Smoking Flashcards
What % of middle-aged smokers die of smoking-related illness?
50%
Why do people smoke?
Initiation - social reasons
Maintenance - pharmacological reasons
Light smokers can be described as…?
Whereas heavy smokers are…?
peak seekers
trough maintainers
Over 97% of quit attempts last less than…?
6 months
What % of smokers rarely (if ever) go a day without a cigarette?
Over 95%
How many % resume smoking after a major smoking-related health crisis?
70%
Name some signs of addiction.
Continued use despite knowledge of harmful effects
Withdrawal symptoms and urges to use the drug during abstinence
Failure of attempts to stop
Addiction is a product of... Person Drug Circumstances Explain this further.
Person, e.g. mental health, personality, coping skills, individual biochemistry etc.
Drug, e.g. its reinforcing properties
Circumstances, e.g. lack of alternatives, stress, access to drug, society views, etc.
Why is nicotine addictive?
Mildly pleasant stimulation
Tolerance develops to aversive effects so frequent dosing becomes possible
Neuroadaptation develops.
Sensitisation to dopaminergic effects, increased
density of ACH receptors.
Discomfort if nicotine level is low, sensitivity to cues
Other chemicals in smoke likely to play a role, e.g. MAO inhibitors
Nicotine depletion leads to a gradual increase in …?
How do cigarettes affect this?
This develops the drive to smoke/nicotine hunger.
mild discomfort (irritability, worsening of mood, etc.) Cigarettes alleviate this immediately and so are perceived as attractive and rewarding – illusion of positive effect
Nicotine stimulates ______ receptors in what area of the brain?
This leads to…?
acetylcholine
ventral-tegmental area
dopamine release in nucleus accumbens
What are the main subjective reasons for smoking?
stress relief, boredom relief, enjoyment
What are the main objective measures of smoking benefits?
Smokers weigh less than non-smokers
Smoking may increase vigilance, but no evidence that smokers perform better
Cigarette consumption is a weak indicator of blood nicotine levels. What three things are more important?
Depth of inhalation, number of puffs, and
length of butts left
Name some other ways to measure dependence.
Time to first cigarette in the morning
Carbon monoxide in expired breath
Nicotine in body fluids
How long is nicotine’s half life?
2 hours
How does success differ quitting with and without support?
Relapse rate is similar, but starting from much higher initial quit rate
Name some subjective withdrawal symptoms.
Mood changes, e.g. irritable, depressed, restless.
Difficulty concentrating
Urges to smoke
Increased hunger
How long do the mood changes generally last in withdrawal?
Average duration < 4 weeks
How long does the difficulty concentrating generally last in withdrawal?
< 2 weeks
What is the average weight gain after quitting?
5-6kg
What are some less frequent withdrawal symptoms?
Night-time awakening
Constipation (17%, 9% severe)
Mouth ulcers (40%, 8% severe), respiratory tract
infections
Productive cough (coughing and breathlessness improve within a month)
What are the main objective signs of withdrawal?
Big drop in heart rate
Decrease adrenaline and cortisol output
Decreased tremor
Increased skin temperature
Decreased metabolism of caffeine and other drugs
How does abstinence affect... clomipramine? clozapine? amitriptyline? diazepam? olonzapine?
1, 2 increases
3 does not change
4 unclear
5 increases
How does abstinence affect... ethanol? risperidone? buproprion? lorazepam? haloperidol?
1,2,3,4 does not change
5 increases
What can predict relapse? (3)
Urges to smoke
Depression
Weight gain
Withdrawal symptoms are worse in smokers with…?
high pre-abstinence nicotine intake
What is the rationale behind nicotine replacement therapies?
Abrupt cessation of nicotine intake causes withdrawal discomfort so access to nicotine via alternative routes
provides relief and assists with transition to complete abstinence.
How much nicotine do NRT products provide?
Most current NRT products provide about 50% of the daily intake from smoking.
Nicotine in the doses of NRT is considered harmless. What are the dangers of smoking mainly due to?
combustion products and other chemicals
Is NRT safe?
Yes, particularly compared to smoking
Can NRT cause dependence?
NRT cannot cause new dependence (users are already dependent on nicotine)
Dependence on NRT is more likely with which products?
Faster absorption products
What % of oral NRT users use it at 1 year?
<10%
Nicotine delivery by cigarettes and NRT products - which is the fastest?
Which is the slowest?
Cigarettes (about 7 minutes)
Patch (more than 2 hours)
What dosage does nicotine chewing gum come in?
2mg and 4mg (6mg to be launched soon)
How long does the gum take to reach plateau?
30 mins
How should you advise patients to use the gum?
10-15 pieces a day, hourly (each piece lasts 30 mins)
Recommend use for up to 3 months
Start chewing slowly, takes a few days to get used to
What slows down the absorption of nicotine from gum?
acidic drinks
What types of transdermal patches are there?
16 hour and 24 hour patches
How long does it take for the transdermal patches to reach plateau?
Hours
Side effect of transdermal patches?
Nightmares (with the 24h patches)
SOME Redness of skin
LOOK OUT FOR ALLERGIC REACTION
How should you advise patients to use the transdermal patches?
Use for two months
Put a new patch on each morning (upper arm, side of torso or other hairless part of body) - don’t put it in the same place
How long does it take for the nicotine nasal spray to reach plateau?
only minutes
How should you advise patients to use the nicotine nasal spray?
