Antero Heloma, MD, PhD; Markku Nurminen, PhD, DrPH; Kari Reijula, MD, PhD; and Jorma Rantanen, MD, PhD

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1 Antero Heloma, MD, PhD; Markku Nurminen, PhD, DrPH; Kari Reijula, MD, PhD; and Jorma Rantanen, MD, PhD ( ) ( ) ( ) 20 y % 28% / / % 20% % (lung cancer); (smoking prevalence); (tobacco control) ( ) 0.5% [1] ( ) [2] [3] 60% 15% CHEST

2 % 20% [3] [4] ; % [5] [15] 20% [6] [6,7] / ~ [7] 64 ( ) Suomen Gallup plc [16] [3,5] [8,9] [10] ? 1974 [11~13] ( ) [17] Doll [14] [7] ( Terry ) ( ) From the Finnish Institute of Occupational Health, Helsinki, Finland. Correspondence to: Kari Reijula, MD, PhD, Director, Regional Institute of the FIOH, Arinatie 3 A, FIN Helsinki, Finland; Kari. Reijula@TTL. fi (1976) [18] ( 346

3 60 1 t P / % < ( ) < ( ) ( ) ( ) < ( ) t / y (P ) ) χ 2 ( ); (1976); ( ) ( ) (S-Plus 58% 32% ( 1) MathSoft Inc Seattle WA) [19] ( 1) ( ) [20,21] [22] ( 20 y [18] P [23] ) 20 y (P < 0.001) ( 2) (r 2 = 0.947) ( 3) ( ) (P = 0.006) t / y ( ) ( 10 ) ( ) CHEST

4 % 80 20% % ( 2) ( ) (P < 0.001) (P = 0.012) 20 y 1975 (P < 0.001) ( 2) (r 2 = 0.642) ( 3) [24] 1984 (P < 0.001) ( 4) 20 y (P < 0.001) (r 2 = ) y ( 10 ) 20 y ( y ( ) y % ( 2) 20 7% [24] t P < ( ) < ( ) < )

5 ; t / y ( 10 ) 1 Act on measures to reduce tobacco smoking (693/1976): Helsinki: Finnish Law, English translation available at: www. tupakka. org. Accessed June 21, Act amending the act on measures to reduce tobacco smoking (765/ 1994): Helsinki: Finnish Law, 1994 (in Finnish). English translation available at: www. tupakka. org. Accessed June 21, Statistics Finland. Tobacco statistics In: Health 2002 (vol 1964 Terry ). Helsinki, Finland: Statistics Finland, Rahkonen O, et al. Br J Addict 1992;87: [24] 5 Helakorpi S, et al. Health behaviour and health among Finnish adult population. Helsinki, Finland: National Public Health Institute, 2001; Publication B16/ Corrao MA, et al, eds. Tobacco control country profiles. Atlanta, GA: American Cancer Society, 2000 [25] 5). Helsinki, Finland: Statistics Finland, 2000 [26] Heloma A, et al. Am J Public Health 2001;91: [25] Biener L, et al. BMJ 2000;321: Fichtenberg CM, et al. N Engl J Med 2000;343: Laugesen M, et al. Tob Control 2000;9: Doll R, et al. BMJ 2004;328: [27] 7 Ahonen H, et al, eds. Causes of death In: Health 2000 (vol 8 Jousilahti P, et al. Scand J Work Environ Health 2002;28(Suppl): 10 Act amending the act on measures to reduce tobacco smoking (487/ 1999). Helsinki: Finnish Law, 1999 (in Finnish). English translation available at: Accessed June 21, US Department of Health and Human Services. Reducing the health consequences of smoking: 25 years of progress: a report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, Office on Smoking and Health, 1989; DHHS Publication No. (CDC) Rimpelä M. Sosiaalilääketieteellinen Aikakauslehti 1978;15: Finnish Cancer Statistics. Available at: www. cancerregistry. fi. Accessed June 21, Venaples WN, et al. Modern applied statistics with S-PLUS. 2nd ed. NY: Springer, CHEST

6 19 MathSoft, Data Analysis Products Division. S-PLUS 2000 guide to statistics. Seattle, WA: MathSoft Inc, Kuhn L, et al. Am J Epidemiol 1994;140: Nurminen M. The use of time series studies in environmental epidemiology. In: Corvalán C, et al, eds. Linkage methods for environment and health analysis: technical guidelines. Geneva, Switzerland: World Health Organization, 1997; National Academy of Sciences. Veterans and agent orange: update Washington, DC: National Academy Press, 1999; Nurminen M. Scand J Work Environ Health 1997;23: Pekurinen M, et al. Soc Sci Med 1987;25: Rimpelä AH. Tob Control 1992;1: Heloma A. Impact and implementation of the Finnish Tobacco Act in workplaces. Helsinki, Finland: Finnish Institute of Occupational Health, 2003; 17-18; People and Work Research Reports Leppo K, et al. Health Promot 1986;1:5 16 CHEST 2004;126: CHEST No CHEST C. Nicotine patch at 22 mg per day. The best smoking abstinence rates at 1 year have been achieved with the combination of bupropion plus nicotine patch. In a recent study, bupropion nearly doubled 12-month point-prevalence abstinence rates (30.3%) relative to placebo (15.6) or the patch (16.4%). The combination of bupropion and the patch was also more efficacious (35.5%) than placebo or the patch. Baced on the quantity of cigarettes smoked by the patient described in this case, the 22 mg/day patch is most appropriate. Nicotine patches are available in doses of 7, 11, 14, 15, 21, and 22 mg. The standard over-the-counter nicotine patch is 21 or 22 mg. This dosage has been found to be sufficient to meet the nicotine needs of moderate smokers (approximately one pack per day). Heavier smokers may need higher doses to achieve initial abstinence and to prevent relapse. Nicotine patches are applied once daily not twice daily. The low dose Nicotine patch (7 mg) may not provide sufficient nicotine to meet this patient's initial needs. Nicotine gum is effective and comes in 2 mg and 4 mg dosages. In general, the 4 mg dose should be used by smokers who smoke greater than 20 cigarettess per day, which does not apply to the patient described in this case, who is smoking one half to one pack of cigarettes per day. Bupropion is the only nonnicotine medication approved by the FDA for use in smoking cessation. This medication is marketed as Zyban for the stop-smoking indication and Wellbutrin for the antidepressant indication. It is important to ensure that the patient does not take both formulations. The step-up does (the dose above which most patients do not derive additional benefit) for the antidepressant indication is 200 mg twice daily. Thus the combination of both formulations at the usual dosage would provide no additional benefit but would increase the possibility of adverse side effects. The initial dose for the smoking cessation indication is 150 mg/d of sustained release bupropion for 3 days, then a dose of 150 mg twice daily initiated 1 week before the patient's stop date. The usual length of treatment is 6 to 12 weeks but bupropion can be used safely much longer. The most common adverse effects are insomnia and dry mouth. As with other antidepressants, there is a small risk of seizures. Typical long-term quit rates are as follows: no therapy =5%, brief advice only = 10%, and behavior therapy only = 15%. If medication (nicotine replacement or bupropion) is added, typical quit rates become: medication only = 10%, brief advice and medication = 20%, and behavior therapy and medication = 30%. 350