Exam 3: Smoking Cessation Flashcards
5 A’s of Smoking Cessation
Ask - identify users Advise - encourage quitting Assess - willingness Assist - aid Arrange - f/u
T/F: You should encourage strict dieting when quitting smoking
False - encourage healthful diet and meal planning, increase water intake or chew sugarless gum, non-food rewards
On avg, quitters gain ___lbs
9-11lbs
- smoking can cause dullness in taste buds? nicotine appetite suppressant?
- Oral fixation replaced with snacking?
How long do withdrawal symptoms last?
start first 1-2 days, peak within first week
Most pass within 2-4 weeks after quitting, cravings can last longer (months-years)
How should patients deal with smoking after meals?
Need to disassociate behaviors
- immediately get up from table
- brush teeth
- take short walk
- call a supportive friend
T/F: Smoking tobacco is the only harmful form of tobacco
False - all forms of tobacco are harmful
How many cigarettes in a pack
20 cigs/pack
How many packs in a carton?
10 packs/carton, 200 cigs/carton
Machine measured Average nicotine yield per cig?
0.9mg
Machine Measured Full-flavor (regular) nicotine yield per cig?
1.1mg
Machine measured Light nicotine yield per cig?
0.8mg
Machine measured Ultra-light nicotine yield per cig?
0.4mg
Smoker’s nicotine yield per cig
1-2mg
Total nicotine content per cig
avg 13.5mg (range 11.9-14.5mg)
E-cig liquid components
Propylene glycol
Glycerin
Flavorings
Nicotine
Potential health risks of e-cig
Propylene glycol may cause respiratory irritation (increased risk of asthma)
Glycerin may cause lipoid pneumonia on inhalation
Nicotine is highly addictive (refill carts with high conc of nic are poisoning risk)
Carcinogens
T/F: E-cigs are safer alternative to smoking tobacco
False - e-cigs not proven to be safe
T/F: Second hand exposure to e-cigs is harmless
False - long term safety is unknown
T/F: E-cigs are recommended for treatment purposes
False - long-term safety and efficacy data are lacking
Nicotine Absorption: In acidic media
Ionized, poorly absorbed across membranes
Nicotine absorption: In Alkaline media
Nonionized, well absorbed across membranes
At physiologic pH, ~31% of nicotine is _____
Physiologic pH = 7.4
Nonionized –> readily absorbed
Buccal mucosa and nicotine absorption
pH = 7.0
Acidic - cigarettes
Alkaline - pipes, cigars, spit tobacco, oral nicotine products (even if not inhaling, nic is absorbed)
*beverages can alter pH, alter absorption
Skin and nicotine absorption
Nicotine is readily absorbed through intact skin (helpful for transdermal products!)
GI Tract and nicotine absorption
Nic well absorbed in small intestine but low bioavailability due to first pass metabolism (why we don’t use nic tabs)
Lung and nicotine absorption
Nicotine “distilled” from burning tobacco and carried in tar droplets
pH=7.4, readily absorbed
Large alveolar surface area, extensive capillary system in lungs
How long does it take for nicotine to reach the brain?
