine polacrilex) • OTC - flexible dosing (2 mg & 4 mg). Actual nicotine bioavailability is approximately 50% of dose listed on packaging. • 10 – 15 minutes to reach the brain. • Often less effective for women.* • Reduces/delays post cessation weight gain. • Not recommended for those with significant dental work (very stiff and sticky on dental appliances and can cause damage). • Can be used in combination with a patch and for relapse prevention. *Killen et al. J Consult Clin Psychol; 1990 Main Menu Next Nicotine Gum • Use 2 mg for patients who smoke less than 15 cigarettes/day (one 2 mg piece every 1-2 hours). • Use 4 mg for patients who smoke more than 15 cigarettes/day (4 mg piece every 1-2 hours. • Common adverse events: jaw pain and mouth soreness. • Average cost/day is $9.33 for 2 mg and $10.33 for 4 mg dose. Main Menu Next Nicotine Inhaler • Rx - flexible dosing. Actual bioavailability is approximately 50% of dose listed on packaging. • 10 – 15 minutes to reach the brain (buccal not lung absorption) similar to gum and lozenge. • May reduce/delay post cessation weight gain. • May be especially useful for those who miss “puffing” from smoking or women due to the similarity to smoking behavior. • Can be used in combination with other NRT. Main Menu Next Nicotine Inhaler • Start with 6-16, 10 mg cartridges per day for three months. • Taper over six to twelve weeks. • Common adverse events: mouth and throat irritation. • Average cost/day is $9.50. Main Menu Next Nicotine Nasal Spray • Rx - flexible dosing. Actual bioavailability greater than 50% of the dose listed on packaging. • 5-7 minutes to reach the brain. Most rapid onset of all NRTs. • Women respond differently than men* • Some clinicians report it is particularly helpful for those with psychiatric or substance abuse disorders due to the quicker onset. • May delay post cessation weight gain. • Can be used in combination with other NRT. *Perkins et al. Exper Clin Psychopharmacology; 1996 Main Menu Next Nicotine Nasal Spray • Start with 1-2 0.5mg doses in each nostril every hour for 3-6 months. • Taper over 4-6 weeks. • Common adverse events: nose and eye irritation. • Average cost/day is $16.00. Main Menu Next Dosing Suggestions For Nicotine Replacement (NRT) • Cigarettes smoked per day can serve as a general guide to dosing NRT (but not other medications). • 1 cigarette delivers 1.0 mg of nicotine on average, e.g., pack smoker = 20 mg daily dose of nicotine. • Goal for NRT(single or combined forms) is steady state replacement of at least 75% -85% of usual daily nicotine dose sufficient to manage withdrawal. • Due to nicotine tolerance from smoking, risk of unintentional overdose from NRT alone or from using NRT while smoking is low.1 1. Benowitz et al. J Pharmacol Exp Ther 1998; 287;958-962. Main Menu Next NRT Overview • Contraindications:* – Patch: current Hx eczema or psoriasis; allergy to adhesives or nicotine patches. – All forms should not be used in patients with Hx of MI within prior 2 weeks. • Common Adverse Events* – Patch: sleep disturbance, site reaction – Lozenge: nausea, hiccups, heartburn due to swallowing nicotine. * Review prescribing instructions for complete list of contraindications and adverse events. Main Menu Next NRT Summary • Flexible dosing forms allows individual tailoring. • Women may respond more poorly to NRT 1,2,3. • Women taking oral contraceptives4 and pregnant women5 have increased nicotine metabolism (more rapid clearance) and may need higher doses to suppress withdrawal symptoms. 1 Killen et al. J Consul Clin Psychol; 1990. 2. Wetter et al. J Consul Clin Psychol; 1999. 3. Perkins et al. Exper Clin Psychopharmacol; 1996. 4. Benowitz et al. Clin Pharmacol Ther 2006. 5. Dempsey et al. J Pharmacol Exper Ther 2002. Main Menu Next NRT Summary • NRT use may result in reduced or delayed post cessation weight gain during treatment. • Smoking while using NRT poses no greater health risk than smoking alone.1 • Quit rates are generally similar for all forms of NRT.2 • Due to nicotine tolerance from smoking, risk of unintentional overdose from NRT alone or from using NRT while smoking is low.1 1. Benowitz. Cardiovascular Diseases 2003;46:91-111. 2. Fiore et al. USDHHS 2000. Main Menu Next Second-Line Medication (Not FDA Approved for Smoking Cessation) Clonidine - Rx – Primarily effective for women1 – Common adverse events: dry mouth, dizziness, drowsiness, sedation.2 – Failure to gradually reduce dose may result in rapid increase in blood pressure, agitation, confusion, tremor.2 1.Covey et al. Br J Addiction; 1991. 2. Fiore et al. USDHHS 2000. Main Menu Next Second-Line Medication (Not FDA Approved for Smoking Cessation) Nortriptyline-Rx (inexpensive) – Efficacious, but less so for women with history of depression 1 – Common side effects: sedation, dry mouth, blurred vision.2 – Cardiovascular disease: risk of changes in contractility and blood flow, arrhythmias. 