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Clinical - Winter > 4 - Smoking Cessation > Flashcards

4 - Smoking Cessation Flashcards

1
Q

__% of smokers are thinking about quitting

A

60%

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2
Q

What are the components of a cigarette?

A
  • Tar
  • Carbon monoxide
  • Nicotine
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3
Q

What are the harmful aspects of tar?

A
  • Contains over 4000 chemicals

- Increases risk of cancers, CV disease, and pulmonary disease

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4
Q

What are the harmful aspects of carbon monoxide?

A

Reduces oxygen-carrying capacity of blood

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5
Q

Addictive nature of nicotine is as strong as _____

A

Cocaine

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6
Q

What kind of cardiovascular effects can cigarettes have?

A
  • Coronary heart disease
  • Cerebrovascular disease (stroke)
  • Peripheral vascular disease
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7
Q

What kind of cancer can cigarettes cause?

A
  • Lung
  • Pharynx, larynx, esophagus
  • Pancreas
  • Kidney
  • Bladder
  • Cervix
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8
Q

What kind of respiratory effects can cigarettes have?

A
  • COPD
  • Pneumonia
  • Emphysema
  • Bronchitis
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9
Q

What effect can cigarettes have on pregnancy?

A
  • Low birth weight
  • Stillbirths
  • Miscarriage
  • Sudden infant death syndrome (SIDS)
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10
Q

What other effects can cigarettes have on the body?

A
  • Peptic ulcer disease
  • Osteoporosis
  • Cataracts
  • Macular degeneration
  • Infertility
  • Impotence
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11
Q

What are the 1st and 2nd leading causes of lung cancer?

A

1) Smoking

2) Secondhand smoke

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12
Q

What type of childhood illnesses can secondhand smoke worsen?

A
  • Ear infections
  • Asthma
  • Bronchitis
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13
Q

What are the stimulant effects of nicotine at low doses?

A
  • Increases alertness
  • Facilitates memory and attention
  • Reduces irritability and aggression (relaxing)
  • Suppresses appetite for sweets
  • Increases energy expenditure
  • Lowers likelihood of weight gain
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14
Q

What is the effect of nicotine at high doses?

A

“Reward” effects via limbic system’s “pleasure system”

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15
Q

How long do it take nicotine to reach the mesolimbic system after smoking?

A

7-10 seconds

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16
Q

What is the half life of nicotine?

A

60-90 minutes

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17
Q

When nicotine levels decrease, so do _____ levels

A

Dopamine

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18
Q

What are the negative effects of nicotine?

A
  • Cough
  • Affects cardiovascular system (increases BP and heart rate)
  • Cold extremities
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19
Q

What changes occur in the body 20 minutes after last cigarette?

A
  • BP and pulse rate return to normal

- Body temp increases to normal

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20
Q

What changes occur in the body 8 hours after last cigarette?

A

Carbon monoxide levels in blood drop and oxygen levels return to normal

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21
Q

What changes occur in the body 48 hours after last cigarette?

A
  • Sense of smell and taste improves

- Chances of heart attack decrease

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22
Q

What changes occur in the body 72 hours after last cigarette?

A

Lung capacity increases

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23
Q

Why is sense of smell and taste increasing significant when quitting smoking?

A

Px may gain weight after quitting

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24
Q

What changes occur in the body 2 weeks to 6 months after last cigarette?

A
  • Nicotine is gone from body
  • Circulation and overall energy increases
  • Coughing, sinus congestion, tiredness and shortness of breath improve significantly
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25
Q

What changes occur in the body 1 year after last cigarette?

A

Risk of heart disease decreases

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26
Q

What changes occur in the body 5-15 years after last cigarette?

A
  • Risk of dying from lung cancer decreases by almost 1/2

- Risk of heart attack is equal to someone who has never smoked

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27
Q

When do nicotine withdrawal symptoms begin and when do they peak and resolve?

A
  • Begin a few hours after quitting
  • Peak at 2-3 days
  • Usually resolve w/in 2 weeks
  • Late onset sx can sometimes last up to 6 months in rare cases
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28
Q

What are some nicotine withdrawal sx?