10-20 seconds
There is a quick spike in ___ plasma conc of nicotine compared to ____
Arterial plasma vs venous
T/F: Rapid high levels of plasma conc of nicotine reinforces behavioral act of administration
True
Nicotine effects on CNS
Pleasure
Arousal, enhance vigilance
Improved task performance (focus)
Anxiety relief
Nicotine effects on CV system
Increased HR, CO, BP
Coronary vasoCONSTRICTION
Cutaneous vasoCONSTRICTION
Other nicotine effects
Appetite suppression
increased metabolic rate
sk muscle relaxation
Dopamine effects
pleasure
appetitie suppression
NE effects
arousal, appetite suppression
ACh effects
Arousal
cognitive enhanacement
Glutamate effects
Learning, memory enhancement
Serotonin effects
Mood modulation, appetite suppression
Beta-Endorphin effects
Reduction of anxiety and tension
GABA effects
reduction of anxiety and tension
Dopamine reward pathway usually stimulated by behaviors we need for survival of our species like …
eating, drinking, sex
What is the effect of upregulation of nicotine receptors
Tolerance, need more to have same effect
Smokers have an ____ of nicotine receptors
upregulation
Withdrawal symptoms
Irritability/frustration/anger anxiety difficulty concentrating restlessness/impatience depressed mood/depression insomnia impaired task performance increased appetitie weight gain cravings
Tobacco smoke and caffeine
PAH induces CYP1A2, metabolizes caffeine more (caffeine levels increase when you quit, may experience insomnia, recommend to decrease caffeine 50% and no caffeine after 1pm)
Tobacco smoke and hormonal contraceptives
smokes who use combined hormonal contraceptives have increased risk of stroke, MI, thromboembolism
- esp if ≥35yo and smoke at least 15 cigs/day
- does not decrease effect of contraceptives
T/F: You can restore original pulmonary function when you quit smoking
False – some irreversible damage but can still regain good amount, beneficial at any age
Tobacco dependence: Physiological»_space; solution
Addiction to nicotine»_space; medications for cessation
Tobacco dependence: behavioral»_space; treatment
Habit of using tobacco»_space; behavior change program
What is QuitKey
an assisted taper based on pt’s smoking level
includes telephone counseling support
What is a good telephone counseling quitline
1-800-QUIT-NOW
Nonpharmacologic method examples
Cold turkey Assisted tapers Formal cessation programs (counseling, self help, group, telephone, web-based) Acupuncture Hypnotherapy Massage therapy
Brief counseling
Ask
Advise
Refer
Smoking cessation pharmacotherapy not recommended for…
pregnant smokers (not enough evidence)
smokeless tobacco user (no FDA indication)
Smokers <10 cigs
Adolescents (need rx if <18)
NRT products approx. ___ quit rates
doubles
Components of nicotine gum
Resin complex (nicotine, polacrilin)
Sugar-free chewing gum base
Buffering agents to enhance buccal absorption (increase pH)
Nicotine gum dosing
2mg, 4mg
Nicorette
Nicotine polacrilex gum
Directions for use of nicotine gum
Chew slowly, stop chewing when tingle or peppery taste, park between cheek and gum, chew again when tingle/taste stops
~30min/piece
Nicotine gum ADE
Mouth and throat irritation hiccups Gi complaints (dyspepsia, nausea) Jaw muscle ache May stick to dental work
Nicotine lozenges dosing
2mg, 4mg
Components of nicotine lozenges
Nicotine polacrilex formulation - delivers ~25% more nicotine than equivalent gum dose
Sugar-free
Buffering agents to enhance buccal absorption of nic
Nicotine lozenges direction of use
Place in mouth and allow to dissolve slowly (may feel warm/tingly)
Do not chew or swallow
Rotate
takes 20-30min
Nicotine lozenges ADE
Mouth and throat irritation
Hiccups
GI complaints (dyspepsia, nausea)
Choosing dosing for gum/lonzenges
Time to first cigarette (TTFC)
2mg - if cig >30min after waking
4mg - if cig ≤30min within waking
Gum/lozenges dosing schedule
1-6 weeks 1 piece q1-2h
7-9weeks 1 piece q2-4h
10-12 weeks 1 piece q4-8h
*to increase changes of quitting use at least 9 pieces/day during first 6 weeks
Max pieces of gum/day
24 pieces
Max pieces of lozenges/day
20 lozenges
Effectiveness of nicotine gum/lozenges may be reduced by foods/beverages …
coffee, wine, juices, soft drinks
Do not eat/drink ____ before or while using gum/lozenges
15 min before
Chewing lozenges or incorrect gum chewing technique can cause excessive/rapid release of nicotine which may cause side effects of …
lightheadedness/dizziness
N/V
Hiccups
Irritation of throat and mouth
Advantages of gum/lozenges
Might serve as oral sub for tobacco
Might delay weight gain
Can be titrated to manage withdrawal symptoms
Can be used in combination with other agents to manage situational urges
Relatively inexpensive
Disadvantages of gum/lozenges
