Smoking Addiction

Question 1

Smoking

Answer 1

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

Question 2

Tobacco

Answer 2

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

Question 3

Statistics

Answer 3

15.1 percent of Americans are current smokers

Question 4

ETS

Answer 4

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

Question 5

Epidemiology

Answer 5

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

Question 6

Pathophysiology

Answer 6

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

Question 7

Nicotine

Answer 7

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

Question 8

Nicotine

Answer 8

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

Question 9

Acute Effects of Nicotine

Answer 9

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

Question 10

Effects of nicotine

Answer 10

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

Question 11

Carbon monoxide

Answer 11

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

Question 12

Respiratory effects

Answer 12

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

Question 13

C ns

Answer 13

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

Question 14

Chronic effects

Answer 14

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

Question 15

MOA B

Answer 15

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

Question 16

Clinical presentation

Answer 16

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

Question 17

Objective

Answer 17

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

Question 18

Diagnostic reasoning

Answer 18

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

Question 19

Diagnostic test

Answer 19

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

Question 20

Management

Answer 20

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

Question 21

Precontemplation stage

Answer 21

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

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

Question 22

Contemplation stage

Answer 22

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

Question 23

Preparation stage

Answer 23

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

Question 24

Action stage

Answer 24

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

Question 25

Maintenance stage

Answer 25

When a smoker has abstained from cigarettes for 6 months

Most quitters relapse and recycle through 3-4 times before long term abstinence

Question 26

Management

Answer 26

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

Question 27

Hypnosis

Answer 27

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

Question 28

Aversion conditioning

Answer 28

Premise that smoking is q learned response

Electric shock, nausea inducing medication, not and smoky air treatments, and rapid smoking

Question 29

Bupropion, Zyban/Wellbutrin

Answer 29

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

Question 30

Chantix

Answer 30

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

Question 31

Nicotine replacement therapy

Answer 31

Nicotine patches, gum, and lozenges available OTC

Question 32

Nicotine gum

Answer 32

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

Question 33

Nicotine patches

Answer 33

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

Question 34

Nasal spray

Answer 34

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

Question 35

Nicotine inhaler

Answer 35

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

Question 36

Follow up and referral

Answer 36

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

Question 37

Education cont.

Answer 37

Smokers die 5 to 8 years earlier than those who have never smoked

Provide information to both family and patiente