2 – Pregnancy caution: has been associated with fetal limb reduction abnormalities. 1. Hall et al.,1998; 2. Fiore et al. USDHHS 2000. Main Menu Next Click here for a copy of “Smoking Cessation Pharmacology at OHSU 2007” Main Menu Special Considerations Long term use Pregnant smokers Patients on psychiatric medications Patients who need more intensive treatment Main Menu Next Longer-Term Use of Cessation Meds • For smokers who have achieved abstinence, but have persistent withdrawal symptoms at the end of the usual course of treatment or to prevent relapse. • Long-term use of NRT does not present a known health risk. • Varenicline is approved for a 2nd 12-week course of treatment (up to 24 weeks total) to maintain abstinence (relapse prevention). • Bupropion SR is approved for a 2nd course of treatment (up to 24 weeks total) to maintain abstinence. Main Menu Next Treatment for Pregnant Smokers • Due to potential unknown fetal risks counseling without cessation medication is the first choice of treatment. • Risks of poor pregnancy outcomes due to fetal exposure to other chemicals in smoke + nicotine are greater than exposure to nicotine alone from nicotine replacement therapies (NRT). • NRTs are pregnancy category D, except for gum and lozenges, which are pregnancy category C. • Varenicline and bupropion SR have not been tested in pregnant smokers and are both pregnancy category C. Main Menu Next Patients On Psychiatric Medications • Dose adjustments may be necessary following tobacco (nicotine) cessation. • Blood levels of some psychiatric medications may increase substantially following smoking cessation (within 3-6 weeks) increasing risk of drug toxicity. • Psychiatric medications that should be monitored include: clozapine, fluphenazine, haloperidol, oxazepam, desmethyldiazepam, clomipramine, nortriptyline, imipramine, desipramine, doxepin, and propranolol. Main Menu Next Patients Who Need More Intensive Treatment • Patients more likely to need more intensive and specialized treatment. – High nicotine dependence who smoke heavily, and/or has first cigarette within 30 minutes after waking in the morning. – Severe withdrawal during previous quit attempts. – Current or recent psychiatric history, especially mood disorders, schizophrenia. Main Menu Next Patients Who Need More Intensive Treatment – Current or recent (in last year) history of alcohol abuse or other chemical dependency. – Current stressful life circumstances or major life changes (recent serious diagnosis or injury, divorce, job loss, marriage, new baby etc.). – Current or recent stressful or high risk employment (police, firefighters, pilots, surgeons, surgical nurses, military personnel etc.). Main Menu Next What Is Intensive Treatment? • Tailored treatment to impact more specific needs of patients including: – Medications • Adjusting cessation medication doses (usually higher). • Longer duration of drug treatment. • Combining cessation therapies. • Adjusting non-cessation medication doses. – Coaching/counseling • • • • More sessions over a longer period of time. Referral to more highly trained specialists. More frequent in-clinic or phone follow-up.. Referrals to other services as needed (e.g. mental health). Main Menu Patient Care at OHSU Hospitals and Clinics Main Menu Next Hospital Admission • Patients are told about tobacco free policy when they schedule admissions and when they register. • Patients are ASKED about tobacco use: – Tobacco use questions are on the initial nursing assessment. – Tobacco use questions are on (some) unit admission orders. – Tobacco use questions will be included in admission orders in the Epic system (Spring 2008). Main Menu Next Nursing education and Tobacco Dependence Consult • For patients who have used any tobacco in the last 12 months (JCAHO), nursing will review “Smoking Cessation Guide for Hospital Patients” (pdf online at www.ohsu.edu/healthsystem/nursing) • For patients who have used tobacco in the last 90 days, MD completes “Tobacco Dependence Inpatient Orders (PO-7290). – Tobacco Treatment Specialist Nurse Practitioner is paged to provide consult at 6-0027. Main Menu Next Tobacco Dependence Consult • Tobacco Treatment Specialist Nurse Practitioner – Completes tobacco dependence assessment & bedside counseling. – Develops a treatment discharge plan. • Includes an FDA approved medication (or combination) & recommendations for counseling/coaching after discharge. • Makes arrangements for follow-up after discharge and leaves instructions for patient. • Completes preprinted progress note (HP 5336) and chart note. • Flags discharge plan. – Contacts medical team to update. Main Menu Next Hospital Discharge • Discharge MD – Review progress note. – Include tobacco cessation discharge plan in dictated discharge summary. – Remind patient of tobacco cessation discharge plan. – Write appropriate prescriptions. – Copy of discharge summary to primary care provider. Main Menu