One shot (0.5mg) in each nostril hourly Recommend use for up to 3 months
Who is the nicotine nasal spray especially useful for?
highly dependent smokers who can tolerate it
How is the inhalator absorbed?
How long does it take to reach plateau?
Absorbed through mouth like gum etc.
30 minutes
How should you advise patients to use the inhalator?
Recommend puffing vigorously for some 10-20 minutes every hour
Shallow puffing as good as inhalation
Each cartridge lasts for several puffing sessions - replace cartridge when weak (not after single
use)
Warming the cartridge improves delivery
How many puffs of the inhalator = one puff from a cigarette?
10
How long does the microtab take to reach plateau?
How long do the pills take to dissolve under the tongue?
30 min
20 minutes
How should you advise patients to use microtabs?
Recommend 15-30 tablets a day
May sting initially
Recommend use for up to three months
Novartis ‘1mg’ lozenge is supplied in how many/day packs?
10/day packs
Nicotine mouth spray - nicotine speed and levels same as?
Faster than?
same as 4mg gum
faster than lozenge
Side effect of quick mist mouth spray?
Hiccups
Mouth strip - how many mg of nicotine?
2.5mg
Mouth strip - how long does it take to dissolve?
3 minutes
Why does Sweden have a 5% smoking prevalence (compared to 16% in the UK)?
Due to snus
Are electronic cigarettes safe?
Several of the carcinogens in cigarette smoke were found in EC vapour, but at levels of some hundred times lower.
Some risks may yet emerge but these are unlikely to exceed some 5% of risks of smoking.
How should NRT be combined?
Combination of patch with faster acting products should allow sufficient nicotine level, and dose increase when needed
Bupropion - what is this?
Initially developed as an antidepressant.
Selective inhibitor of neuronal re-uptake of noradrenaline and dopamine
Contraindications of bupropion.
Current or previous seizure disorder Known CNS tumour Benzodiazepine or alcohol withdrawal Eating disorders Hepatic cirrhosis Bipolar disease Taking MAOI’s Pregnancy or breast feeding Age <18 years
Risk factors for seizures to look out for before prescribing bupropion. (4)
Alcohol abuse, History of head trauma, Hypoglycaemia, Use of stimulants or anorectic products
Drug interactions of bupropion. (3)
Beta-blockers, Antiarrythmics (Type 1C), Codeine base medications, etc.
Dosage of bupropion.
150mg daily for the first 6 days, then 150mg twice daily from day 7 (8 hours apart).
FOR 8 weeks.
Set quit day between day 8 and 14
Common side effects of bupropion. (4)
Insomnia
Headache
Dry mouth
Rash
Uncommon side effects of bupropion. (2)
Seizure
Severe allergic reaction
Zyban is the brand name for…?
bupropion
Champix is the brand name for…?
varenicline
Varenicline is a … agonist.
α4β2 Receptor Partial Agonist
How does nicotine result in release of dopamine?
Binding of nicotine at the α4β2 nicotinic receptor in the ventral tegmental area is believed to cause release of dopamine at the nucleus accumbens.
How does varenicline work?
Has dual agonist and antagonist activities - it binds to the receptors in the VTA and causes release of dopamine in the nucleus accumbens.
Which medication is most effective in terms of quitting rates?
Champix/varenicline - more than doubles your chance of success
What is the half life of Champix?
Cmax?
Steady state?
~24 hours
Cmax within 3 to 4 hours
Steady state reached within 4 days
Dose adjustments may need to be made for what group of patients using Champix?
Severe renal impairment
Side effect of Champix?
How can this be helped?
Nausea
Tablet after meals, or anti-emetic medication (not normally used)
Champix contraindications. (2)
End-stage renal disease
< 18 years of age
Champix precautions. (2)
Pregnancy and lactation
Renal impairment – reduce to 1mg/day
What packs of Champix are available?
Initiation blister packs (2-weeks) - 11 x 0.5 mg tablets plus 14 x 1mg tablets
Maintenance packs (2-weeks) - 28 x 0.5 mg or 56 x 0.5 mg tablets. 28 x 1mg or 56 x 1mg tablets
4-week packs also available
How should you prescribe Champix (in terms of dosing)?
When should patients quit smoking?
Days 1-3 - 0.5 mg once daily
Days 4-7 - 0.5 mg twice daily
From Day 8 - 1mg twice daily
Quit date 1-2 weeks after starting treatment
I smoke 10 a day and want to quit. Shall I gradually cut down to 5 a day then 2 a day etc.?
No, this extends withdrawal discomfort and exhausts
resources. If done ad-lib with NRT or Champix, can
be helpful.
Can I still smoke marijuana?
Not advised as lowers chance of success in stopping
smoking (possibly because mixed/associated with tobacco).
What Stop-Smoking Specialist Services do?
Assess Set up a quit date Prepare for quitting Provide intensive treatment over 4 weeks of abstinence Relapse prevention over one year
Henry has put on 2 kg in first two weeks of abstinence, and asks what to do. A good advice would be to…?
Focus on not smoking and leave the weight problem for later
Sally became tearful and irritable in the first week of abstinence. She is using 5 Microtabs a day. What could help her?
Using more NRT (15-30 microtab pills a day)
