47. Smoking Cessation

Question 1

Berryl is pregnant and wants to quit smoking. Which of the following agents is pregnancy category C?

A. Bupropion SR
B. Nicotine patch
C. Nicotine inhaler
D. Nicotine nasal spray
E. Methotrexate

Answer 1

A. Bupropion SR is pregnancy category C.

Also the gum and lozenges are C.

Question 2

What are the most common side effects of bupropion therapy?

A. Insomnia and dry mouth
B. Rash and itching
C. Sedation and lethargy
D. Weight gain and increased blood glucose
E. Anxiety and depression

Answer 2

A. Insomnia and dry mouth are 2 of the most common side effects with bupropion.

Question 3

Laura will use bupropion for smoking cessation. Which of the following statements concerning bupropion are correct? (Select ALL that apply.)

A. Patients should not stop smoking until 1 week after starting bupropion.
B. If you cannot swallow the tablets it is acceptable to crush them or cut in half into smaller pieces.
C. Do not use if you have a seizure disorder.
D. It is safe to use in patients taking Parnate.
E. Do not use if you have either anorexia or bipolar disorder.

Answer 3

A, C, E. Do not chew, cut, or crush tablets (medication may be released too rapidly).

Question 4

Chantix requires dose adjustment for which of the following conditions?

A. Hepatic dysfunction
B. Renal dysfunction
C. Geriatric patients
D. Psychiatric conditions
E. Patients with asthma or COPD

Answer 4

B. Chantix requires dose reduction in patients with significant renal impairment (CrCl < 30 mL/min).

Question 5

Choose the correct counseling statement for Nicotrol inhaler:

A. Once a cartridge is opened, it is only good for 2 days.
B. Clean the mouthpiece by sterilizing it in a dishwasher.
C. Frequent, continuous puffing for 20 minutes is advised with each cartridge.
D. The device should be stored at less than 40 degrees Fahrenheit.
E. The inhaler is pregnancy category A.

Answer 5

C. Once a cartridge is opened, it is only good for 1 day. After using the inhaler for a total of 20 minutes, remove the used cartridge and throw it away out of reach of children and pets. The mouthpiece is reusable. Clean the mouthpiece with soap and water regularly. Delivery of nicotine from the inhaler declines significantly below 40 degrees F. In cold weather, the inhaler and cartridge should be kept in an inside pocket or other warm area.

Question 6

Which of the following smoking-cessation nicotine products comes as a transdermal patch?

A. Commit
B. Nicotrol inhaler
C. Nicotrol nasal spray
D. Nicorette
E. NicoDerm

Answer 6

E.

Question 7

Beth wishes to quit smoking. She has tried using gum in the past. She has never participated in any type of support program. Choose the correct statement(s). (Select ALL that apply.)

A. Counseling and medication are more effective when used together.
B. There is a strong correlation between counseling intensity and quitting success.
C. Varenicline is the one agent that does not require behavioral support; it is a strong agent and works for most patients without the additional support.
D. Many patients fail with nicotine gum or lozenges because they do not use enough.
E. There are state and federal support programs available to help Beth.

Answer 7

A, B, D, E. Varenicline is a potentially dangerous drug; if used, the patient should be given the option that would increase the chance of success-this means drug plus psychological support, such as individual or group counseling. More counseling, with any method, provides a better chance of success.

Question 8

Which of the following statements is true regarding varenicline use for smoking cessation?

A. Varenicline should be started the day after the patient’s quit date.
B. Varenicline is pregnancy category X.
C. Varenicline should be taken with food and a full glass of water.
D. Varenicline is not associated with any gastrointestinal side effects.
E. Varenicline has a boxed warning for seizure risk.

Answer 8

C.

Question 9

Max is starting smoking cessation and is going to use the 4 mg gum. How much should he use initially?

A. At least 1 piece of gum every 1-2 hours during the start of therapy (for the 1st 6 weeks)
B. At least 1 piece of gum every 30 minutes during the start of therapy (for the 1st 6 weeks)
C. At least 1 piece of gum every 2-4 hours during the start of therapy (for the 1st 6 weeks)
D. At least 10 pieces of gum every 30 minutes every 1-2 hours during the start of therapy (for the 1st 6 weeks)
E. At least 2 pieces of gum every 1-2 hours during the start of therapy (for the 1st 6 weeks)

Answer 9

A. Patients often do not use enough gum to obtain optimal clinical effects. Instruct the patient to use at least 1 piece of gum every 1-2 hours during the start of therapy (for the 1st 6 weeks), then 1 piece of gum every 2-4 hours for 3 weeks, then 1 piece of gum every 4-8 hours for the last three weeks.