A
  • Constipation, diarrhea
  • Fatigue
  • Headache, dizziness
  • Restlessness/anxiety
  • Cough, dry throat/mouth
  • Insomnia
  • Irritability, anger
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29
Q

How can nicotine withdrawal sx be managed?

A

NRT and behavioural tx

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30
Q

What are the top 3 questions you should ask about readiness to quit?

A
  • Do you smoke?
  • Have you ever considered quitting?
  • Is now a good time to quit?
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31
Q

What does the Fagerstrom Questionnaire assess?

A
  • Degree of physical dependence

- Those that will benefit from pharmacotherapy (those w/ score of 6 of more)

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32
Q

What do the values of the Fagerstrom Questionnaire represent?

A
  • Less than 5 = low nicotine dependence
  • 5 = moderate dependence
  • 6-7 high dependence
  • 8-10 = very high dependence
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33
Q

How is “pack years” calculated?

A

(# cigarettes per day * # of years smoked) / 20

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34
Q

What are some common barriers to quitting?

A
  • Lack of reason to change
  • Emotional stress
  • Social habits (smoking during and after meals, when on phone)
  • Discouragement b/c of past failed attempts
  • Fear of withdrawal sx and cravings
  • Attachments to smoking rituals
  • Influence of other people smoking
  • Sense of loss in giving up cigarettes
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35
Q

What is needed to successfully quit smoking?

A
  • Overcome pharmacologic nicotine dependence
  • Cope w/ nicotine withdrawal
  • Extinguish strong behavioural associated w/ smoking
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36
Q

What are some non-pharm suggestions for smoking cessation?

A
  • Set target quit date
  • Get professional help
  • Enlist social support
  • Use problem-solving methods of counselling to quit and remain smoke free
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37
Q

What are some coping strategies for smoking cessation?

A
  • Managing cravings and triggers
  • Stress relief
  • Environmental control
  • Social support
  • Motivational thinking and rewards
  • Handling withdrawal sx
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38
Q

What are some counselling tips for withdrawal sx?

A
  • Withdrawal is real and severity depends on personal characteristics, number of years and amount smoked per day, method used to quit
  • Cravings will only last a few minutes
  • First 24-48 hours is most challenging; lessens after 3-4 days; diminish in intensity over 2 weeks
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39
Q

What are some counselling tips for handling lapses?

A
  • Remind px that slip-ups are normal
  • Avoid “all or nothing” thinking
  • Think of it as a learning opportunity
  • Encourage px (not a lack of willpower but a lack of an effective strategy in a specific situation)
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40
Q

What are the methods for smoking cessation?

A
  • Self-treatment nicotine replacement therapy (NRT)
  • Prescription therapy
  • Natural health product (cytisine)
  • Non-pharm aids
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41
Q

What is the purpose of pharm therapy for smoking cessation?

A

To reduce physical effects of nicotine withdrawal

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42
Q

NRT increases quit rates by ____ compared to placebo

A

1.5-2 fold

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43
Q

NRT is best used along w/ _______

A

Behavioural modifications

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44
Q

What are the brand names for nicotine polacrilex gum?

A

Nicorette and Thrive

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45
Q

What is one of the fastest delivery forms for nicotine other than smoking? What is the peak time?

A
  • Gum, buccal mucosa

- Time to peak = 20-30 mins

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46
Q

How is the nicotine polacrilex gum formulated and what effect does this have on the release of nicotine?

A
  • Buffered ion exchange resin

- Allows gradual release of nicotine

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47
Q

What are the available strengths of nicotine polacrilex gum?

A

2 mg or 4 mg

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48
Q

Can nicotine polacrilex gum be used in combination w/ other NRTs or bupropion?

A

Yes, w/ caution

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49
Q

When should a person use 2 mg nicotine gum?

A
  • Smokes first cigarette more than 30 minutes after waking
  • Fagerstrom score less than or equal to 6
  • Smokes less than 25 cigarettes/day
    (Can be any 1 of the 3, doesn’t have to be all 3)
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50
Q

When should a person use 4 mg nicotine gum?

