Smoking Cessation

Question 1

Pack-year Calculation

Answer 1

Cig. packs/d X # of years smoked

Question 2

5 As

Answer 2

• Ask about use
• Advise to quit
• Assess willingness to quit
• Assist in quit attempt (establish quit day is within 2-4 weeks)
• Arrange follow-up

1-800-QUIT-NOW = national smoking cessation hotline

Question 3

Tx Principles

Answer 3

• Counseling strongly correlated to success (behavioral and social support)
• Encourage meds in all patient UNLESS CI
• CI: prego, “light smokers”, e-cig users, adolescents (behavioral over drug therapy)

Question 4

Smoking DDI

Answer 4

• Chemicals in cigarettes induce CYP450s, especially 1A2
• Quitting this induction can make medications SUPRAtherapeutic and may require reduces doses
• Caffeine, theophylline, and warfarin (increased bleeding risk) should all be monitored/reduced in those quitting smoking
• Smoking, women >= 35 yo should NOT use estrogen-containing contraception (increased CV event risk)

Question 5

Vaccines + Smoking

Answer 5

• Routine vaccines: flu

- Pneumovax 23 if between 19-64 yo

Question 6

NicoDerm CQ

Answer 6

• Nicotine patch
• Long-term nicotine replacement
• Can be 24 hours on, or 16 on/8 off if insomnia is a problem
• Dose based on # cigs/day
• Remove before MRI
• DON’T cut patch
• SE: INSOMNIA, vivid dreams

Question 7

Nicorette

Answer 7

• Nicotine gum
• Short-term nicotine replacement
• Dosing based on timing of first cigarette in a day
• Chew and park the medication buccally
• SE: INSOMNIA, nausea, hiccup, cough, heartburn

Question 8

Nicorette Mini

Answer 8

• Nicotine lozenge
• Short-term nicotine replacement
• Dosing based on timing of first cigarette in a day
• Park the medication buccally
• SE: INSOMNIA, nausea, hiccup, cough, heartburn

Question 9

Nicotine Inhaler

Answer 9

• Rx treatment
• Avoid in asthma/COPD
• Use 6-16 cartridges/day
• Use up to 6 months
• One open cartridge lasts one day
• Short, frequent puffs
• SE: INSOMNIA, mouth/throat irritation, asthma exacerbation

Question 10

Nicotine NS

Answer 10

• Rx treatment
• Avoid in asthma, COPD, and rhinitis patients
• Can cause nasal irritation (80%) and asthma exacerbation
• SE: INSOMNIA
• Fastest nicotine delivery; highest risk of dependency

Question 11

Nicotine Considerations

Answer 11

• No sale of nicotine products <18 yo
• Combination of short/long acting NRT is more effective
• ALL have a SE for insomnia

Question 12

Nicotine Patch Dosing

Answer 12

• > 10 cigs/day: 21 mg x 6 weeks, 14x2, 7x2

- <10 cigs/day: 14 mg x 6 weeks, 7x2

Question 13

Nicotine Gum/Lozenge Dosing

Answer 13

• Start at a minimum of 9 pieces/day
• First cig =< 30 mins after waking: 4 mg starting dose
• First cig > 30 mins after waking: 2 mg starting dose

Question 14

Zyban

Answer 14

• Bupropion, brand specifically for depression (increases DA/NE)
• Start at least 1 week before quitting
• Okay to give with NRT
• CI: seizure (increases risk), MAOI use, other bupropion products
• SE: weight loss, insomnia, tremors
• Can separate doses 1 at waking, 2nd in 8 hours to reduce insomnia

Question 15

Chantix

Answer 15

• Varenicline, partial nicotinic receptor agonist
• NOT okay to use with NRT
• Start at least 1 week before quitting
• Warning for serious seizure risk
• SE: abnormal/vivid dreams, nausea, HA
• Take with a full glass of water and food to reduce nausea