Question 10

Which of the following smoking cessation therapies works by reducing nicotine craving by blocking reuptake of dopamine and reducing withdrawal symptoms by blocking norepinephrine reuptake?

A. Bupropion
B. Nicotine inhaler
C. Varenicline
D. Nicotine patch
E. Nicotine lozenge

Answer 10

A.

Question 11

Which of the following smoking-cessation products should be avoided in those that drive or operate heavy machinery such as pilots, truck drivers?

A. Habitrol
B. Nicotrol NS
C. Chantix
D. Nicorette
E. Nicoderm

Answer 11

C. Avoid use in pilots, air traffic controllers, commercial truckers and bus drivers. Chantix can impair the operator’s ability to safely direct the vehicle/s or direct air traffic, and lapse in these professions can cause significant danger to others.

Question 12

Which of the following agents would be useful for a patient who needs to treat both depression and a smoking addiction? (Select ALL that apply.)

A. Zyban
B. Elavil
C. Chantix
D. Buproban
E. Zyprexa

Answer 12

A, D. Do not use Zyban/Buproban and other forms of bupropion together-they are the same drug.

Question 13

HG is a 17 year old female who is interested in smoking cessation. She asks about starting on nicotine gum. What advice should the pharmacist offer?

A. Encourage her to start behavioral counseling first.
B. Encourage her to start behavioral counseling and the nicotine gum at the same time (to improve success rate).
C. Encourage her to start behavioral counseling, nicotine gum and bupropion at the same time (to improve success rate).
D. Encourage her to start behavioral counseling, nicotine gum and varenicline at the same time (to improve success rate).
E. She is a good candidate for the nicotine gum.

Answer 13

A. FDA prohibits sale of nicotine products to individuals younger than 18 years of age (REMS).

Question 14

What are the most common side effects of varenicline therapy?

A. Dry mouth and blurry vision
B. Rash and itching
C. Sedation and dizziness
D. Nausea and abnormal dreams
E. Increased serum creatinine and hypotension

Answer 14

D. Nausea, insomnia and abnormal dreams are a few common side effects of varenicline.

Question 15

Chantix has a boxed warning for this serious, possible adverse effect:

A. Pancreatitis
B. Gallstones
C. Acute renal failure with oliguria
D. Serious psychiatric events including depression and suicide
E. Liver failure

Answer 15

D. Serious neuropsychiatric events including depression, suicidal ideation, suicide attempt and completed suicide have been reported in patients taking Chantix. Instructions should include directions to stop taking the medication if they become hostile, agitated, depressed, or have changes in behavior or thinking that are not typical.

Question 16

Bert, who smokes an average of 8 cigarettes per day for the last year, is interested in smoking cessation. He’s interested in using the patch. What dose would you recommend for him?

A. Use 21 mg/24 hr patch for 6 weeks, then the 14 mg/24 hr patch for 4 weeks, then 7 mg/24 hr patch for 4 weeks
B. Use 21 mg/24 hr patch for 6 weeks, then the 14 mg/24 hr patch for 2 weeks, then 7 mg/24 hr patch for 2 weeks
C. Use 14 mg/24 hr patch for 6 weeks, then 7 mg/24 hr patch for 4 weeks
D. Use 14 mg/24 hr patch for 6 weeks, then 7 mg/24 hr patch for 2 weeks
E. Use 7 mg/24 hr patch for 6 weeks

Answer 16

D.

If >10 cigs/day: 21mg x 6wk, then 14mg x 2wk, then 7mg x 2wk

If ≤10 cigs/day: 14mg x 6kk, then 7mg x 2wk

Question 17

Frank is prescribed Chantix for smoking cessation. What is the generic name of Chantix?

A. Bupropion
B. Varenicline
C. Cilostazol
D. Ciclesonide
E. Vardenafil

Answer 17

B. The generic name of Chantix is varenicline.

Question 18

Which of the following products is/are available over-the-counter? (Select ALL that apply.)

A. Nicotine gum
B. Nicotine lozenge
C. Nicotine patch
D. Nicotine inhaler
E. Nicotine nasal spray

Answer 18

A, B, C. Nicotine gum, lozenge, and patch are all available OTC. Spray and inhalers are Rx only.