A
  • Smokes first cigarette less than 30 minutes after waking
  • Fagerstrom score greater than or equal to 7
  • Smokes 25 or more cigarettes/day
    (Can be any 1 of the 3, doesn’t have to be all 3)
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51
Q

What are the directions for use of nicotine gum?

A
  • Chew 1 piece at a time, no more than 1 per hour
  • 10-12 pieces/day initially; max 20/day
  • Chew and park between teeth and cheeks
  • Repeat chew every minute or so (until tingling sensation is felt)
  • Each piece lasts ~ 30 mins
  • Use for 12 weeks to reduce urges; best to use on a fixed schedule for first month
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52
Q

What happens if the px is still having difficulty after using nicotine gum for 3 months?

A

Px can chew 1 piece if urge to smoke returns

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53
Q

When should a px be referred who is using nicotine gum?

A

If using product for more than 6 months

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54
Q

What can incorrect chewing of nicotine gum lead to?

A
  • Nicotine is released too quickly, causing it to be swallowed instead of absorbed through buccal mucosa
  • Reduces efficacy/results in unpleasant taste
  • Leads to sx similing to over-smoking (nausea, hiccups, cough, light-headedness)
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55
Q

What are the 3 main indications of nicorette gum?

A

1) Stop to quit (px choose a quit date and initiate gum on that day to minimize withdrawal)
2) Temporary abstinence
3) Reduce to quit method (for users who are not ready or unable to quit abruptly)

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56
Q

What are the drug/food interactions w/ nicotine gum?

A
  • Avoid food/drink 15 mins before and during use (acidic beverages may interfere w/ bioavailability/absorption of nicotine)
  • Smoking w/ gum (or any other NRT) no longer contraindicated (caution w/ nicotine toxicity)
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57
Q

What are the most common side effects w/ nicotine gum?

A
  • Jaw pain, dental problems
  • Throat irritation, cough, hiccups
  • Headache, dizziness, insomnia
  • Chest pain
  • Indigestion
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58
Q

What are contraindications for nicotine gum?

A
  • TMJ
  • Gastric ulcers
  • Px in immediate post-MI period, px w/ life-threatening arrhythmias
  • Pregnancy and breastfeeding
  • Children under 18 y/o
59
Q

How can most side effects of nicotine gum be prevented?

A

Proper technique

60
Q

What is the time to peak and indication for NRT lozenges?

A
  • Time to peak = 20-60 mins

- Indication = stop to quit

61
Q

What is a special instruction for use of NRT lozenges?

A

Do not eat or drink 15 mins before or during lozenge use

62
Q

What is the approx. dosing regimen for NRT lozenges?

A
  • 1 lozenge q1-2h for 6 weeks
  • 1 lozenge q2-4h for 3 weeks
  • 1 lozenge q4-8h for 3 weeks
  • Discontinue when using 1-2 lozenges per day
63
Q

What are the available strengths of Thrive lozenges? When is each used? What is the max/day of each?

A
  • 1 mg for less than 20 cigarettes per day (max 25 lozenges/day)
  • 2 mg for 20 or more cigarettes per day (pack or more/day); max 15 lozenges/day
64
Q

What is the technique to use a Thrive lozenge?

A
  • Suck on lozenge until strong taste, then park lozenge btwn cheek and gum
  • Repeat when taste diminishes
65
Q

What are the available strengths of Nicorette mini lozenges? When is each used? What is the max/day of each?

A
  • 2 mg if first cigarette is more than 30 mins after waking
  • 4 mg if first cigarette is less than 30 mins after waking
  • Max 15 lozenges for both strengths per day
66
Q

What is the technique to use a nicorette lozenge?

A
  • Once lozenge is in mouth, move intermittently from one site to other side
  • Try to avoid swallowing
67
Q

What are contraindications for the NRT lozenge?

A

Same as for NRT gum

68
Q

How long does it take to reach max concentration for NRT mouth sprays?

A

13 mins

69
Q

What is the excipient in NRT mouth sprays?

