Smoking Addiction Flashcards by Whitley Whyte

Smoking

A pack a day smoker takes more than 70,000 puffs per year

The act of smoking reinforces cigarette addiction by establishing secondary reinforces such as the sight and smell of cigarettes, the act of lighting, association of cigarette with meal, cup of coffee or alcohol drink

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Tobacco

Tobacco use is the leading preventable cause of disease, disability and death is the US particularly from cardiovascular disease, cancer, and lung disease

Cigarettes are responsible for one in every 5 deaths in the United States
8.6 million people have serious illness cause by smoking

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Statistics

15.1 percent of Americans are current smokers

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ETS

Environmental tobacco smoke
Combination of the smoke emoted by a burning cigarette, cigar, or pipe and the smoke exhaled by smokers

Increased risk of Lung cancers and other cancer

Exposure to ETS causes about 3,000 deaths from hung cancer per year in non smokers and damages respiratory health of hundreds of thousands of children who live with smoking parents

150,000-300,000 of respiratory illness occurring in kids up to 18 months from ETS due to increased risk of respiratory tract infection

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Epidemiology

1/5 Americans still smoke
90 percent of smokers start before the age of 18
Increased in low socioeconomic status and low education
Oral cancer occurs more frequently among those who dip
E-cigarettes possible adolescent addition
Bans haven’t helped slow smoking

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Pathophysiology

4000 chemicals and gases inhaled into the lung
Carcinogens, 3,4-benzypyrene is the most dangerous
Carcinogens,cocarcinogens, tumor promoters, tumor initiators, and mutagens

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Nicotine

Extremely toxic, clear, oily liquid with characteristic odor
Low dose=stimulant
High dose=CNS depressant
Inhalation the most common route
Absorption in mouth, throat, bronchi, alveoli
Dip(snuff) mucosal lining absorption

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Nicotine

Inhalation is quickest and most effective delivery
90% of nicotine that reaches the alveoli of the lungs in each breath is absorbed
Cigarettes contain 15-20 mg only 1-2 mg is absorbed
25% immediately goes to brain and affects biochemistry
60 mg can be a LETHAL dose

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Acute Effects of Nicotine

Affects transmission of nervous system signals by mimicking acetylcholine, occupies receptors at the synapses and prevents the transmissions nerve impulses

Direct adrenergic agonist, causes release of epi which increases heart rate, systemic vascular resistance, and BP, coronary vascular resistance

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Effects of nicotine

Negative inotropic effect, resulting in increased myocardial oxygen consumption and decreased oxygen deliver caused by carbon monoxide

Construction of blood vessels riding motility of bowel and loss of appetite

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Carbon monoxide

Binding affinity 250 times greater than oxygen
Reduces oxygen carrying capacity
15% of hemaglobin may may be bound to CO
Hearts need for oxygen is increased but supply is reduced so the heart pumps more to supply tissues with oxygen

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Respiratory effects

Hyperplasia of cells such as goblet cells which increase mucus production
Reduces airway diameter and increase difficulty clearing secretions
Loss of collated cells, destruction of alveolar walls
Alters pulmonary immune defense by lowering neutrophils, immunoglobulin? Ms rip hate adherence, natural killer t lymphocytes

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C ns

Generalized depression of the CNS When blood levels of nicotine reach a critical point the brains vomiting center may be activated

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Chronic effects

Development of tolerance and chemical dependence
Hallmarks of physical dependence is tolerance and withdraw symptoms
Withdraw - dysphoric or depressed mood, insomnia, irritability, frustration, anger, anxiety, poor concentration restlessness decreased hr and increased appetite

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MOA B

Smokers had 40% decrease of this brain enzyme
The enzyme breaks down dopamine, a neurotransmitter associated with feelings of pleasure
Nicotine stimulates dopamine, making smoking pleasurable
Cycle of less MOA B = more pleasure = moresmoking

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Clinical presentation

Drink more alcohol, coffee, and tea, other abuse disorders
Lover weight and blood pressure
Higher heart rate
Decreased fertility
Increase early menopause
SIDS 2-4 times more common in infants whose mother smoked During pregnancy
Ration forHDL to LDL is lower
Cad, pad, cancer, miscarriage, intrauterine growth retardation
Depression two times more common
Women have early menopause, decreased bone density, osteoporosis

Objective

Smell of tobacco
Stained fingers and nails
Periodontal disease
Lumps in mouth
Sore or patches in mouth
Cough, dyspnea I wheezing, fatigue
Frequent respiratory infections
Copd, emphysema, ILD
Tachycardia,high blood pressure , cardiac dysrhythmia
Signs of withdraw start with hours of last cigarette, peaks within 48 to 72 hours, baseine within 3-4 weeks

