Prescription Medications for Smoking Cessation for Adults >18 years

Medical Directive ID: 
Lead Contact Person: 
Tomasina Chevalier
Physician/Nurse Lead: 
Dr. Sonny Cejic
Dr. Stacey Valiquet
Family Medicine - Byron Family Medical Centre
Family Medicine - Victoria Family Medical Centre
Approval By: 
Medical Advisory Committee
Original Effective Date: 
Wednesday, January 11, 2017
Revised Date: 
Wednesday, January 11, 2017
To Be Reviewed Date: 
Saturday, January 11, 2020
This Medical Directive Applies to the following sites: 
This Medical Directive Applies to the following patient population: 



Initiation and renewal of smoking cessation products by Registered Pharmacists

Guidelines for initiating the order:

1.Assess patients readiness to change smoking cessation habits and history of smoking includes pastattempts Assessment may be completed by other members of the Family Health Team

2.If patient is in preparation/action stage set stop smoking date.

3.Assess nicotine addiction using Revised Fagerstrom Nicotine Addiction Scale (Appendix 2)

4.If rating is greater than3/10 review pharmaceutical options, including nicotine replacement therapy(NRT).

5.If rating is less than 3/10 patient may not require medication.

6.Assess if any contraindications to bupropion (zyban), varenicline(champix), NRT-Nicotine ReplacementDosing information (Appendix 3).

7.Ensure other smoking cessation strategies (behavior modification and supportive) are in place for stopsmoking date.

8.Arrange follow-up appointment in person, if patient requests.

9.Order appropriate medication according to list of medications for smoking cessation (Appendix 1), asper usual standard with the family physicians name on the prescription.

10.Decision tree to address nicotine withdrawal (Appendix 4).

Appendix Attached? Yes No

Click the link to view the entire medical directive in detail: 


SurnameKnown ByDate Signed
CejicSonnyFeb 27 2017 09:48:55:867AM
CooksonChristinaFeb 14 2017 01:49:51:507PM
DalesLaurenceFeb 20 2017 10:40:50:003AM
FreemanTomFeb 27 2017 09:46:37:723AM
GrushkaDanielFeb 10 2017 08:18:05:873PM
HammondJo-AnneFeb 8 2017 09:08:20:850AM
JordanJohnFeb 21 2017 05:50:11:093PM
KimGeorgeFeb 24 2017 08:59:30:623PM
McKayScottMar 10 2017 12:23:14:113PM
McKeoughNancyMar 7 2017 03:18:11:200PM
Pawelec-BrzychczyAnnaFeb 27 2017 03:14:49:377PM
ThompsonCaitlinFeb 16 2017 05:25:15:970PM
ValiquetStaceyMar 20 2017 12:26:10:383PM
WetmoreStephenFeb 27 2017 09:47:23:950AM
WickettJamieFeb 8 2017 01:43:01:450PM