4 - Smoking Cessation Flashcards
__% of smokers are thinking about quitting
60%
What are the components of a cigarette?
- Tar
- Carbon monoxide
- Nicotine
What are the harmful aspects of tar?
- Contains over 4000 chemicals
- Increases risk of cancers, CV disease, and pulmonary disease
What are the harmful aspects of carbon monoxide?
Reduces oxygen-carrying capacity of blood
Addictive nature of nicotine is as strong as _____
Cocaine
What kind of cardiovascular effects can cigarettes have?
- Coronary heart disease
- Cerebrovascular disease (stroke)
- Peripheral vascular disease
What kind of cancer can cigarettes cause?
- Lung
- Pharynx, larynx, esophagus
- Pancreas
- Kidney
- Bladder
- Cervix
What kind of respiratory effects can cigarettes have?
- COPD
- Pneumonia
- Emphysema
- Bronchitis
What effect can cigarettes have on pregnancy?
- Low birth weight
- Stillbirths
- Miscarriage
- Sudden infant death syndrome (SIDS)
What other effects can cigarettes have on the body?
- Peptic ulcer disease
- Osteoporosis
- Cataracts
- Macular degeneration
- Infertility
- Impotence
What are the 1st and 2nd leading causes of lung cancer?
1) Smoking
2) Secondhand smoke
What type of childhood illnesses can secondhand smoke worsen?
- Ear infections
- Asthma
- Bronchitis
What are the stimulant effects of nicotine at low doses?
- Increases alertness
- Facilitates memory and attention
- Reduces irritability and aggression (relaxing)
- Suppresses appetite for sweets
- Increases energy expenditure
- Lowers likelihood of weight gain
What is the effect of nicotine at high doses?
“Reward” effects via limbic system’s “pleasure system”
How long do it take nicotine to reach the mesolimbic system after smoking?
7-10 seconds
What is the half life of nicotine?
60-90 minutes
When nicotine levels decrease, so do _____ levels
Dopamine
What are the negative effects of nicotine?
- Cough
- Affects cardiovascular system (increases BP and heart rate)
- Cold extremities
What changes occur in the body 20 minutes after last cigarette?
- BP and pulse rate return to normal
- Body temp increases to normal
What changes occur in the body 8 hours after last cigarette?
Carbon monoxide levels in blood drop and oxygen levels return to normal
What changes occur in the body 48 hours after last cigarette?
- Sense of smell and taste improves
- Chances of heart attack decrease
What changes occur in the body 72 hours after last cigarette?
Lung capacity increases
Why is sense of smell and taste increasing significant when quitting smoking?
Px may gain weight after quitting
What changes occur in the body 2 weeks to 6 months after last cigarette?
- Nicotine is gone from body
- Circulation and overall energy increases
- Coughing, sinus congestion, tiredness and shortness of breath improve significantly
What changes occur in the body 1 year after last cigarette?
Risk of heart disease decreases
What changes occur in the body 5-15 years after last cigarette?
- Risk of dying from lung cancer decreases by almost 1/2
- Risk of heart attack is equal to someone who has never smoked
When do nicotine withdrawal symptoms begin and when do they peak and resolve?
- 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
What are some nicotine withdrawal sx?
- Constipation, diarrhea
- Fatigue
- Headache, dizziness
- Restlessness/anxiety
- Cough, dry throat/mouth
- Insomnia
- Irritability, anger
How can nicotine withdrawal sx be managed?
NRT and behavioural tx
What are the top 3 questions you should ask about readiness to quit?
- Do you smoke?
- Have you ever considered quitting?
- Is now a good time to quit?
What does the Fagerstrom Questionnaire assess?
- Degree of physical dependence
- Those that will benefit from pharmacotherapy (those w/ score of 6 of more)
What do the values of the Fagerstrom Questionnaire represent?
- Less than 5 = low nicotine dependence
- 5 = moderate dependence
- 6-7 high dependence
- 8-10 = very high dependence
How is “pack years” calculated?
