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CDM1 > Exam 3: Smoking Cessation > Flashcards

Exam 3: Smoking Cessation Flashcards

1
Q

5 A’s of Smoking Cessation

A 
Ask - identify users 
Advise - encourage quitting
Assess - willingness
Assist - aid
Arrange - f/u
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2
Q

T/F: You should encourage strict dieting when quitting smoking

A

False - encourage healthful diet and meal planning, increase water intake or chew sugarless gum, non-food rewards

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3
Q

On avg, quitters gain ___lbs

A

9-11lbs

  • smoking can cause dullness in taste buds? nicotine appetite suppressant?
  • Oral fixation replaced with snacking?
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4
Q

How long do withdrawal symptoms last?

A

start first 1-2 days, peak within first week

Most pass within 2-4 weeks after quitting, cravings can last longer (months-years)

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5
Q

How should patients deal with smoking after meals?

A

Need to disassociate behaviors

  • immediately get up from table
  • brush teeth
  • take short walk
  • call a supportive friend
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6
Q

T/F: Smoking tobacco is the only harmful form of tobacco

A

False - all forms of tobacco are harmful

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7
Q

How many cigarettes in a pack

A

20 cigs/pack

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8
Q

How many packs in a carton?

A

10 packs/carton, 200 cigs/carton

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9
Q

Machine measured Average nicotine yield per cig?

A

0.9mg

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10
Q

Machine Measured Full-flavor (regular) nicotine yield per cig?

A

1.1mg

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11
Q

Machine measured Light nicotine yield per cig?

A

0.8mg

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12
Q

Machine measured Ultra-light nicotine yield per cig?

A

0.4mg

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13
Q

Smoker’s nicotine yield per cig

A

1-2mg

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14
Q

Total nicotine content per cig

A

avg 13.5mg (range 11.9-14.5mg)

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15
Q

E-cig liquid components

A

Propylene glycol
Glycerin
Flavorings
Nicotine

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16
Q

Potential health risks of e-cig

A

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

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17
Q

T/F: E-cigs are safer alternative to smoking tobacco

A

False - e-cigs not proven to be safe

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18
Q

T/F: Second hand exposure to e-cigs is harmless

A

False - long term safety is unknown

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19
Q

T/F: E-cigs are recommended for treatment purposes

A

False - long-term safety and efficacy data are lacking

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20
Q

Nicotine Absorption: In acidic media

A

Ionized, poorly absorbed across membranes

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21
Q

Nicotine absorption: In Alkaline media

A

Nonionized, well absorbed across membranes

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22
Q

At physiologic pH, ~31% of nicotine is _____

A

Physiologic pH = 7.4

Nonionized –> readily absorbed

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23
Q

Buccal mucosa and nicotine absorption

A

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

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24
Q

Skin and nicotine absorption

A

Nicotine is readily absorbed through intact skin (helpful for transdermal products!)

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25
Q

GI Tract and nicotine absorption

A

Nic well absorbed in small intestine but low bioavailability due to first pass metabolism (why we don’t use nic tabs)

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26
Q

Lung and nicotine absorption

A

Nicotine “distilled” from burning tobacco and carried in tar droplets
pH=7.4, readily absorbed
Large alveolar surface area, extensive capillary system in lungs

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27
Q

How long does it take for nicotine to reach the brain?

A

10-20 seconds

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28
Q

There is a quick spike in ___ plasma conc of nicotine compared to ____

A

Arterial plasma vs venous

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29
Q

T/F: Rapid high levels of plasma conc of nicotine reinforces behavioral act of administration

A

True

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30
Q

Nicotine effects on CNS

A

Pleasure
Arousal, enhance vigilance
Improved task performance (focus)
Anxiety relief

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31
Q

Nicotine effects on CV system

A

Increased HR, CO, BP
Coronary vasoCONSTRICTION
Cutaneous vasoCONSTRICTION

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32
Q

Other nicotine effects

A

Appetite suppression
increased metabolic rate
sk muscle relaxation

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33
Q

Dopamine effects

A

pleasure

appetitie suppression

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34
Q

NE effects

A

arousal, appetite suppression

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35
Q

ACh effects

A

Arousal

cognitive enhanacement

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36
Q

Glutamate effects

A

Learning, memory enhancement

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37
Q

Serotonin effects

A

Mood modulation, appetite suppression

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38
Q

Beta-Endorphin effects

A

Reduction of anxiety and tension

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39
Q

GABA effects

A

reduction of anxiety and tension

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40
Q

Dopamine reward pathway usually stimulated by behaviors we need for survival of our species like …

A

eating, drinking, sex

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41
Q

What is the effect of upregulation of nicotine receptors

A

Tolerance, need more to have same effect

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42
Q

Smokers have an ____ of nicotine receptors

A

upregulation

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43
Q

Withdrawal symptoms

A 
Irritability/frustration/anger
anxiety
difficulty concentrating
restlessness/impatience
depressed mood/depression
insomnia
impaired task performance
increased appetitie
weight gain
cravings
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44
Q

