SMOKING CESSATION Flashcards
The 5 A’s Approach to smoking cessation
– 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
Proactive approach for smoking cessation
Offering in a positive way rather than promoting it as optional – increases likelihood they will at least try the treatment
3 types of pharmacotherapies for smoking cessation
1) nicotine replacement therapy
2) varenicline (chantix)
3) buproprion (zyban)
nicotine replacement therapy (NRT)
- Multiple dosage forms available to suit the patient’s needs
- Patches, gum, lozenge, inhalers, and nasal spray
Varenicline (chantix)
How does it work?
Route?
Modulates the mesolimbic dopamine system associated with nicotine addiction
Oral therapy
Buproprion (zyban)
How does it work?
inhibits the reuptake of dopamine- stimulates the “reward” system of the brain and curbs cravings
MOA of nicotine
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
ADR of nicotine therapy
1) HA
2) dyspepsia
Nicotine metabolism and excretion
1) it is cleared by hepatic and renal system so consider dose adjustments in someone with ESRD or hepatic impairment
Nicotine patches dosing
1) 21 mg for >10 cigarettes/ day
2) 14 mg for 10 or fewer
3) 7 mg for titration down or tolerability issues
Adminsitration of nicotine patches
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
Advantages of nicotine patch
1) ease of use
2) steady nicotine levels
3) OTC
disadvantage of nicotine patches
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)
Nicotine gum Dosing
1) 2 mg if the first cigarette is >30 minutes after waking
2) 4 mg if first cigarette is <30 min after waking
Nicotine gym administration
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
Advantages of nicotine gum
1) user controls nicotine dose
2) oral sensation- good substitute for cigarettes
Disadvantages of nicotine gum
1) unpleasant taste, mouth irritation, jaw soreness, heartburn, nausea, hiccups
2) potentially damaging to dental work
3) difficult for those with dentures
Nicotine Lozenge dosing
1) 2 mg if first cigarette is >30 min after waking
2) 4 mg if first cigarette is < 30 minutes before or during use
Advantage of nicotine lozenges
1) user controls nicotine dose
2) oral sensation - good substitute for cigarettes
3) can be used by smokers with poor dentition or dentures
Disadvantage of nicotine Lozenge
1) unpleasant taste
2) mouth irritation
3) hiccups
4) heart burn or nausea
Nicotine Inhaler Dosing
10 mg catridge
Administration of nicotine inhaler
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
Advantages of the nicotine inhaler
1) user controls the nicotine dose
2) oral sensation- good substitute for cigs
Disadvantages of nicotine inhaler
1) visible when being used (social aspect)
2) caution in reactive airway diseases (COPD/asthma)
3) mouth/throat irritation
Nicotine nasal spray dosing
0.5 mg per spray
Nicotine nasal spray administration
apply 1 spray to each nostril every 1 - 2 hours prn (may 10 sprays/ hours, 80 sprays/ day)
advantages of nicotine nasal spray
1) user controls nicotine dose
2) most rapid delivery of nicotine amongst NRT products
Disadvantage of nicotine nasal spray
1) localized irritation to the nasal mucosa- poor tolerability long term
2) nasal/throat irritation along with coughing, sneezing, and teary eyes
Vareniclne indications
smoking cessation
moa of varenicline
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
Route of varenicline
oral tablets
- starter pack and continuing packs- 7 day titration in starter pack
ADR of varenicline
1) abnormal dreams,
2) SLEEPWALKING
3) harmful behaviors
4) n/v
5) DEPRESSION, SI and behaviors
6) seizures
Buproprion SR Indications
smoking cessation
Buproprion SR US box warrnings
suicide risk- increases the risk of suicidal thoughts and behaviors in pediatric, adolescent or young adult patients
MOA of buproprion SR
dopamine and norepinephrine reuptake inhibitor- increases amount of dopamine available for stimulation of dopamine receptors
-stimulates the reward system and curves cravings
Contraindications for buproprion
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
ADR of buproprion SR
1) tachycardia and diaphoresis
2) weight loss
3) GI disturbances
4) agitation, dizziness, insomnia, migraines, tremors, blurred vision
benefit of buproprion sr
good agent for someone with untreated depression - 2 birds with one stone
how to choose therapy selection for smoking cessation
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
Follow up for smoking cessation
- focus on reinforcement of quitting, monitor response to smoking cessation, optimize treatment with first-line therapies, monitor for adverse effects
- additionally, address any problems that develop as a result of smoking cessation- weight gain, depression, change in relationship statuses with those that still smoke
- relapse prevention and counseling - encourage continued total abstinence
- 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