(# cigarettes per day * # of years smoked) / 20
What are some common barriers to quitting?
- 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
What is needed to successfully quit smoking?
- Overcome pharmacologic nicotine dependence
- Cope w/ nicotine withdrawal
- Extinguish strong behavioural associated w/ smoking
What are some non-pharm suggestions for smoking cessation?
- Set target quit date
- Get professional help
- Enlist social support
- Use problem-solving methods of counselling to quit and remain smoke free
What are some coping strategies for smoking cessation?
- Managing cravings and triggers
- Stress relief
- Environmental control
- Social support
- Motivational thinking and rewards
- Handling withdrawal sx
What are some counselling tips for withdrawal sx?
- 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
What are some counselling tips for handling lapses?
- 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)
What are the methods for smoking cessation?
- Self-treatment nicotine replacement therapy (NRT)
- Prescription therapy
- Natural health product (cytisine)
- Non-pharm aids
What is the purpose of pharm therapy for smoking cessation?
To reduce physical effects of nicotine withdrawal
NRT increases quit rates by ____ compared to placebo
1.5-2 fold
NRT is best used along w/ _______
Behavioural modifications
What are the brand names for nicotine polacrilex gum?
Nicorette and Thrive
What is one of the fastest delivery forms for nicotine other than smoking? What is the peak time?
- Gum, buccal mucosa
- Time to peak = 20-30 mins
How is the nicotine polacrilex gum formulated and what effect does this have on the release of nicotine?
- Buffered ion exchange resin
- Allows gradual release of nicotine
What are the available strengths of nicotine polacrilex gum?
2 mg or 4 mg
Can nicotine polacrilex gum be used in combination w/ other NRTs or bupropion?
Yes, w/ caution
When should a person use 2 mg nicotine gum?
- 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)
When should a person use 4 mg nicotine gum?
- 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)
What are the directions for use of nicotine gum?
- 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
What happens if the px is still having difficulty after using nicotine gum for 3 months?
Px can chew 1 piece if urge to smoke returns
When should a px be referred who is using nicotine gum?
If using product for more than 6 months
What can incorrect chewing of nicotine gum lead to?
- 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)
What are the 3 main indications of nicorette gum?
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)
What are the drug/food interactions w/ nicotine gum?
- 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)
What are the most common side effects w/ nicotine gum?
- Jaw pain, dental problems
- Throat irritation, cough, hiccups
- Headache, dizziness, insomnia
- Chest pain
- Indigestion
What are contraindications for nicotine gum?
- TMJ
- Gastric ulcers
- Px in immediate post-MI period, px w/ life-threatening arrhythmias
- Pregnancy and breastfeeding
- Children under 18 y/o
How can most side effects of nicotine gum be prevented?
Proper technique
What is the time to peak and indication for NRT lozenges?
- Time to peak = 20-60 mins
- Indication = stop to quit
What is a special instruction for use of NRT lozenges?
Do not eat or drink 15 mins before or during lozenge use
What is the approx. dosing regimen for NRT lozenges?
- 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
What are the available strengths of Thrive lozenges? When is each used? What is the max/day of each?
- 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
What is the technique to use a Thrive lozenge?
- Suck on lozenge until strong taste, then park lozenge btwn cheek and gum
- Repeat when taste diminishes
What are the available strengths of Nicorette mini lozenges? When is each used? What is the max/day of each?
- 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
What is the technique to use a nicorette lozenge?
- Once lozenge is in mouth, move intermittently from one site to other side
- Try to avoid swallowing
What are contraindications for the NRT lozenge?
Same as for NRT gum
How long does it take to reach max concentration for NRT mouth sprays?
13 mins
What is the excipient in NRT mouth sprays?
Ethanol, mint flavoured
What are the directions for use of NRT mouth spray?
- 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
What is the dosing of NRT mouth spray?
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
What is the max dose of NRT mouth spray?
2 sprays at a time, 4 sprays per hour, 64 sprays per day
What are some side effects of NRT mouth spray?
