Chapter 36: Tobacco Cessation

Question 1

Which nicotine replacement therapy (NRT) products are available OTC and which are Rx only?

Answer 1

OTC NRT includes nicotine patch, gum, and lozenge. The nicotine inhaler and nasal spray are only available with a prescription.

NRT and other smoking cessation medications aim to reduce withdrawal symptoms associated with decreased nicotine use. Symptoms of withdrawal include: urge to smoke, depressed mood, trouble sleeping, irritability, frustration, anger, anxiety, difficulty concentrating, restlessness, bradycardia, and increased appetite or weight gain.

Question 2

Smoking results in CYP1A2 enzyme:

A. Induction
B. Inhibition
C. no effect on CYP450 enzymes

Answer 2

A. Induction

Compounds in smoke induce hepatic CYP450 enzymes, primarily CYP1A2. If a smoker quits, be careful of medications metabolized by 1A2 since they will be less metabolized b/c the inducer is now gone, resulting in higher concentration of medications and potential SE. Some common CYP1A2 substrates are theophylline, caffeine, clozapine, olanzapine (Zyprexa®), zolmitriptan, frovatriptan, amitriptyline (Elavil®), notriptyline (Pamelor®), Fluvoxamine (Luvox®), mirtazepine (Remeron®), tizanidine (Zanaflex®), and melatonin

Question 3

Which vaccinations are recommended for all smokers greater than 19 y/o?

Answer 3

1. annual influenza
2. PPSV23 (Pneumovax®) for every smoker 19-64y/o. If 65 or older and its been more than 5 years since last PPSV23, a 2nd dose is needed.

Question 4

In smokers using greater than 10 cigarettes/day who want to quit, which patch should they start with, for how long, and what will be the total treatment duration? Will they use the same patch for the entire treatment duration?

Answer 4

Smokers using greater than 10 cigarettes/day will use a nicotine patch for a total of 10 weeks treatment duration. Patient will apply the 21mg/day patch when they wake up on the morning if their quit date, applying a new patch every morning x6 weeks. Then change to 14mg/day x2 weeks, then change to 7mg/day x2 weeks.

Question 5

Which of the following are contraindications to NRT? (Select all that apply)

A. Recent MI (within 2 months)
B. Life-threatening arrhythmia
C. Worsening angina
D. CKD
E. Pregnancy

Answer 5

B, C, and E are correct.

NRT is contraindicated in patients who recently had an MI (within 2 weeks, not 2 months), life-threatening arrhythmia, severe or worsening angina, and pregnancy. CKD is not a CI

Question 6

Name some common SE from NRT?

Answer 6

1. HA
2. insomnia
3. dyspepsia
4. dizziness
5. nervousness

Question 7

T/F:

Patients purchasing NRT must be greater than or equal to 18 y/o?

Answer 7

True

Question 8

Which of the following statements are correct? (Select all that apply)

A. Nicotine gum has been shown to reduce weight gain associated with quitting smoking
B. Avoid coffee and soda for 15 min before and during nicotine gum, lozenge, and inhaler use
C. Quitting smoking may increase the risk of bleeding in patients concomitantly taking warfarin
D. Nicotine patches do not need to be removed prior to MRI
E. Maximum pieces of nicotine gum/day is 20 pieces

Answer 8

A, B, C are correct

Patient using nicotine gum, lozenge, or inhaler must avoid acidic beverages like coffee, soda, and fruit juices due to altered buccal absorption of nicotine. Smoking is an enzyme inducer, primarily 1A2, but can also affect other CYPenzymes. Warfarin is primarily metabolized by 2C9, but is also metabolized by 3A4 and 1A2.

D and E are incorrect
Nicotine patches must be removed prior to MRI and the max pieces of gum/day is 24 pieces. Max number of lozenges/day is 20

Question 9

What is the MOA of Zyban® thought to reduce cravings and nicotine withdrawal symptoms?

Answer 9

Bupropion (Zyban®) blocks neural re-uptake of dopamine and/or NE.

Question 10

What are the (2) most common AE of bupropion?

Answer 10

1. dry mouth

2. insomnia

Question 11

What is the (1) most common AE of Chantix®?

Answer 11

Varenicline (Chantix®) causes nausea in about 30% of patients and is dose dependent

Question 12

Which of the following statements are correct? (Select all that apply)

A. Proper use of nicotine nasal spray does not include sniffing, swallowing, or inhaling
B. Patients who experience insomnia from the nicotine patch should discontinue use and try a different NRT or medication
C. Park nicotine gum between cheek and gum for about 30 minutes
D. Take varenicline on an empty stomach to decrease incidence of nausea
E. Patient can continue to smoke after starting Buproban®

Answer 12

A, C, and E are correct
Patients should not sniff, swallow, or inhale through the nose while administering dose b/c this increases irritating effects of the nasal spray. Patient should lean head slightly forward for best delivery. Bupropion and varenicline are both started 1 week before patient’s quit date to allow medication to build up in their system. During this 1st week, the patient can continue to use tobacco

B and D are incorrect
Insomnia is one of the AE of NRT. If this becomes an issue, remove the patch prior to bedtime, or use the 16-hr patch, but don’t give up! Varenicline should be taken with food or after a meal with a full 8oz of water to decrease incidence of nausea, NOT on an empty stomach