Smoking Cessation

Question 1

5 A’s

Answer 1

Ask about tobacco use
Advise quitting
Assess readiness to quit
Assist to quit with pharmacotherapy
Arrange follow up in 1-2 weeks

Question 2

Nicotine Replacement Therapy

Answer 2

Multiple dosage forms available

Patches, gum, lozenge, inhalers, and nasal spray

Question 3

Bupoprion SR

Answer 3

Zyban
Inhibits dopamine reuptake to curb cravings
BOX: Suicide risk
CONTRA: seizures, anorexia/bulimia, abrupt discontinuation of alcohol/ethanol, MAOIs
ADR: Tachy, weight loss, GI, Agitation/head issues

Question 4

Nicotine

Answer 4

For smoking cessation
Reward effect in limbic system and stimulation in the cortex
ADR: headaches and dyspepsia (tummy pain)
Dose adjustments to protect renal and hepatic system

Question 5

Nicotine patches (Nicoderm CQ)

Answer 5

Dosing: 21mg for more than 10 cigs a day
14 mg for 10 or fewer
7mg for titration down or tolerability issues
Daily patches. Easy, steady, OTC.
Can’t alter nicotine levels, takes 3 hours for peak effect

Question 6

Nicotine Gum (Nicorette)

Answer 6

2mg if first cig is 30 mins or more after waking
4mg if first cig is within 30 mins of waking
1 piece every hour with no food or drink 30 mins before or after
User controlled dose, oral sensation
Unpleasant taste and oral complaints, difficult with dentures

Question 7

Nicotine Lozenge (Nicorette)

Answer 7

2mg if first cig is 30 mins or more after waking
4mg if first cig is within 30 mins of waking
1 every 1-2 hours, no food or drink
User controlled, oral sensation, can be used with dentures
Unpleasant taste, oral complaints

Question 8

Nicotine Inhaler (Nicotrol)

Answer 8

10mg cartridge. 1 cartridge every 1-2 hours PRN (max 16)
Deep inhale into back of throat
User controlled, oral sensation
Visible (social), caution with COPD, oral complaints

Question 9

Nicotine Nasal Spray

Answer 9

0.5mg per spray. 1 spray to each nostril every 1-2 hours as needed (max 10/HOUR or 80/day)
User controlled, most rapid delivery of nicotine
Nasal/throat irritation

Question 10

Varenicline (Chantix)

Answer 10

ADR: Bad dreams/sleep behavior, nausea/vomiting, depression, SEIZURES
Oral tabs, partial agonism stimulates some dopamine activity but to a much smaller degree than nicotine and decreases cravings and withdrawal symptoms
Dose adjustment in severe kidney dysfunction

Question 11

Therapy Selection and Follow Up

Answer 11

Pt preference
2 agents for NRT initially. Patch (long acting) and a short acting for cravings
Buproprion is not recommended for initial therapy

Focus on reinforcement of quitting, address problems, encourage abstinence, weening of pharmacotherapy eventually