SMOKING CESSATION

Question 1

The 5 A’s Approach to smoking cessation

Answer 1

– Five-step framework that serves as a guide to encourage patients to quit smoking – recommended in the national guidelines since 2008 Ask about tobacco use – ask in a way that you can identify various kinds and intermittent use

Advise quitting – Clear evidence that brief (<5 mins) at each encounter can make a difference

Assess readiness to quit – Focus conversations and actions based on readiness ‘stage’

Assist smokers ready to quit – Create plan, provide support, recommend pharmacotherapy

Arrange follow-up – Ideally within 1-2 weeks of agreed upon quit date

Question 2

Proactive approach for smoking cessation

Answer 2

Offering in a positive way rather than promoting it as optional – increases likelihood they will at least try the treatment

Question 3

3 types of pharmacotherapies for smoking cessation

Answer 3

1) nicotine replacement therapy
2) varenicline (chantix)
3) buproprion (zyban)

Question 4

nicotine replacement therapy (NRT)

Answer 4

• Multiple dosage forms available to suit the patient’s needs
• Patches, gum, lozenge, inhalers, and nasal spray

Question 5

Varenicline (chantix)

How does it work?

Route?

Answer 5

Modulates the mesolimbic dopamine system associated with nicotine addiction

Oral therapy

Question 6

Buproprion (zyban)

How does it work?

Answer 6

inhibits the reuptake of dopamine- stimulates the “reward” system of the brain and curbs cravings

Question 7

MOA of nicotine

Answer 7

1) agonist at the nicotine receptors - two main effects are believed to be positive properties
a) reward effect is exerted in the limbic system
b) stimulating effect is exerted in the coortex

Question 8

ADR of nicotine therapy

Answer 8

1) HA
2) dyspepsia

Question 9

Nicotine metabolism and excretion

Answer 9

1) it is cleared by hepatic and renal system so consider dose adjustments in someone with ESRD or hepatic impairment

Question 10

Nicotine patches dosing

Answer 10

1) 21 mg for >10 cigarettes/ day
2) 14 mg for 10 or fewer
3) 7 mg for titration down or tolerability issues

Question 11

Adminsitration of nicotine patches

Answer 11

1) apply one patch daily *can remove in the evenings for insomnia, vivid dreams or other ADRs
2) MAY START THE PATCH BEFORE THE QUIT DATE
3) rotate the application site

Question 12

Advantages of nicotine patch

Answer 12

1) ease of use
2) steady nicotine levels
3) OTC

Question 13

disadvantage of nicotine patches

Answer 13

1) can’t alter nicotine levels in case of cravings
2) takes up to 3 hours to reach peak effect when applied (if removed for nighttime can be problematic in morning)

Question 14

Nicotine gum Dosing

Answer 14

1) 2 mg if the first cigarette is >30 minutes after waking
2) 4 mg if first cigarette is <30 min after waking

Question 15

Nicotine gym administration

Answer 15

1) chew 1 piece every hour prn (24 pieces per day)
2) no food or drink for 30 min before or during use
3) chew slowly until it tingles, then park the gum between check and gum until tingle is gone- repeat until tingling no longer happens

Question 16

Advantages of nicotine gum

Answer 16

1) user controls nicotine dose
2) oral sensation- good substitute for cigarettes

Question 17

Disadvantages of nicotine gum

Answer 17

1) unpleasant taste, mouth irritation, jaw soreness, heartburn, nausea, hiccups
2) potentially damaging to dental work
3) difficult for those with dentures

Question 18

Nicotine Lozenge dosing

Answer 18

1) 2 mg if first cigarette is >30 min after waking
2) 4 mg if first cigarette is < 30 minutes before or during use

Question 19

Advantage of nicotine lozenges

Answer 19

1) user controls nicotine dose
2) oral sensation - good substitute for cigarettes
3) can be used by smokers with poor dentition or dentures