Question 19

Which of the following drug levels would increase in a patient who stops smoking?

A. Lopid
B. Zyprexa
C. Klonopin
D. Geodon
E. Abilify

Answer 19

B. Smoking induces the metabolism of caffeine, theophylline, olanzapine and clozapine–and some other agents. If a patient suddenly stopped smoking but continued to take either of these, the concentration would increase as the induction effect wore off.

Question 20

Max smokes 1.5 to 2 packs of cigarettes per day. What strength of gum should he use at the initiation of nicotine replacement therapy?

A. 8 mg gum pieces
B. 6 mg gum pieces
C. 4 mg gum pieces
D. 3 mg gum pieces
E. 1 mg gum pieces

Answer 20

C. If less than 25 cigarettes daily, use the 2 mg gum. If more than 25 cigarettes daily, use the 4 mg gum.

Question 21

Max’s doctor has advised him to use the nicotine patch with the gum. Why did the doctor offer this advice to use a combination of nicotine products? (Select ALL that apply.)

A. Higher chance of success
B. Less tachycardia
C. Less nighttime insomnia
D. He should not have. This is terrible advice.
E. The gum may be useful to control breakthrough cravings that occur with the patch.

Answer 21

A, E. Using the combination of the nicotine patch with either the gum, nasal spray or the lozenge will work better than just one form of nicotine replacement alone.

Question 22

Benjamin is a 50 year male who has stopped smoking since starting the nicotine patch two weeks ago but now complains of insomnia. What advice should the pharmacist offer?

A. Inform him that insomnia is a temporary side effect and will go away with time.
B. Advise him to wear the patch during waking hours (for 16 hours, instead of 24 hours).
C. Advise him to cut the patch in half and wear each portion for 12 hours (to decrease amount of drug in his system).
D. Advise him to place the patches further away from his head such as his legs.
E. Inform him that this is not an expected side effect; this is due to normal smoking withdrawal.

Answer 22

B. The patches should not be cut.

Question 23

Which of the following products simulates a “hand-to-mouth” movement and can be useful for patients who wish to repeat a hand-to-mouth habit?

A. Nicotine gum
B. Nicotine patch
C. Nicotine inhaler
D. Nicotine nasal spray
E. Bupropion

Answer 23

C. The nicotine inhaler is ideal for someone who wishes to repeat a hand to mouth habit.

Question 24

A patient asks the pharmacist for advice on using the Nicorette lozenge. She states that she doesn’t feel much benefit after using one. The pharmacist asks how the patient uses the lozenge, and the patient replies she chews it and swallows it. Which of the following counseling statements for the lozenge is correct?

A. The lozenges should be used in combination with Chantix.
B. A prescription will be required if the patient wishes to use this beyond 2 weeks.
C. Use 1 lozenge every 1-2 hours during the first 6 weeks of treatment.
D. Do not eat or drink anything other than water for 15 minutes before or during the lozenge.
E. Dissolve the lozenge in the mouth; do not chew.

Answer 24

C, D, E. The lozenge should be allowed to dissolve in the mouth rather than chewing or swallowing it. Acidic beverages (e.g., coffee, juices, soft drinks) interfere with the buccal absorption of nicotine, so eating and drinking anything except water should be avoided for 15 minutes before or during use of the nicotine lozenge. Patients often do not use enough nicotine replacement medications to obtain a good response. Use 1 lozenge every 1-2 hours during the first 6 weeks of treatment, with a minimum of 9 lozenges daily, then decrease over time.

Question 25

Max smokes so often that he smells like an ash-tray. His family has been begging him to quit and Max finally seems ready to apply himself seriously to this effort. He has agreed to use the gum as he thinks he must have something in his mouth to replace the cigarette. Which of the following counseling statements concerning the nicotine gum are correct?

A. Chew slowly until a “flavored” taste emerges, then “park” the gum between the cheek and gum.
B. To increase the chance of his quit attempt, Max should combine the gum with varenicline.
C. Max can drink diet soda while using the gum, if desired.
D. Use a piece of gum every 30 minutes.
E. Max should use a maximum of 12 pieces of gum per day.

Answer 25

A. Acidic beverages (e.g., coffee, juices, soft drinks) interfere with the buccal absorption of nicotine, so eating and drinking anything except water should be avoided for fifteen minutes before or during chewing. Varenicline should not be used in combination with NRT.