331.4 📋 章末速記 Summary

331.4.1 🔑 一句話總結

Tobacco use = 全球 #1 preventable cause of death (~ 8 million/yr)；causes lung cancer (top, 80-85% of US cases), CV disease (#1 absolute number), COPD, stroke, atherosclerosis, PAD, AAA, 多種 cancers (head/neck, esophageal, bladder, kidney, pancreas), pregnancy complications；5A’s framework：Ask + Advise + Assess + Assist + Arrange；5R’s for unwilling patients：Relevance + Risks + Rewards + Roadblocks + Repetition；first-line pharmacotherapy：(1) varenicline (α4β2 nicotinic partial agonist — most effective single agent, EAGLES no excess neuropsychiatric risk)；(2) NRT (patch + gum/lozenge/inhaler/nasal spray; combination NRT > single)；(3) bupropion (NDRI; avoid if seizure or eating disorder)；cytisine plant-derived alternative cheaper than varenicline (FDA approval pending 2024-2025)；combination varenicline + NRT synergistic in select；behavioral support essential (CBT, MI, quitlines, mobile apps)；e-cigarettes controversial harm reduction tool (some efficacy data; EVALI from vitamin E acetate concerns)；special populations：pregnancy (NRT considered)、CV disease (varenicline safe, EAGLES)、mental health (varenicline safe per EAGLES)、cancer survivors (critical — 5-year survival ↑ 30-50%)、pre-op (≥ 4-8 weeks cessation reduces complications)。

331.4.2 💊 治療精要

  • varenicline：0.5 mg × 3 d → 1 mg BID × 12 weeks (can extend to 24)；most effective single agent；nausea + vivid dreams common
  • NRT combination preferred：patch (21 mg for heavy smokers) + short-acting (gum 4 mg or lozenge for cravings)；8-12 weeks
  • bupropion：150 mg daily × 3 d → 150 mg BID × 12 weeks；quit date 7-14 d after starting；avoid in seizure, eating disorder
  • cytisine：plant-derived α4β2 partial agonist；cheaper than varenicline；FDA pending 2024-2025
  • combination varenicline + NRT：synergistic in heavy smokers
  • behavioral support：CBT + motivational interviewing + telephone quitlines + text messaging + mobile apps；most effective combined with pharmacotherapy
  • e-cigarettes：not first-line；harm reduction tool for refractory smokers (with caveats);EVALI concerns
  • smoking cessation in cancer survivors：lung cancer 5-year survival ↑ 30-50% — single most impactful intervention

331.4.3 🎯 盧醫師的考前提醒

  1. smoking 是 #1 preventable cause of death（global ~ 8 million/yr）；lung cancer 80-85% in US；CV mortality numerically highest
  2. 5A’s framework：Ask + Advise + Assess + Assist + Arrange — 每次門診都應該執行
  3. 5R’s for unwilling patients：Relevance + Risks + Rewards + Roadblocks + Repetition — repeated motivational interviewing
  4. Stages of Change (Prochaska + DiClemente)：precontemplation → contemplation → preparation → action → maintenance → relapse；tailor intervention to stage
  5. first-line pharmacotherapy：varenicline (most effective single) + NRT (combination patch + gum/lozenge for synergy) + bupropion (NDRI, avoid seizure + eating disorder)
  6. EAGLES (2016)：varenicline > bupropion > NRT > placebo；no excess neuropsychiatric risk in mental health → FDA removed boxed warning 2016
  7. combination NRT > single NRT：patch + short-acting (gum, lozenge, inhaler, nasal spray) more effective than either alone
  8. cytisine 2024-2025 FDA approval pending：plant-derived α4β2 partial agonist；cheaper alternative to varenicline；comparable efficacy
  9. smoking cessation in lung cancer survivors：5-year survival ↑ 30-50%；most impactful single intervention；emphasize at every visit
  10. e-cigarettes (vapes)：not first-line cessation;harm reduction tool for refractory smokers but EVALI (vitamin E acetate from THC) + youth uptake concerns；台灣 regulation evolving；selected use only