smoking cessation Flashcards
how do withdrawal symptoms occur?
- the number of nicotinic acetylcholine receptors increase once nicotine is removed, which results in withdrawal symptoms
- withdrawal symptoms can last up to 4 weeks
- agitation, trouble sleeping, anxiety, depression
what are the 5 A’s of smoking cessation?
ask, advise, assess, assist, arrange
ask
- ask all patients about tobacco use: e-cigs, cigs
- “do you ever smoke or use tobacco or nicotine, such as e-cigs?”
- “condition (asthma, HTN, etc) is caused or worsened by exposure to tobacco smoke. do you, or someone in your household smoke?”
advise
- advise patient to quit
- “quitting is the most important thing you can do to protect your health now and in the future. i have training to help my patients quit, and when you are ready we can create a treatment plan”
assess
- assess readiness to quit
- what are your thoughts about quitting?
- would you consider quitting in the next month?
2 questions to gauge patient’s readiness to quit
- would you like to be a non-tobacco user?
2. do you think you have a change of quitting successfully?
assist
- assist with quitting
- current use: type(s) tobacco, amount, time to first cigarette
- past use: duration of tobacco use, changes in level of use recently
- past quit attempts: what did or didn’t work? why or why not?
- prior med administrations, dose, adherence, duration of treatment
some OTC meds may be limited due to the following medical conditions:
- pulmonary conditions (asthma, COPD)
- skin conditions (psoriasis, sensitive skin, eczema)
- cardiac history (heart attack, atrial fibrillation)
- nasal polyps
- insomnia
assist (cont)
- reasons/motivations for wanting to quit
- triggers for tobacco use
- discuss methods for quitting: pros and cons
- adherence, proper use, with demonstration
- discuss withdrawal
- set a quit date: ideally 2 weeks away
- determine occupation/lifestyle for ideal therapy*
assist: STAR
- S: set a quit date ideally within 2 weeks
- T: tell family, friends, co-workers about quitting and ask them for support
- A: anticipate challenges to the upcoming quit attempt
- R: remove tobacco products from the patient’s environment and make home smoke free
arrange
- follow up contact should occur during the 1st week after quitting
- 2nd follow up should be after the 1st month
- these follow ups can be telephone, email, face/face etc
- address the challenges, triggers, temptations
- congratulate patients for success and reinforce need for continued support
is nicotine replacement therapy (NRT) available with or without an rx?
without
OTC NRT
gum, lozenge, patch
gum
nicorette, zonnic, generic
lozenge
nicorette mini lozenge, generic
patch
NicoDerm CQ, generic
prescription NTR
- metered nasal spray: Nicotrol NS
- oral inhaler: nicotrol inhaler
- bupropion SR: Zyban
- varenicline: Chantix
precautions that must be assessed prior to starting GUM
- recent myocardial infarction <2 weeks
- serious underlying arrhythmias
- serious of worsening angina pectoris
- TMJ disease
- pregnancy and breastfeeding
- adolescents
precautions that must be assessed prior to starting LOZENGE
- recent MI <2 weeks
- serious underlying arrhythmias
- serious of worsening angina pectoris
- adolescents
precautions that must be assessed prior to starting TRANSDERMAL PATCH
- recent MI <2 weeks
- serious underlying arrhythmias
- serious of worsening angina pectoris
- pregnancy and breastfeeding
- adolescents
precautions that must be assessed prior to starting NASAL SPRAY
- recent MI <2 weeks
- serious underlying arrhythmias
- serious of worsening angina pectoris
- severe reactive airway disease (nasal polyps, rhinitis, allergy, sinusitis)
- underlying chronic nasal disorders
- pregnancy and breastfeeding
- adolescents
precautions that must be assessed prior to starting ORAL INHALER
- recent MI <2 weeks
- serious underlying arrhythmias
- serious of worsening angina pectoris
- bronchospastic disease (asthma, COPD)
- pregnancy and breastfeeding
- adolescents
1st cigarette <30 minutes after waking
4 mg gum OR lozenge
1st cigarette >30 minutes after waking
2 mg gum OR lozenge
gum/lozenge week 1-6
1 piece every 1-2 hours
gum/lozenge weeks 7-9
1 piece every 2-4 hours
gum/lozenge weeks 10-12
1 piece every 4-8 hours
what is the maximum pieces per day for a GUM
24 pieces/day
what is the maximum pieces per day for LOZENGE
20 pieces/day
duration for gum/lozenge
duration up 12 weeks
transdermal patch
-based on number of cigs/day
patch: >10 cigs/day
- 21 mg/day for 4-6 weeks
- 14 mg/day for 2 weeks
- 7 mg/day for 2 weeks
patch: <10 cigs/day
- 14 mg/day for 6 weeks
- 7 mg/day for 2 weeks
transdermal patch duration
8-10 weeks
transdermal patch duration
8-10 weeks
nasal spray dosing
1-2 doses/hour (8-40 doses/day)
what is one dose of nasal spray?