A

Ethanol, mint flavoured

70
Q

What are the directions for use of NRT mouth spray?

A
  • First time, point nozzle away and press top of dispenser several times until fine mist; repeat if spray has not been used for 2 or more days
  • Point nozzle towards open mouth, holding as close as possible
  • Press top of dispenser for release of one spray into mouth (avoid lips)
  • Do not inhale while spraying, avoid swallowing for a few seconds after spraying
71
Q

What is the dosing of NRT mouth spray?

A

1-2 sprays when you normally smoke a cigarette or have a craving to smoke

  • Use 1 spray first and if craving does not disappear w/in a few minutes, use 2nd spray
  • Most smokers = 1-2 sprays every 30-60 minutes
72
Q

What is the max dose of NRT mouth spray?

A

2 sprays at a time, 4 sprays per hour, 64 sprays per day

73
Q

What are some side effects of NRT mouth spray?

A
  • Altered sense of taste
  • Headache
  • Nausea, vomiting
  • Hiccups
  • Dry mouth, burning lips
  • Dyspepsia
74
Q

What is the dosing schedule for NRT mouth spray?

A
  • Weeks 1-6 = use prn up to 1-2 sprays q30min
  • Weeks 7-9 = decrease by 50% average number of sprays per day
  • Weeks 10-12 = use 2-4 sprays per day
  • Discontinue after week 12
75
Q

What is the dosing for NRT transdermal patches?

A

Once daily application, can be worn up to 24 hours

76
Q

What is the time to peak w/ NRT transdermal patches?

A

2-6 hours

77
Q

Can px smoke while wearing NRT transdermal patches?

A

No

78
Q

What are the available strengths of NRT transdermal patches?

A

7 mg, 14 mg, 21 mg

79
Q

What are the advantages to NRT transdermal patches?

A
  • Eliminates variability of GI absorption
  • May enhance patient compliance
  • Discreet/easy to use
  • Low risk of addiction b/c no spikes
80
Q

What are disadvantages to NRT transdermal patches?

A
  • May cause local skin irritation

- No spikes in concentration to correspond w/ cravings

81
Q

What is the difference btwn Nicoderm and Habitrol patches?

A
  • Nicoderm is system-controlled, so nicotine release regulated by a rate-controlling membrane and releases nicotine at a constant rate
  • Habitrol is a skin-controlled patch, so nicotine release regulated by the rate at which nicotine can cross the individual’s skin, so rate of release dependent on individual’s skin permeability
82
Q

Which patch has an adhesive that contains nicotine?

A

Nicoderm

83
Q

What is the dosing for Nicoderm patches?

A
  • Step 1 = 21 mg for 6 weeks; step 2 = 14 mg for 2 weeks; step 3 = 7 mg for 2 weeks
  • OR step 2 = 14 mg for 6 weeks; step 3 = 7 mg for 2 weeks
84
Q

What is the dosing for Habitrol?

A
  • Step 1 = 21 mg for 4 weeks; step 2 = 14 mg for 2 weeks; step 3 = 7 mg for 2 weeks
  • OR step 2 = 14 mg for 6 weeks; step 3 = 7 mg for 2 weeks
85
Q

What is the maximum duration of transdermal therapy?

A

3 months (if one doesn’t work well for px, find out why and try again or try another)

86
Q

What is the starting dose for nicotine patches?

A

Px smoking 10 or more cigarettes per day start at 21 mg

87
Q

Which px should start w/ step 2 of NRT transdermal patch?

A
  • Those who smoke less than 10 cigarettes per day
  • Those weighing less than 100 lbs
  • Those w/ cardiac/heart disease
88
Q

What are steps to take to ensure NRT transdermal patch stays in place for 24 hours?

A
  • Site should be clean, non-hairy, and completely dry
  • Apply pressure to patch for about 10 seconds on application
  • Rotate sites frequently
89
Q

What are common side effects of NRT transdermal patches?

A
  • Local skin reaction (erythema, burning, pruritus)
  • Less common = vivid or abnormal dreams, insomnia, headache
  • Sleep disturbances, so remove patch at bedtime
90
Q

What are contraindications of NRT transdermal patch?