Need frequent dosing (adherence)
GI adverse effects may be bothersome
Specific to gum - might be problematic for pts w sig dental work, proper chewing technique required, chewing might not be acceptable/desirable for some pts
Nicotine transdermal patch examples
Generic
NicoDerm CQ
Advantages of transdermal patch
once-daily dosing (adherence) Less obvious NRT product option Can be used in combo with other agents, delivers consistent nicotine levels over 24 hrs Relatively inexpensive (OTC, usually covered by insurance)
Disadvantages of transdermal patch
When used as monotherapy, cannot be titrated to acutely manage withdrawal (short acting use like gum/lozenges is better)
Not recommended for pts with dermatologic conditions
Nicotine transdermal dosing: Light smoker ≤10cigs/day
Step 2 (14mg x 6weeks) Step 3 (7mg x2weeks)
Nicotine transdermal dosing: Heavy smoker >10cigs/day
step 1 (24mg x6 weeks for brand, x4 weeks for generic) Step 2 (14mg x2 weeks) Step 3 (7mg x2 weeks)
Pt counseling for transdermal patches
Choose area of skin on upper body or upper outer part of arm
Make sure skin is clean, dry, hairless, and not irritated
Apply to different area each day (do not repeat area for at least 1 week)
Wash hands (nicotine on hands can irritate eyes/nose
Do not leave for over 24 hrs (can cause irritation)
Remove sticky residue with alc or acetone
Fold patch onto itself when throwing out
T/F: You can cut nicotine patches in half to save money
False - unpredictable nicotine delivery
Please remove nicotine patch before ___
MRI procedures
If applied correctly, you can ___ with nicotine patch
bathe, swim, shower, and exercise
ADE Nicotine patches
Irritation at patch application site (itching, burning, tingling) Sleep disturbances (remove before bedtime if so -- abnormal/vivid dreams, insomnia) Skin may be red when you remove (if longer than 4 days or swell/rash then might be allergic)
Nicotine inhaler absorbed by ___
Mostly buccal mucosa, little absorbed in lungs
Advantages of nicotine inhaler
Might serve as oral sub for tobacco
Can be titrated to manage withdrawal symptoms
Mimics hand to mouth
Can be used in combo with other agents
Disadvantages of nicotine inhaler
Need for freq dosing (adherence)
Cartridges may be less effective in cold
cost of treatment
Nicotine inhaler ADE
Mild irritation of mouth/throat
cough
hiccups
GI complaints (dyspepsia, nausea)
*severity generally rated as mild, frequency declines with continued use
Counseling pts for nicotine inhaler
Use inhaler at room temp (>60F)
Use inhaler longer and more often at first to control cravings (freq continuous puffing over 20 min)
Effectiveness of nicotine inhaler may be reduced by some foods/bevs (absorbed via buccal)
Do not eat/drink 15min before or during use
Nicotine Nasal Spray examples
Nicotrol NS
Nicotine Inhaler exampels
Nicotrol
Nicotine nasal spray doses/bottle
100 doses/bottle (1 dose = 2 sprays (1 per nostril = 200 sprays/bottle)
Advantages of nasal spray
Can be titrated to rapidly manage withdrawal symptoms
Can be used in combo with other agents
Disadvantages of nasal spray
Need for freq dosing (adherence)
Nasal admin might not be acceptable/desirable for some pts (nasal irritation often problematic)
Not recommended for pts with chronic nasal disorders or severe reactive airway disease
Cost of treatment
T/F: You can blow your nose right after using nasal spray
False - wait 2-3 min before blowing nose
T/F: Sniff/inhale as you spray nicotine nasal spray
False - do not
Pt Counseling for nasal spray
1st week - hot peppery feeling in back of throat or nose, sneezing, coughing, watery eyes, runny nose
ADE lessen over few days (regular use during first week helps tolerance of irritant effects)
If ADE persist after a week, contact PCP for alternative
Bupropion SR brand
Wellbutrin for antidepressant
Zyban for smoking cessation
Non-nicotine cessation aid example
Bupropion SR
Varenicline
Bupropion SR: MOA
Atypical antidepressant through to affect levels of various brain NT like dopamine and NE
Clinical effects of bupropion SR
Decrease craving for cigs and decrease symptoms of nicotine withdrawal
Bupropion absorption
Bioavailability 5-20%
Bupropion SR metabolism
extensive hepatic metabolism (CYP2B6)
Bupropion SR elimination
urine (87%) and feces (10%)
Half-life of bupropion
21 hrs
Metabolites (20-37hrs)
Advantages of bupropion SR
Oral dosing is simple, associated with fewer adherence problems Might delay weight gain Might benefit pts with depression? Can be used in combo with NRT agents Relatively inexpensive (generic)
Disadvantages of bupropion SR
Seizure risk is increased
Several CI and precautions
Monitor for neuropsychiatric symptoms
When should pts begin bupropion SR therapy?