Tobacco smoke and caffeine

A

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)

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45
Q

Tobacco smoke and hormonal contraceptives

A

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
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46
Q

T/F: You can restore original pulmonary function when you quit smoking

A

False – some irreversible damage but can still regain good amount, beneficial at any age

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47
Q

Tobacco dependence: Physiological&raquo_space; solution

A

Addiction to nicotine&raquo_space; medications for cessation

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48
Q

Tobacco dependence: behavioral&raquo_space; treatment

A

Habit of using tobacco&raquo_space; behavior change program

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49
Q

What is QuitKey

A

an assisted taper based on pt’s smoking level

includes telephone counseling support

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50
Q

What is a good telephone counseling quitline

A

1-800-QUIT-NOW

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51
Q

Nonpharmacologic method examples

A 
Cold turkey
Assisted tapers
Formal cessation programs (counseling, self help, group, telephone, web-based) 
Acupuncture
Hypnotherapy
Massage therapy
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52
Q

Brief counseling

A

Ask
Advise
Refer

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53
Q

Smoking cessation pharmacotherapy not recommended for…

A

pregnant smokers (not enough evidence)
smokeless tobacco user (no FDA indication)
Smokers <10 cigs
Adolescents (need rx if <18)

54
Q

NRT products approx. ___ quit rates

A

doubles

55
Q

Components of nicotine gum

A

Resin complex (nicotine, polacrilin)
Sugar-free chewing gum base
Buffering agents to enhance buccal absorption (increase pH)

56
Q

Nicotine gum dosing

A

2mg, 4mg

57
Q

Nicorette

A

Nicotine polacrilex gum

58
Q

Directions for use of nicotine gum

A

Chew slowly, stop chewing when tingle or peppery taste, park between cheek and gum, chew again when tingle/taste stops
~30min/piece

59
Q

Nicotine gum ADE

A 
Mouth and throat irritation
hiccups
Gi complaints (dyspepsia, nausea)
Jaw muscle ache
May stick to dental work
60
Q

Nicotine lozenges dosing

A

2mg, 4mg

61
Q

Components of nicotine lozenges

A

Nicotine polacrilex formulation - delivers ~25% more nicotine than equivalent gum dose
Sugar-free
Buffering agents to enhance buccal absorption of nic

62
Q

Nicotine lozenges direction of use

A

Place in mouth and allow to dissolve slowly (may feel warm/tingly)
Do not chew or swallow
Rotate
takes 20-30min

63
Q

Nicotine lozenges ADE

A

Mouth and throat irritation
Hiccups
GI complaints (dyspepsia, nausea)

64
Q

Choosing dosing for gum/lonzenges

A

Time to first cigarette (TTFC)
2mg - if cig >30min after waking
4mg - if cig ≤30min within waking

65
Q

Gum/lozenges dosing schedule

A

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

66
Q

Max pieces of gum/day

A

24 pieces

67
Q

Max pieces of lozenges/day

A

20 lozenges

68
Q

Effectiveness of nicotine gum/lozenges may be reduced by foods/beverages …

A

coffee, wine, juices, soft drinks

69
Q

Do not eat/drink ____ before or while using gum/lozenges

A

15 min before

70
Q

Chewing lozenges or incorrect gum chewing technique can cause excessive/rapid release of nicotine which may cause side effects of …

A

lightheadedness/dizziness
N/V
Hiccups
Irritation of throat and mouth

71
Q

Advantages of gum/lozenges

A

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

72
Q

Disadvantages of gum/lozenges

A

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

73
Q

Nicotine transdermal patch examples

A

Generic

NicoDerm CQ

74
Q

Advantages of transdermal patch

A 
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)
75
Q

Disadvantages of transdermal patch

A

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

76
Q

Nicotine transdermal dosing: Light smoker ≤10cigs/day

A 
Step 2 (14mg x 6weeks)
Step 3 (7mg x2weeks)
77
Q

Nicotine transdermal dosing: Heavy smoker >10cigs/day

A 
step 1 (24mg x6 weeks for brand, x4 weeks for generic) 
Step 2 (14mg x2 weeks)
Step 3 (7mg x2 weeks)
78
Q

Pt counseling for transdermal patches

A

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

79
Q

T/F: You can cut nicotine patches in half to save money

A

False - unpredictable nicotine delivery

80
Q

Please remove nicotine patch before ___

A

MRI procedures

81
Q

If applied correctly, you can ___ with nicotine patch

A

bathe, swim, shower, and exercise

82
Q

ADE Nicotine patches

A 
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)
83
Q

Nicotine inhaler absorbed by ___

A

Mostly buccal mucosa, little absorbed in lungs

84
Q

Advantages of nicotine inhaler

A

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

85
Q

Disadvantages of nicotine inhaler

A

Need for freq dosing (adherence)
Cartridges may be less effective in cold
cost of treatment