A
  • Px w/ generalized skin disorders
  • Px in immediate post-MI period, px w/ life-threatening arrhythmias, px w/ severe or worsening angina pectoris
  • Pregnancy and breastfeeding
  • Non-smokers or occasional smokes and children under 18 y/o
91
Q

What is the fastest form of NRT?

A

Nicotine inhaler

92
Q

How does the nicotine inhaler deliver nicotine?

A

As an inhaled vapour which is absorbed across the buccal mucosa and throat (not lungs)

93
Q

What are advantages to the nicotine inhaler?

A
  • Reduce nicotine withdrawal sx

- May provide some degree of comfort by providing hand-to-mouth ritual

94
Q

Nicotine inhaler absorption is ____ dependent

A

Temperature (cold decreases absorption)

95
Q

What is the time to peak w/ nicotine inhalers?

A

15 mins

96
Q

One cartridge for nicotine inhaler gives about ___ mins of inhalation and lasts ___ hours once punctured

A

20 mins; 24 hours

97
Q

What is the dosing for nicotine inhalers?

A
  • Each 10 mg cartridge delivers 4 mg nicotine (2 mg systemically absorbed)
  • Can puff for 5-10 mins at a time like you would w/ a cigarette
98
Q

What is the dosing schedule for nicotine inhalers?

A

First 6-12 weeks = 1 cartridge as needed

99
Q

What is the max # of cartridges per day for nicotine inhaler?

A

6-12

100
Q

What is the recommended length of tx w/ nicotine inhalers?

A
  • About 12 weeks followed by a tapering schedule over another 6-12 weeks if needed
  • Discontinue use when daily use is 1-2 times
101
Q

What are the most common side effects of nicotine inhalers?

A
  • Cough
  • Throat irritation
  • Pharyngitis
  • Stomatitis
  • Rhinitis
  • Headache
  • Nausea
102
Q

What are the directions for use of nicorette inhaler?

A
  • Place cartridge inside device
  • Place tapered end of inhaler in mouth and inhale deeply into back of throat, or puff in short shallow breaths
  • Avoid drinking acidic beverages (coffee, tea, soft drinks, alcohol) when using inhaler or before use
103
Q

What are contraindications for NRT inhalers?

A
  • Hypersensitivity to nicotine or menthol
  • Px in immediate post-MI period, px w/ life-threatening arrhythmias, px w/ severe or worsening angina pectoris
  • Pregnancy and breastfeeding
  • Non-smokers or occasional smokers and children under 18 y/o
104
Q

When can px use a combination of NRT products?

A

Heavy smokers under physician supervision

105
Q

What should determine the choice of monotherapy or combination therapy?

A
  • Failed attempt w/ monotherapy
  • Px experiencing breakthrough cravings or withdrawal sx
  • Nicotine dependence level
106
Q

Which NRT products can be used in combination?

A
  • Patch and gum/lozenge/inhaler

- Buproprion and NRT

107
Q

What is buproprion? What strength is used?

A
  • Antidepressant

- 150 mg sustained release (Rx)

108
Q

What is the dosing of buproprion for smoking cessation?

A
  • 1 tablet daily for 3 days, then increase to 1 tablet BID for remaining 7-12 weeks
  • Max = 300 mg/day
109
Q

What should the px quit date be when on buproprion?

A

1 week after initiating buproprion

110
Q

What is the proposed MOA for buproprion for smoking cessation?

A

Increases mesolimbic reward system dopamine and NE levels and blocks brain nicotinic receptors involved in tobacco addiction

111
Q

What are the benefits to buproprion?

A
  • Reduces withdrawal symptoms and cravings
  • Less weight gain
  • Cheapest alternative overall
112
Q

What are some side effects of buproprion?

A
  • Insomnia
  • Agitation
  • Tremor
  • Decreased appetite
  • GI upset
  • Dry mouth
  • Increased risk of seizures
113
Q

What are contraindications for buproprion?

A
  • Those w/ personal/family history of seizures or eating disorders
  • Px on MAOI agents (w/in 14 days)
  • Px who use alcohol excessively
114
Q

What are some drug interactions w/ buproprion?