- Altered sense of taste
- Headache
- Nausea, vomiting
- Hiccups
- Dry mouth, burning lips
- Dyspepsia
What is the dosing schedule for NRT mouth spray?
- 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
What is the dosing for NRT transdermal patches?
Once daily application, can be worn up to 24 hours
What is the time to peak w/ NRT transdermal patches?
2-6 hours
Can px smoke while wearing NRT transdermal patches?
No
What are the available strengths of NRT transdermal patches?
7 mg, 14 mg, 21 mg
What are the advantages to NRT transdermal patches?
- Eliminates variability of GI absorption
- May enhance patient compliance
- Discreet/easy to use
- Low risk of addiction b/c no spikes
What are disadvantages to NRT transdermal patches?
- May cause local skin irritation
- No spikes in concentration to correspond w/ cravings
What is the difference btwn Nicoderm and Habitrol patches?
- 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
Which patch has an adhesive that contains nicotine?
Nicoderm
What is the dosing for Nicoderm patches?
- 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
What is the dosing for Habitrol?
- 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
What is the maximum duration of transdermal therapy?
3 months (if one doesn’t work well for px, find out why and try again or try another)
What is the starting dose for nicotine patches?
Px smoking 10 or more cigarettes per day start at 21 mg
Which px should start w/ step 2 of NRT transdermal patch?
- Those who smoke less than 10 cigarettes per day
- Those weighing less than 100 lbs
- Those w/ cardiac/heart disease
What are steps to take to ensure NRT transdermal patch stays in place for 24 hours?
- Site should be clean, non-hairy, and completely dry
- Apply pressure to patch for about 10 seconds on application
- Rotate sites frequently
What are common side effects of NRT transdermal patches?
- Local skin reaction (erythema, burning, pruritus)
- Less common = vivid or abnormal dreams, insomnia, headache
- Sleep disturbances, so remove patch at bedtime
What are contraindications of NRT transdermal patch?
- 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
What is the fastest form of NRT?
Nicotine inhaler
How does the nicotine inhaler deliver nicotine?
As an inhaled vapour which is absorbed across the buccal mucosa and throat (not lungs)
What are advantages to the nicotine inhaler?
- Reduce nicotine withdrawal sx
- May provide some degree of comfort by providing hand-to-mouth ritual
Nicotine inhaler absorption is ____ dependent
Temperature (cold decreases absorption)
What is the time to peak w/ nicotine inhalers?
15 mins
One cartridge for nicotine inhaler gives about ___ mins of inhalation and lasts ___ hours once punctured
20 mins; 24 hours
What is the dosing for nicotine inhalers?
- 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
What is the dosing schedule for nicotine inhalers?
First 6-12 weeks = 1 cartridge as needed
What is the max # of cartridges per day for nicotine inhaler?
6-12
What is the recommended length of tx w/ nicotine inhalers?
- About 12 weeks followed by a tapering schedule over another 6-12 weeks if needed
- Discontinue use when daily use is 1-2 times
What are the most common side effects of nicotine inhalers?
- Cough
- Throat irritation
- Pharyngitis
- Stomatitis
- Rhinitis
- Headache
- Nausea
What are the directions for use of nicorette inhaler?
- 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
What are contraindications for NRT inhalers?
- 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
When can px use a combination of NRT products?
Heavy smokers under physician supervision
What should determine the choice of monotherapy or combination therapy?
- Failed attempt w/ monotherapy
- Px experiencing breakthrough cravings or withdrawal sx
- Nicotine dependence level
Which NRT products can be used in combination?
- Patch and gum/lozenge/inhaler
- Buproprion and NRT
What is buproprion? What strength is used?
- Antidepressant
- 150 mg sustained release (Rx)
What is the dosing of buproprion for smoking cessation?
- 1 tablet daily for 3 days, then increase to 1 tablet BID for remaining 7-12 weeks
- Max = 300 mg/day
What should the px quit date be when on buproprion?
1 week after initiating buproprion
What is the proposed MOA for buproprion for smoking cessation?