Diagnostic reasoning

Ask about smoking status - starting at adolescence
Questionnaires
Fagerstrom test for nicotine dependence, May help predict smoking cessation success, as well as inform nicotine replacement dosages as a function of the classification of dependence

Diagnostic test

Labs- thiocyanate,cotinine, nicotine and COHb in urine, blood, breath, or saliva
Nicotine ua
COHb- 2% level suggest that smoking has occurred

Management

Every patient who smokes is offered smoking cessation at every visit
5 As- ask, advise, assess, assist, and arrange
Advise the need to quit( 3Rs- discuss risk, discuss relevance of smoking to symptoms and recent illness, discuss reward of cessation)
Assess motivation to quit
Assist- ready to quit, uncertain, not ready
Arrange follow up
Offer pregnant patients intensive counseling treatment
Chose a quit date within 30 days

Precontemplation stage

Have no desire to quit in the next 6-12 months

Benefit from motivational interventions that increase awareness of the adverse effects of smoking

Contemplation stage

Smokers who seriously thinking about and express interest inquitting but are not ready to do so
Benefit from motivational counseling emphasizing the negative effects of smoking

Preparation stage

Smokers who are serious about quitting and have taken the initial steps towards cessation

Action stage

The smoker quits smoking.
This last several weeks to 6 months
Interventions address relapse, it is common during this time
Congratulations and reward ing success

Maintenance stage

When a smoker has abstained from cigarettes for 6 months | Most quitters relapse and recycle through 3-4 times before long term abstinence

Management

Effective by behavior modification Developing alternative coping strategies Support from everyone Support groups

Hypnosis

Goal is to enable the smoker to achieve an altered state of consciousness that enhances the ability to quit Often short lived

Aversion conditioning

Premise that smoking is q learned response | Electric shock, nausea inducing medication, not and smoky air treatments, and rapid smoking

Bupropion, Zyban/Wellbutrin

Anti-deppresent and smoking deterrent Weak inhibitor of the uptake of norepi and dopamine but hasno effect on serotonin The dopaminergic activity affects areas in the brain associated with reinforcement activity affecting nicotine withdrawl Adverse effect of headache, insomnia and dry mouth Don't give to epilepsy, Head trauma, eating disorder, recent heart attack, unstable heart disease, or active alcoholism Start 1-2 weeks before the quit date 150mg - 3 days 150 BID 7-12 weeks

Chantix

Nicotine acerylchoine receptor partial agonist used to aid. Begin one week before quit date .5 for 3 days. .5 BID for4 days, then 1 mg BID X12 weeks Ad verse effect include neuropsychiatric symptoms particularly those with mental illness

Nicotine replacement therapy

Nicotine patches, gum, and lozenges available OTC

Nicotine gum

40-60% ' cessation Has correctly chewed to a soft stated then place Buccal mucosa Every 1-2 hours first 6 weeks 2-4 hours for 3 weeks Nicotine absorption decreases with acidic food and beverages Do not eat 15 minutes before or during the use of the gum

Nicotine patches

Applied every morning and warn for 24 hours Used for 8-12 weeks Change site daily Highest dose to those Who smoke more than 10 cigarettes a day Adverse reactions of vivid dreams s insomnia, mylagias Remove at night if occurs

Nasal spray

More rapid than gum and patches .5 mg pls pray Two doses per hours up to 6 months/40 max per day Not recommended for those with asthma, pud, nasal disorders, renal impairment, liver disease, diabetes, and hyperthyroid When used in combination with the nicotine patch there was more effective long-term smoking cessation then would either alone Can cause heart dysrhythmias, angina, hypertension in post MI patients

Nicotine inhaler

``` Nicotine vapor 10 mg per cartridge with 1 mg menthol Nicotine into buccally not in lungs Cartridge last 20 min 6-16 cartridges per day for 3 months Mimics the behavioral aspects of smoking Increase efficiency if using the patch with the inhaler ```

Follow up and referral

Follup up after the initial intervention Supportive call 1 week after quit date Office follow up One to three months after quit date Set new quit date in the case of relapse Only 4% of smokers are able to quit each year Give age appropriate literature on tobacco Association and counseling on tobacco related mortality Possible constipation may need meds Exercise Education on alternative coping strategies Info on rewards of not smoking

Education cont.

Smokers die 5 to 8 years earlier than those who have never smoked Provide information to both family and patiente