43. Tobacco Cessation

Question 1

Treatment guidelines recommend behavioral counseling alone (no meds) for certain patient populations. What are they?

Answer 1

Pregnant women
Adolescents
Smokeless tobacco users (e.g. chewing tobacco)
“Light smokers” (<10 cigs/day)

Question 2

Non-nicotine chemicals in tobacco smoke induce CYP450 enzymes, primarily ___

Answer 2

1A2

Question 3

Smokers who quit may experience side effects from supratherapeutic levels of _____

Answer 3

Caffeine
Theophylline
Warfarin (R-isomer, less potent)

Others: fluvoxamine, olanzapine, clozapine

Question 4

What female patient population should not take estrogen-containing oral contraceptives?

Answer 4

women ≥35yo who smoke (increased risk of CV events)

Question 5

Smokers age ____ should receive a pneumococcal vaccine and influenza vaccine (in addition to other age-appropriate vaccines)

Answer 5

19-64yo

Question 6

What are OTC nicotine replacement therapy (NRT) options?

Answer 6

Patch, gum, lozenge

(Inhaler and nasal spray is Rx only)

Question 7

Warnings for NRT

Answer 7

Avoid in immediate post-MI period, life-threatening arrhythmias, severe or worsening angina and pregnancy

Question 8

Side effects for NRT (all)

Answer 8

Insomnia

Others: HA, dizziness, nervousness, dyspepsia

Question 9

Side effects for NRT patch

Answer 9

vivid dreams, skin irritation

Question 10

Side effects for NRT inhaler

Answer 10

Mouth/throat irritation, cough, rhinitis

Question 11

Side effects for NRT nasal spray

Answer 11

Nasal irritation

Others: watery eyes, sneezing, transient changes in taste/smell

Question 12

How old do you have to be to buy nicotine products?

Answer 12

≥18yo (need ID to buy)

Question 13

T/F: nicotine patch must be removed before MRI

Answer 13

Yes

Question 14

Which strength of gum/lozenges can reduce or delay weight gain?

Answer 14

4mg

Question 15

How long should you wait to eat/drink before or during gum/lozenge use?

Answer 15

15min

acidic beverages/foods decrease buccal absorption

Question 16

Which NRT option has the fastest delivery (useful for rapid relief of withdrawal symptoms)?

Answer 16

Nasal spray

Question 17

Which NRT option has highest risk of dependence?

Answer 17

Nasal spray

Question 18

Which NRT option has highest adherence rate?

Answer 18

Patch

Question 19

Patient smokes 1ppd, first cigarette is right after they wake up. What NRT regimen do you recommend?

Answer 19

Patch 21mg x6 weeks (decrease to 14mg x2 weeks, 7mg x2 weeks)
Gum/Lozenge 4mg q1-2h x6 weeks (q2-4h x3 weeks, 4-8h x3 weeks)

Question 20

Patient smokes 5 cigs/day, first cigarette is during their lunch break. What NRT regimen do you recommend?

Answer 20

Patch 14mg x 6 weeks (decrease to 7mg x2 weeks)
Gum/Lozenge 2mg q1-2h x6 weeks (decrease q2-4h x3 weeks, q4-8h x3 weeks)

Question 21

MOA of buprorpion

Answer 21

blocks neuronal reuptake of dopamine and/or NE (results in reduced cravings and other withdrawal symptoms)

Question 22

Dosing for Buproprion SR (Zyban)

Answer 22

150mg QAM for 3 days, then 150mg BID
Max dose: 300mg/day
Use up to 6 months

Question 23

Boxed warning for bupropion SR (Zyban)

Answer 23

Increased risk of suicidal thinking and behavior in children, adolescents and young adults taking antidepressants

Question 24

Contraindications for bupropion SR (Zyban)

Answer 24

Seizure
Hx anorexia/bulimia
Concurrent use with MAOi, linezolid, or IV methylene blue

Question 25

Warnings for bupropion SR (Zyban)

Answer 25

Serious neuropsychiatric events (e.g. mood changes, hallucinations, paranoia, aggression, anxiety) Others: activation of mania/hypomania, HTN, angle-closure glaucoma, rash (including SJS)

Question 26

Side effects for bupropion SR (Zyban)

Answer 26

Dry mouth, insomnia, tremors, weight loss Others: agitation, anxiety, tachycardia, HA, sweating, N/V, constipation

Question 27

Patient is planning to quit smoking. They were prescribed bupropion. Current med list includes lisinopril, atorvastatin, and Wellbutrin. What is your concern?

Answer 27

Do NOT use bupropion with other forms of buprropion (Wellbutrin is bupropion for depression)

Question 28

Patient recently started on bupropion and is now experiencing insomnia. What do you recommend?

Answer 28

Take 1st dose upon waking up and 2nrd dose 8 hrs after 1st dose

Question 29

Patient has been on Bupropion SR for smoking cessation for 5 weeks and has no significant process. What do you recommend?

Answer 29

If no significant process by week 7, consider discontinuation

Question 30

MOA varenicline (Chantix)

Answer 30

Partial neuronal alpha-4 beta-2 nicotinic receptor agonist - low level stimulation of the receptor while blocking ability of nicotine to bind = relieves symptoms of withdrawal and breaks reinforcement/reward cycle of smoking)

Question 31

Warnings for varenicline (Chantix)

Answer 31

Serious neuropsychiatric events (e.g. agitation, depression, suicidal thoughts/behaviors) Seizures Others: increased effects of alcohol, somnambulism (sleepwalking), accidental injury (e.g. traffic accidents), CVD risk, hypersensitivity reactions (e.g. angioedema, SJS)

Question 32

Side effects for varenicline (Chantix)

Answer 32

Nausea (~30%, dose dependent) Insomnia Abnormal dreams HA Others: constipation, vomiting

Question 33

To decrease nausea a/w Chantix, what do you recommend?

Answer 33

Take after eating with full glass of water; can reduce dose if needed

Question 34

Patient wants to quit smoking but is concerned of weight gain. What do you recommend?

Answer 34

Gum/lozenges and bupropion SR (all delay weight gain)

Question 35

Patient wants to quit smoking but also has depression. What do you recommend?

Answer 35

Use bupropion SR

Question 36

Patient wants to quit smoking but also has a hx of seizures. What do you recommend to avoid?

Answer 36

Avoid bupropion and varenicline

Question 37

Patient wants to quit smoking but also has a hx of anorexia. What do you recommend to avoid?

Answer 37

Avoid bupropion

Question 38

How do you use nicotine patches?

Answer 38

Apply to clean, dry, and relatively hairless area (hold ~10 seconds) Wear for 24 hrs (16hrs if insomnia) Folding sticky ends together and place back in original pouch and discard Wash hands after applying and removing patch Rotate application site (do not apply to same site for at least 1 week, may cause skin irritation) Never cut patch or wear more than 1 patch at a time

Question 39

How do you use nicotine gum?

Answer 39

Chew slowly until tingle/peppery flavor Park between cheek and gum When tingle/peppery flavor goes away, chew again and then park again Repeat until all tingle/flavor goes away (~30 min) Do not eat or drink 15min before or during chewing