Increases mesolimbic reward system dopamine and NE levels and blocks brain nicotinic receptors involved in tobacco addiction
What are the benefits to buproprion?
- Reduces withdrawal symptoms and cravings
- Less weight gain
- Cheapest alternative overall
What are some side effects of buproprion?
- Insomnia
- Agitation
- Tremor
- Decreased appetite
- GI upset
- Dry mouth
- Increased risk of seizures
What are contraindications for buproprion?
- Those w/ personal/family history of seizures or eating disorders
- Px on MAOI agents (w/in 14 days)
- Px who use alcohol excessively
What are some drug interactions w/ buproprion?
- May increase plasma levels of drugs metabolized by CYP 2D6
What are some special considerations w/ buproprion?
- Can be used in pregnancy w/ Dr. monitoring
- Combination of buproprion and NRT has been successful in significantly reducing cravings and withdrawal
What is champix (varenicline)?
- Highly selective/ partial nicotinic acetylcholine receptor agonist/ antagonist
- Binds specifically to alpha 4/ beta 2 receptors preventing binding of nicotine to these receptors
How does varenicline help w/ smoking cessation?
Decreases sense of satisfaction and reward that would normally come from nicotine
What is the half life of varenicline?
About 24 hours
What is the dosing regimen for varenicline?
- Days 1-3 = 0.5 mg once daily
- Days 4-7 = 0.5 mg BID
- Days 8-14 = 1 mg BID
When should the px set their quit date when starting varenicline therapy?
1-2 weeks after starting treatment
What is the duration of varenicline therapy?
Generally 12 weeks
What are common side effects of varenicline?
- Nausea (prevent by taking w/ full cup of water)
- Insomnia
- Fatigue
- Constipation
- Headache
- Taste disturbance
Is varenicline safe to use in children or pregnant women?
No
Can varenicline be used w/ NRTs?
No
What is the dosing of nortriptyline for smoking cessation?
75-100 mg once daily
When should px set their quit date when starting nortriptyline? What is the duration of nortriptyline therapy?
- Quit date 10-28 days after initiating nortriptyline
- Duration = 12 weeks
What are side effects of nortriptyline?
- Sedation
- Dry mouth
- Blurred vision
- Lightheadedness
- Constipation
- Weight gain
What is the dosing and duration of clonidine for smoking cessation?
0.15-0.45 mg/day for 12 weeks
What are side effects to clonidine?
- Dry mouth
- Sedation
- Dizziness
What is cytisine?
NHP that is a partial agonist of nicotinic acetylcholine receptors
What are some side effects of cytisine?
- Nausea, vomiting
- Stomach upset
- Sleep disturbances
Are electronic cigarettes approved by Health Canada as a smoking cessation tool?
No
Nicotine causes coronary and cutaneous ______
Vasoconstriction
What is first line therapy for smoking cessation in pregnant women?
- Behavioural modifications
- If non-pharms insufficient, refer to physician
Which NRTs can be used in pregnancy?
- Immediate release options (gum, lozenge, inhaler)
* *Lowest effective dose for shortest amount of time recommended
What is a recommendation for pregnant women using NRT patch?
Only use during waking hours and remove at night
When is nicotine safe w/ respect to CVD?
- Px w/ stable CVD (ex: controlled hypertension)
- Px w/ CVD who smoked while on patches
- General population of NRT users
Can buproprion be used in px w/ CVD?
No, raises BP
Can clonidine be used in px w/ CVD?
Yes b/c decreases BP, but may cause rebound hypertension upon discontinuation
What is the smoking cessation tx for px under 18 y/o?
- Non-pharms first
- Refer to physician for NRT
What determines nicotine’s addictive potential?
Rate and route of administration
Does NRT have the same addictive potential as nicotine in cigarettes?
No (still caution w/ gum more so than the patch)
What is included in the monitoring for smoking cessation?
Monitor smoking, desire to smoke, withdrawal sx, treatment of side effects and OD sx, weight gain, stress and mood
