Nicotine Dependence

Question 1

nicotine delivery to brain

Answer 1

delivered to brain via smoking in 10 seconds

Question 2

nicotine stimulates which receptors?

Answer 2

stimulates CNS nAch receptors –> DA release

repeated use –> more receptors –> tolerance

Question 3

nicotine w/d sx

Answer 3

nicotine craving
irritability/anger/impatience
restlessness
difficulty concentrating
insomnia
anxiety
depressed mood
increased appetite

Question 4

pharmacologic addiction to nicotine vs. physiological dependence on smoking

Answer 4

physiological dependence

behavioral cues (meals)

coping w/ stress, emotions (anger)

Question 5

smoking populations (show less progress compared to general decreasing smoking trend in US)

Answer 5

Low SES (below poverty level: 29%; Medicaid: 25%)
Low educational attainment (GED: 41%; Less than HS: 24%)
People with psychological distress (36%)
Chronically homeless (80%)
LGBT persons (27%)
People living with HIV (42%)
American Indian, Alaska Natives (32%)

Question 6

common causes of death attributable to tobacco use (starting w/ most common)

Answer 6

lung cancer
ischemic heart disease
COPD
other 
stroke
other cancers

Question 7

second hand smoke exposure effects on adult nonsmokers

Answer 7

Lung cancerCoronary heart disease

Question 8

second hand smoke exposure effects on children

Answer 8

SIDS
Acute respiratory and ear infections
Worse asthma
Slowed lung growth

Question 9

buproprion and varenicline contraindications

Answer 9

buproprion and varenicline are not recommended for patients with depression or other psychiatric history and, sometimes, for otherwise healthy patients as they may cause suicidal thoughts (suicidality) and other adverse effects.

Question 10

Are most smokers trying to quit?

Answer 10

Over two thirds of smokers are interested in quitting

Over half have tried to quit in the past year

But fewer than 10% have successfully done so

Only about 30% of smokers used evidence based treatments in their quit attempts

Question 11

smoking cessation methods

Answer 11

pharmacotherapy
behavioral counseling
combination

Question 12

nicotine replacement

Answer 12

gum
skin patch (most effective, fixed dose)
inhaler
lozenge

Question 13

long-acting, slow onset nicotine replacement

Answer 13

Skin patch

Constant nicotine level to avoid withdrawal

Simple to use, best compliance
Fixed dose (start higher if smoking more)

Question 14

short-acting, faster onset

Answer 14

Oral or nasal treatments thru oro/nasal pharyngeal mucosa

Gum, lozenge, inhaler or nasal spray

User controls dose

Nicotine blood levels fluctuate more

Requires more training to use properly

Question 15

tx showing highest chance of quitting

Answer 15

combination NRT (w/ buproprion or varenicline)

Question 16

varenicline (chantix)

Answer 16

Binds selectively to α4β2 nicotinic receptor
–>Subtype that mediates nicotine dependence

DUAL MOA
1. Partial agonist
Stimulates receptor to ↓ craving and withdrawal

2. Antagonist
   Blocks nicotine binding to receptor if smoking

Start 1 week before quit date, so don’t feel reward of the last cigarettes

Question 17

Bupropion (Zyban)

Answer 17

Antidepressant - NE and DA reuptake inhibitor and releasing agent

↓ Cravings for cigarettes
↓ Nicotine withdrawal sx

Consider this in patients worried about weight gain

Question 18

physician intervention for nicotine cessation

Answer 18

Routine advice to quit is effective
Brief counseling is more effective

5As model of Brief counseling
Ask
Advise
Assess
Assist
Arrange

Question 19

Asking about smoking

Answer 19

“Do you smoke?”
or better:
“Do you ever smoke tobacco?”
AND
“Do you live with a smoker?”

Question 20

Advising smokers to stop

Answer 20

“Quitting smoking now is the most important action you can take …”

Firm and clear
Be positive (talk about health benefits, not consequences)
Personalize information about benefits of quitting

Question 21

Assessing readiness to quit

Answer 21

Precontemplation
Contemplation
Preparation
Action

NEWER method: don’t ask if ready, just offer tx.
–> “Quitting smoking can be hard, but there is good treatment and I can help you. Would you like to try?”

Question 22

Assisting smokers interested in quitting

Answer 22

Set a quit date

Offer behavioral tips

Help make a treatment plan

• Offer pharmacotherapy
• Refer to MA Quitline (1-800-QUIT-NOW)

Question 23

Arrange

Answer 23

arrange follow-up soon after quit date

address at next visit

Question 24

electronic cigarettes

Answer 24

heated vapor, deliver nicotine to respiratory tract w/o combustion

not FDA approved

mostly used by current smokers (adults) (vs younger population –> never used conventional cigarettes)