A
  • May increase plasma levels of drugs metabolized by CYP 2D6
115
Q

What are some special considerations w/ buproprion?

A
  • Can be used in pregnancy w/ Dr. monitoring

- Combination of buproprion and NRT has been successful in significantly reducing cravings and withdrawal

116
Q

What is champix (varenicline)?

A
  • Highly selective/ partial nicotinic acetylcholine receptor agonist/ antagonist
  • Binds specifically to alpha 4/ beta 2 receptors preventing binding of nicotine to these receptors
117
Q

How does varenicline help w/ smoking cessation?

A

Decreases sense of satisfaction and reward that would normally come from nicotine

118
Q

What is the half life of varenicline?

A

About 24 hours

119
Q

What is the dosing regimen for varenicline?

A
  • Days 1-3 = 0.5 mg once daily
  • Days 4-7 = 0.5 mg BID
  • Days 8-14 = 1 mg BID
120
Q

When should the px set their quit date when starting varenicline therapy?

A

1-2 weeks after starting treatment

121
Q

What is the duration of varenicline therapy?

A

Generally 12 weeks

122
Q

What are common side effects of varenicline?

A
  • Nausea (prevent by taking w/ full cup of water)
  • Insomnia
  • Fatigue
  • Constipation
  • Headache
  • Taste disturbance
123
Q

Is varenicline safe to use in children or pregnant women?

A

No

124
Q

Can varenicline be used w/ NRTs?

A

No

125
Q

What is the dosing of nortriptyline for smoking cessation?

A

75-100 mg once daily

126
Q

When should px set their quit date when starting nortriptyline? What is the duration of nortriptyline therapy?

A
  • Quit date 10-28 days after initiating nortriptyline

- Duration = 12 weeks

127
Q

What are side effects of nortriptyline?

A
  • Sedation
  • Dry mouth
  • Blurred vision
  • Lightheadedness
  • Constipation
  • Weight gain
128
Q

What is the dosing and duration of clonidine for smoking cessation?

A

0.15-0.45 mg/day for 12 weeks

129
Q

What are side effects to clonidine?

A
  • Dry mouth
  • Sedation
  • Dizziness
130
Q

What is cytisine?

A

NHP that is a partial agonist of nicotinic acetylcholine receptors

131
Q

What are some side effects of cytisine?

A
  • Nausea, vomiting
  • Stomach upset
  • Sleep disturbances
132
Q

Are electronic cigarettes approved by Health Canada as a smoking cessation tool?

A

No

133
Q

Nicotine causes coronary and cutaneous ______

A

Vasoconstriction

134
Q

What is first line therapy for smoking cessation in pregnant women?

A
  • Behavioural modifications

- If non-pharms insufficient, refer to physician

135
Q

Which NRTs can be used in pregnancy?

A
  • Immediate release options (gum, lozenge, inhaler)

* *Lowest effective dose for shortest amount of time recommended

136
Q

What is a recommendation for pregnant women using NRT patch?

A

Only use during waking hours and remove at night

137
Q

When is nicotine safe w/ respect to CVD?

A
  • Px w/ stable CVD (ex: controlled hypertension)
  • Px w/ CVD who smoked while on patches
  • General population of NRT users
138
Q

Can buproprion be used in px w/ CVD?

A

No, raises BP

139
Q

Can clonidine be used in px w/ CVD?

A

Yes b/c decreases BP, but may cause rebound hypertension upon discontinuation

140
Q

What is the smoking cessation tx for px under 18 y/o?

A
  • Non-pharms first

- Refer to physician for NRT

141
Q

What determines nicotine’s addictive potential?

A

Rate and route of administration

142
Q

Does NRT have the same addictive potential as nicotine in cigarettes?

A

No (still caution w/ gum more so than the patch)

143
Q

What is included in the monitoring for smoking cessation?

A

Monitor smoking, desire to smoke, withdrawal sx, treatment of side effects and OD sx, weight gain, stress and mood

Clinical - Winter (24 decks)

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