Next Flow Chart Main Menu Next Outpatient Clinics “ASK and ACT” Main Menu Next ASK • Patients are reminded of OHSU policy when they schedule and check in for clinic visits. • All patients are ASKED about tobacco use by the medical assistant. (Questions are included in the Epicare system). • Patients who report tobacco use are asked if they would like help to quit. • If NO, give Oregon Tobacco Quitline number to call when ready (1-800-784-8669). If YES, ACT (or REFER). Main Menu Next ACT • Provider discusses quitting with patient: “Quitting is the most important thing you can do for your health” and assesses when patient wants to quit. • If patient is not planning to quit now or IS planning to quit but in greater than 30 days, recommend that patient call the Oregon Tobacco Quitline when they are ready (1-800-784-8669.) • If patient is planning to quit in next 30 days, develop a tobacco cessation TREATMENT PLAN. – An evidence-based stop smoking treatment plan includes BOTH medications to stop smoking AND follow-up for behavioral support. Main Menu Next ACT • TREATMENT PLAN Development – Medications: • Prescribe one or a combination of the FDA approved stop smoking/tobacco medications (see “Smoking Cessation Pharmacology at OHSU 2007” at www.ohsu.edu/smokingcessation/patientcare. – Behavioral Support: • Recommend that OHSU employees follow-up with OHSU Employee Wellness 4-9355. • Recommend that patient call the Oregon Tobacco Quitline. – The OTQL will triage patients to follow-up services covered by insurance. Also, all callers are eligible for 2 weeks of free patches; uninsured callers are eligible for 4 weeks. Main Menu Next ACT • Treatment Plan (cont.) – Behavioral Support (cont.) • Consider encouraging patients to fill prescriptions at OHSU outpatient pharmacy. OHSU outpatient pharmacists are trained to provide tobacco cessation consultation for patients. • Add “Getting Ready to Quit?” patient stop smoking guide to after visit summary (Epic smart phrase “SMOKINGCESSATION.”) Main Menu Next REFER • REFERRAL OPTION TO OHSU OUTPATIENT PHARMACIES: – OHSU outpatient pharmacists are trained to develop tobacco cessation treatment plans following a specific, OHSU medically supervised protocol. – OHSU providers can refer their patients to any of the outpatient pharmacies to develop tobacco cessation treatment plans. – Only refer patients who are ready to quit within 30 days. – To refer patients: • Write, call, or fax prescription to OHSU outpatient pharmacy with “Tobacco Cessation per OHSU Protocol” on prescription. – Trained pharmacist will see patient, enter into Epic, and send information to referring provider. Main Menu Next The Quitting Process Precontemplation Refer patients to the pharmacy program who are in the PREPARATION or ACTION stage of quitting. Relapse Contemplation Want to quit sometime Preparation Will quit in next 30 days Action Will quit in the next 2 weeks Maintenance Adapted from Knight, 1997 Main Menu Don’t want to quit Next Termination Outpatient Pharmacy Program OHSU Collaborative Drug Therapy Management Agreement (CDTM) Main Menu Next OHSU Collaborative Drug Therapy Management Agreement • OHSU outpatient pharmacists can provide patient cessation services through the OHSU Collaborative Drug Therapy Management Agreement. • The CDTM permits pharmacists to: – Recommend smoking cessation medications and behavioral follow-up and develop a treatment plan. – Prescribe medications based on an OHSU approved treatment algorithm. • Patients are referred to the pharmacy program who are ready to quit in the next 30 days (preparation/action stage). Main Menu Next Getting Started • For patients ready to quit, pharmacists will • Develop a treatment plan. – Treatment plan includes an FDA approved medication (or combination) & recommendations for counseling/coaching. • Write and fill prescriptions under the CDTM. • Make arrangements for follow-up. • Send information to referring provider. • Enter into Epicare. Main Menu Next OHSU Treatment Plan Development • Treatment planning begins with an assessment – – – – Smoking and quitting history Tobacco dependence Motivation and readiness Health and medication histories • Treatment Plan is based on assessment data – Medications + counseling/coaching recommendations – either standard or intensive – Prescription(s), dispensing – Consideration of referral for additional non-cessation treatments – Follow-up type (in-clinic, phone, quit line etc) and frequency. Main Menu Next REMEMBER . . . Quitting smoking is the most important thing your patients can do to protect their present and future health. With your help, they can be successful. Your efforts will save lives! Main Menu Next For more information… Visit www.osu.edu/tobaccofree and click on “Information for health professionals” or visit www.ohsu.edu/smokingcessation/patientcare Email [email protected] with questions or comments Call 503 494-FREE (3733) Main Menu