- one dose = 2 sprays (1 in each nostril)
- each spray delivers 0.5 mg of nicotine
what is the maximum dose of nasal spray?
-maximum is 5 doses/hour or 40 doses/day
how many doses of nasal spray for best results?
-for best results initially use at least 8 doses/day
nasal spray duration
3-6 months
oral inhaler dosing
6-16 cartridges/day
initially use 1 cartridge every 1-2 hours
oral inhaler duration
3-6 months
gum: administration & counseling
- use the chew and park method
- chew each piece slowly
- park between cheek and gum when peppery or tingling appears
- rotate areas in mouth
- resume chewing when tingling fades
- repeat chew/park until no longer tingles (30 min)
- no food or beverages 15 min before or during use
lozenge administration & counseling
- allow to dissolve slowly (about 10 minutes)
- nicotine release may cause warm tingling sensation
- DO NOT chew or swallow
- rotate to different areas of the mouth
- no food or beverages 15 minutes before or during use
transdermal patch administration & counseling
- rotate patch application site daily on clean, dry skin on upper body or upper arm
- do not apply patch to the same skin site for at least 1 week
- can wear patch 16-24 hours
- can remove the patch at bedtime if having vivid dream/insomnia
- do not cut patch
- do not wear more than one patch
- remove prior to MRI since it may contain metal
nasal spray administration & counseling
-do not sniff, swallow, or inhale through the nose as the spray is being administered
oral inhaler administration & counseling
- nicotine in cartridges is depleted after 20 min of active puffing
- best effects with continuous puffing for 20 min
- inhale into back of throat or puff in short breaths
- do NOT inhale into the lungs (like a cig) but “puff” as if lighting a pipe
- open cartridge retains potency for 24 hours
gum adverse effects
- mouth/jaw soreness
- mouth irritation
- hiccups
- dyspepsia
- hyper salivation
effects associated with incorrect chewing technique (gum)
- lightheadedness
- nausea/vomiting
- throat and mouth irritation
lozenge adverse effects
- nausea
- mouth irritation/jaw soreness
- hiccups
- cough
- heartburn
- headache
- flatulence
- insomnia
transdermal patch adverse effects
- local skin reactions
- headache
- sleep disturbances
nasal spray adverse effects
- nasal and/or throat irritation (hot, peppery, or burning sensation)
- rhinitis (stuffy nose)
- tearing
- sneezing
- cough
- headache
oral inhaler adverse effects
- mouth and/or throat irritation
- cough
- headache
- rhinitis
- dyspepsia
- hiccups
advantages of GUM and LOZENGE
- might serve as an oral substitute for tobacco
- might delay weight gain
- short-acting allows for flexible dosing
- can be titrated to manage withdrawal symptoms
- can be used in combo with other agents to manage situational urges
lozenge: additional advantage
-may be easier than gum, especially patient with dental work or dentures
transdermal patch advantages
- once a day dosing
- use is the least obvious NRT
- can be used in combo with other agents
- delivers consistent nicotine levels over 24 hours
- can be removed at bedtime if having insomnia
nasal spray & oral inhaler advantages
- can be used in combo with other agents to manage situational urges
- short-acting allows flexible dosing
- can be titrated to manage withdrawal symptoms
additional advantages of ORAL INHALER
- mimics hand-to-mouth ritual of smoking
- might serve as an oral substitute for tobacco
disadvantages of GUM
- need for frequent dosing can affect adherence
- might be problem for patients with significant dental work
- proper chewing technique is necessary for effectiveness
- gum chewing might not be acceptable for some patients
disadvantages of LOZENGE
- need for frequent dosing can affect adherence
- GI side effects (nausea, hiccups, heartburn) might be bothersome
disadvantages of transdermal patch
- when used as monotherapy cannot be titrated to acutely manage withdrawal symptoms
- not recommended for use by patients with dermatologic conditions
- may cause insomnia
- insomnia & vivid dreams may lessen after three to four days
disadvantages of nasal spray
- need for frequent dosing can compromise adherence
- nasal administration might not be acceptable or desirable for some patients; nasal irritation often problematic
- not recommended for use by patients with chronic nasal disorders or severe reactive airway disease
oral inhaler disadvantages
- need for frequent dosing can compromise adherence
- cartridges might be less effective in cold environments (<60F)
