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What is your date of birth?

HOW MANY PACKS OF CIGARETTES PER DAY DO YOU SMOKE?

HOW LONG HAVE YOU BEEN SMOKING (ANY AMOUNT) OF CIGARETTES?

WHAT TYPE OF TOBACCO PRODUCTS DO YOU USE? PLEASE CHECK ALL THAT APPLY

DO YOU SMOKE WITHIN THE FIRST 30 MINUTES OF WAKING UP?

HOW MANY TIMES HAVE YOU TRIED TO QUIT BEFORE?

AT WHAT AGE DID YOU START SMOKING?

HAVE YOU USED PRESCRIPTIONS MEDICATIONS TO QUIT BEFORE?

PLEASE LIST WHICH ONES

IF YES, WOULD YOU LIKE TO USE THE SAME MEDICATION AGAIN?

HOW MOTIVATED ARE YOU TO QUIT?

YOU NEED TO SET A QUIT DATE WITHIN THE NEXT 2-4 WEEKS

YOU WILL NEED TO QUIT SMOKING ON YOUR SET QUIT DATE. WE SUGGEST USING BEHAVIORAL SUPPORT WITH YOUR MEDICATION

PLEASE CHECK ALL THAT APPLY TO YOU

DO YOU HAVE OTHER MEDICAL HEALTH ISSUES?

ARE YOU ALLERGIC TO ANY MEDICATIONS?

ARE YOU CURRENTLY TAKING ANY MEDICATIONS? PLEASE INCLUDE OVER THE COUNTER MEDICATIONS AND HERBAL OR VITAMIN SUPPLEMENTS

WHICH ONE

IS THERE ANYTHING ELSE YOU THINK WE SHOULD KNOW ABOUT YOU OR YOUR MEDICAL HISTORY?

TREATMENT

PLEASE SELECT ONE

FAQ'S

Smoking is the leading preventable cause of death in the US. There are two first-line medications used to help people quit smoking. The two options are Chantix (Varenicline) and Wellbutrin (Bupropion). These medications work by lessening the effects of withdrawals.

Medication choice is based largely off of patient preference, with the exception of a few indications not to take a certain medication.

Bupropion is technically an antidepressant, but has been approved for smoking cessation. Treatment starts 1 week before your target quit date. One 150mg tablet is taken once per day for days 1-3. A 150 mg tablet is taken twice per day from days 4 and on. Smoking cessation should be achieved after 7-12 weeks of treatment. You can take this medication with or without meals. Bupropion may be less effective than Chantix but some patients may choose this medication over Chantix because of price, and concern for weight gain.Do not take this medication if you have a seizure disorder or have kidney or liver damage. Do not take this medication if you are allergic to Bupropion.

Common side effects of Bupropion include headaches, restlessness, agitation, and difficulty sleeping. Some patients may also experience increased heart rate, weight loss, tremors, or blurred vision.

This medication may increase depression or suicidal ideation. If you start to experience behavioral or mood changes stop the medication right away and contact a medical provider.

Bupropion is the generic version of this medication. Brand name medications include Wellbutrin XL. Bupropion is generally covered by Medicaid and most insurances although coupon prices might be lower. The price of this medication without insurance is around $25.00 for one month’s supply. Treatment can last from 7-12 weeks. Prices taken from www.goodrx.com

Chantix is FDA approved to help users stop smoking. You should take this medication after a meal and with a full glass of water. You should start Chantix 1 week before your target quit date. You start with a 0.5mg tablet once per day for three days. Then you increase to 0.5mg tablet twice per day from day 4-7. Day 8 and beyond, you take a 1mg tablet twice per day for 11 weeks. This is a total of three months of treatment (12 weeks).

20% or less of patients experience side effects include headaches, nausea, vomiting, difficulty sleeping, abnormal dreams, depression or suicidal ideation. Do not take this medication if you are allergic to Chantix. If you start to experience behavioral or mood changes stop the medication and contact a medical provider. Patients should exercise caution when driving or operating machinery until they know how this medication effects them, as it can cause drowsiness.

Chantix is a brand name drug. There currently is no generic form available. Chantix is covered by most Medicaid and insurance plans. Chantix, without insurance, can be costly. Prices without insurance are approximately $450 for one month. Typically, patients take Chantix for three months. Prices taken from www.goodrx.com

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