Question 20

Disadvantage of nicotine Lozenge

Answer 20

1) unpleasant taste
2) mouth irritation
3) hiccups
4) heart burn or nausea

Question 21

Nicotine Inhaler Dosing

Answer 21

10 mg catridge

Question 22

Administration of nicotine inhaler

Answer 22

1) inhaler 1 cartridge every 1-2 hours prn (max 16 catridges / day)
2) do NOT inhale like a cigarette into lungs - deeply inhale in the back of the throat or puff in short breaths- lasts about 20 min with active puffing

Question 23

Advantages of the nicotine inhaler

Answer 23

1) user controls the nicotine dose
2) oral sensation- good substitute for cigs

Question 24

Disadvantages of nicotine inhaler

Answer 24

1) visible when being used (social aspect)
2) caution in reactive airway diseases (COPD/asthma)
3) mouth/throat irritation

Question 25

Nicotine nasal spray dosing

Answer 25

0.5 mg per spray

Question 26

Nicotine nasal spray administration

Answer 26

apply 1 spray to each nostril every 1 - 2 hours prn (may 10 sprays/ hours, 80 sprays/ day)

Question 27

advantages of nicotine nasal spray

Answer 27

1) user controls nicotine dose
2) most rapid delivery of nicotine amongst NRT products

Question 28

Disadvantage of nicotine nasal spray

Answer 28

1) localized irritation to the nasal mucosa- poor tolerability long term
2) nasal/throat irritation along with coughing, sneezing, and teary eyes

Question 29

Vareniclne indications

Answer 29

smoking cessation

Question 30

moa of varenicline

Answer 30

1) partial agonist at alpha 4, beta 2 nicotinic receptors- prevents nicotine stimulation of mesolimbic dopamine system a/w nicotine addiction
a) partial agonism stimulates SOME dopamine activity, but to a much smaller degree than nicotine
b) decreases cravings and withdrawal sxs

Question 31

Route of varenicline

Answer 31

oral tablets
- starter pack and continuing packs- 7 day titration in starter pack

Question 32

ADR of varenicline

Answer 32

1) abnormal dreams,
2) SLEEPWALKING

3) harmful behaviors
4) n/v
5) DEPRESSION, SI and behaviors
6) seizures

Question 33

Buproprion SR Indications

Answer 33

smoking cessation

Question 34

Buproprion SR US box warrnings

Answer 34

suicide risk- increases the risk of suicidal thoughts and behaviors in pediatric, adolescent or young adult patients

Question 35

MOA of buproprion SR

Answer 35

dopamine and norepinephrine reuptake inhibitor- increases amount of dopamine available for stimulation of dopamine receptors
-stimulates the reward system and curves cravings

Question 36

Contraindications for buproprion

Answer 36

1) seizures
2) hx of anorexia
3) pts undergoing abrupt d/c of ethanol or sedatives (seizures risk)
4) use of MAOIs concomitantly or within the last 14 days

Question 37

ADR of buproprion SR

Answer 37

1) tachycardia and diaphoresis
2) weight loss
3) GI disturbances
4) agitation, dizziness, insomnia, migraines, tremors, blurred vision

Question 38

benefit of buproprion sr

Answer 38

good agent for someone with untreated depression - 2 birds with one stone

Question 39

how to choose therapy selection for smoking cessation

Answer 39

1) largely based on patient preference with a few notable exceptions for contraindications/ tolerability
2) typically for NRT, two agents are suggested for initial therapy- patch (long acting) and some form of short acting for cravings
3) varenicline and NRT is an option too- additive nausea and sleep disturbances can be bothersome
4) bupropian appears to be somewhat less effective in clinical trails so is typically NOT first line

• may be first liine in a patient with UNTREATED depression
  
  • tends to be the least expensive as well

Question 40

Follow up for smoking cessation

Answer 40

1. focus on reinforcement of quitting, monitor response to smoking cessation, optimize treatment with first-line therapies, monitor for adverse effects
2. additionally, address any problems that develop as a result of smoking cessation- weight gain, depression, change in relationship statuses with those that still smoke
3. relapse prevention and counseling - encourage continued total abstinence
4. consider weening pharmacotherapy after 3-6 months - careful attention to check for relapse - one meta analysis indicated continued pharmacotherapy for 18 months help prevent relapse