86
Q

Nicotine inhaler ADE

A

Mild irritation of mouth/throat
cough
hiccups
GI complaints (dyspepsia, nausea)

*severity generally rated as mild, frequency declines with continued use

87
Q

Counseling pts for nicotine inhaler

A

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

88
Q

Nicotine Nasal Spray examples

A

Nicotrol NS

89
Q

Nicotine Inhaler exampels

A

Nicotrol

90
Q

Nicotine nasal spray doses/bottle

A

100 doses/bottle (1 dose = 2 sprays (1 per nostril = 200 sprays/bottle)

91
Q

Advantages of nasal spray

A

Can be titrated to rapidly manage withdrawal symptoms

Can be used in combo with other agents

92
Q

Disadvantages of nasal spray

A

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

93
Q

T/F: You can blow your nose right after using nasal spray

A

False - wait 2-3 min before blowing nose

94
Q

T/F: Sniff/inhale as you spray nicotine nasal spray

A

False - do not

95
Q

Pt Counseling for nasal spray

A

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

96
Q

Bupropion SR brand

A

Wellbutrin for antidepressant

Zyban for smoking cessation

97
Q

Non-nicotine cessation aid example

A

Bupropion SR

Varenicline

98
Q

Bupropion SR: MOA

A

Atypical antidepressant through to affect levels of various brain NT like dopamine and NE

99
Q

Clinical effects of bupropion SR

A

Decrease craving for cigs and decrease symptoms of nicotine withdrawal

100
Q

Bupropion absorption

A

Bioavailability 5-20%

101
Q

Bupropion SR metabolism

A

extensive hepatic metabolism (CYP2B6)

102
Q

Bupropion SR elimination

A

urine (87%) and feces (10%)

103
Q

Half-life of bupropion

A

21 hrs

Metabolites (20-37hrs)

104
Q

Advantages of bupropion SR

A 
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)
105
Q

Disadvantages of bupropion SR

A

Seizure risk is increased
Several CI and precautions
Monitor for neuropsychiatric symptoms

106
Q

When should pts begin bupropion SR therapy?

A

1-2 weeks PRIOR to quit date

107
Q

Initial treatment of bupropion SR

A

150mg po qAM for 3 days

108
Q

Maintenance dosing for bupropion SR

A

150mg po bid for 7-12 weeks
Doses at least 8 hrs apart
Tapering not necessary when discontinuing therapy

109
Q

Bupropion SR ADE

A

Insomnia (avoid bedtime dosing)
Dry mouth
Nausea
Less common but reported effects: anxiety/difficulty concentrating, constipation, tremor, skin rash

110
Q

Bupropion SR CI

A

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)

111
Q

Bupropion SR BBW

A

Neuropsychiatric symptoms and suicide risk, later removed in Dec 2016

112
Q

Varenicline brand

A

Chantix

113
Q

Varenicline MOA

A

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

114
Q

Varenicline absorption

A

virtually complete (~90%) after oral admin, not affected by food

115
Q

Varenicline metabolism

A

Minimal metabolism

116
Q

Varenicline elimination

A

Primarily renal thru glomerular filtration and active tubular secretion
92% excreted unchanged in urine

117
Q

Varenicline half life

A

24 hrs

118
Q

Advantages for varenicline

A

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

119
Q

Disadvantages for varenicline

A

Cost of treatment

Monitor pts for potential neuropsychiatric symptoms

120
Q

Which cessation agent is most effective as monotherapy?

A

Varenicline

121
Q

Varenicline Day 1-3 dosing

A

0.5mg qd

122
Q

Varenicline Day 4-7 dosing

A

0.5mg BID

123
Q

Varenicline Day 8-last day (up to 12 weeks)

A

1mg BID

124
Q

3 approaches to varenicline

A

Fixed quit, flexible quit, gradual quit

125
Q

Fixed quit approach for varenicline

A

Set quit date for 1 week after starting varenicline

Continue treatment for 12 weeks

126
Q

Flexible quit approach for varenicline

A

start taking varenicline and pick quit date between 8-35 days from treatment initiation
Continue for 12 weeks

127
Q

Gradual quit approach for varenicline

A

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

128
Q

Varenicline ADE

A

Nausea, insomnia, abnormal dreams, headache

Less common: GI (flatulence, constipation), taste alteration

129
Q

Varenicline BBW

A

Neuropsychiatric symptoms and suicide risk, later removed

130
Q

Pt Counseling for varenicline

A

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

131
Q

Combo NRT

A

Long-acting (patch) + short-acting (Gum, inhaler. lozenge, nasal spray)

Bupropion SR + nicotine patch (1.5x likelihood of sustained quit)

132
Q

Compare cessation options

A

Combo NRT and varenicline are more effective than bupropion SR or NRT monotherapy

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