1-2 weeks PRIOR to quit date
Initial treatment of bupropion SR
150mg po qAM for 3 days
Maintenance dosing for bupropion SR
150mg po bid for 7-12 weeks
Doses at least 8 hrs apart
Tapering not necessary when discontinuing therapy
Bupropion SR ADE
Insomnia (avoid bedtime dosing)
Dry mouth
Nausea
Less common but reported effects: anxiety/difficulty concentrating, constipation, tremor, skin rash
Bupropion SR CI
Pts with seizure disorder (lower seizure threshold)
Pts with bulimia or anorexia nervosa (electrolyte abnormality can lead to seizure)
Pt undergoing abrupt d/c of alc, benzos, barbiturates, and antiepileptic drugs
MAOi (within 14 days of initiating or d/c therapy)
Bupropion SR BBW
Neuropsychiatric symptoms and suicide risk, later removed in Dec 2016
Varenicline brand
Chantix
Varenicline MOA
Partial nicotinic receptor agonist
Competitively inhibits binding of nic
Decreases symptoms of nicotine withdrawal
Blocks dopaminergic stimulation responsible for reinforcement and reward associated with smoking
Varenicline absorption
virtually complete (~90%) after oral admin, not affected by food
Varenicline metabolism
Minimal metabolism
Varenicline elimination
Primarily renal thru glomerular filtration and active tubular secretion
92% excreted unchanged in urine
Varenicline half life
24 hrs
Advantages for varenicline
Oral dosing is simple (less adherence problems)
Offers diff MOA for pts who failed other agents
Most effective agent for cessation when used as monotherapy
Disadvantages for varenicline
Cost of treatment
Monitor pts for potential neuropsychiatric symptoms
Which cessation agent is most effective as monotherapy?
Varenicline
Varenicline Day 1-3 dosing
0.5mg qd
Varenicline Day 4-7 dosing
0.5mg BID
Varenicline Day 8-last day (up to 12 weeks)
1mg BID
3 approaches to varenicline
Fixed quit, flexible quit, gradual quit
Fixed quit approach for varenicline
Set quit date for 1 week after starting varenicline
Continue treatment for 12 weeks
Flexible quit approach for varenicline
start taking varenicline and pick quit date between 8-35 days from treatment initiation
Continue for 12 weeks
Gradual quit approach for varenicline
Start taking varenicline and reduce smoking by 50% within first 4 weeks, an additional 50% in next 4 weeks, and continue until complete abstinence by 12 weeks
Varenicline ADE
Nausea, insomnia, abnormal dreams, headache
Less common: GI (flatulence, constipation), taste alteration
Varenicline BBW
Neuropsychiatric symptoms and suicide risk, later removed
Pt Counseling for varenicline
Doses should be taken after eating with a full glass of water
Nausea and insomnia are usually temporary (if persistent, contact PCP)
May experience vivid, unusual, strange dreams during treatment
Use caution driving, drinking alc, and operating machinery until effects of quitting smoking with varenicline are known
Combo NRT
Long-acting (patch) + short-acting (Gum, inhaler. lozenge, nasal spray)
Bupropion SR + nicotine patch (1.5x likelihood of sustained quit)
Compare cessation options
Combo NRT and varenicline are more effective than bupropion SR or NRT monotherapy
