Smoking

Question 1

Smoking: essential info to get in history? (3)

Answer 1

Pack-years & Current cigs/d

Previous attempts to stop: why failed, withdrawal symptoms, medications/interventions

Dependency: wake up at night to smoke, smoke within 5min of waking?

Question 2

What are pharmacological options for smoking cessation? (4)

Answer 2

NRT

Varenicline (partial nicotine r agonist)

Bupropion (NA/D re-uptake inhibitor)

Nortryptyline (TCA)

Question 3

Smoking cessation - what is your approach?

Answer 3

Dedicated session to offer education & advice

• Feedback on harms of smoking
• Listen to their concerns
• Advice on benefits of quitting - financial & health
• Goal: set a quit date (not smoking less cigarette - ineffective)
• offer Strategies - pharmacological & non-pharmacological

Non-pharmacological

• Enlist support of family & friends
• ***Warn potential AEs of quitting
  
  • Explain that these are short lasting: weight gain, irritability, depression
• Dealing with craving: alternative activities, e.g. exercise
• Written information packs: benefits, harm, side effects of quitting
• Address barriers as much as possible: ETOH, friends, social situation, Caffeine
• Refer to QUITLINE or smoking cessation clinic
• Relapse rate is highest in the 1st week (50%) - so I will follow-up weekly for the first 2 weeks (then GP f/u regularly)

Pharmacological

• Cautions if cardiac disease: NRT, Varenicline (Champix - nicotine receptor partial agonist)
• Bupropion, Nortryptiline are ok

Question 4

NRT: side effect (1) and contraindications (2)

Answer 4

Nicotine - basically cardiac

Chest pain.

Recent MI/CV event

Severe arrythmia

Question 5

Dose of NRT patches depending on dependency?

Answer 5

Low-mod: 14mg/24h

mod-high dependency: 21mg/24h

aim to stop at 12 weeks

Consider combination therapy (e.g. with NRT gum, 2mg PRN) - improves abstinence rates.

Question 6

Bupropion - contraindications (4)?

Answer 6

Remember - you can’t use Bupropion on people with Brain problems or Bulimia.

Side effects: Insomnia, Seizures

Epilepsy

CNS tumour

Bulimia or Anorexia nervosa

Withdrawal from ETOH/BDZ

Question 7

Varenicline (Champix) - side effects (2), contraindications (3).

Is it safe to use in patients with heart disease?

Answer 7

Is a partial agonist at nicotine receptor

Side effects: Nausea and Abnormal dreams

Contraindications: epilepsy, psych illness/suicidality, pregnancy/lactation

A Cochrane review found no significant differences in neuropsychiatric events (0.15% v 0.21%) or cardiac events (0.6% v 0.5%) in trials comparing varenicline with placebo - so probably can use it but I would still be cautious if known cardiac disease.