Smoking Cessation Flashcards
How does nicotine dependence work?
There’s a physiological and psychological addiction
Pharm effect = acts as agonist at nicotine Ach receptor in peripheral & CNS –> through BB to cortex and hippocampus –> release of NA, DA, 5HT, Ach –> anxiety relief, reduced hunger, improved task performance, tachycardia, vasocon, skeletal muscle relax, pleasure, inc metabolic rate
What is the role of the pharmacist in smoking cessation
Raise awareness of:
Health risks = lung cancer, heart disease, erectile dysfunction
RIsks for non-smoking fam members and contacts = coughing, headaches, childhood illness
Maternal risks = reduce O2 to baby, affects fetal heartbeat/breathing, inc risk of ectopic preg
Benefits of quitting = improved taste, smell, exercise tolerance
Quitting strategies
Prior to stopping smoking, what does the pharmacist need to determine
Assess level of nicotine dependence, strategies for dealing with cravings
Assess barriers to quitting, assess stage of change, patient motivations
support
sell benefits of quitting
What questions are asked to assess nicotine dependence?
How many minutes after waking to first cigarette?
Number of cigarettes per day?
Craving or w/drawal symptoms in previous attempts?
What are the stages of change?
Pre-contemplation
contemplation
preparation
action
maintenance
Discuss the pre-contemplation stage of change
smoked not thinking about quitting in next 6 months
Discuss the contemplation stage of change
smoker begins to think seriously about quitting in next 6 months
Discuss the preparation stage of change
Quit attempt is planned within next 30 days
Discuss the action stage of change
quit attempt is made lasting for at least 24 hrs
Discuss the maintenance stage of change
Person becomes a non-smoker for at least six months
What drugs interact with smoking?
Smoking induces CYP1A2 and CYP2B6 (NRT) does not influence theres
CYP1A2 activity = inc clearance of drugs (abrupt smoking, new SS CYP1A2 activity will be reached in 1 weeks)
Stop smoking = reduction in enzyme activity –> reduces clearance and inc risk of ADRs
Discuss NRT use in smoking cessation
First line for all motivated smokers, all equally effective –> abrupt smoking cessation is better
What S4 drugs are available to treat smoking cessation?
1) Varenicline = equal to NRT but superior efficacy to NRT monotherapy
2) Bupropion
What considerations are made for pharmacotherapy in smoking cessation?
Previous exp with pharmacotherapy
Cost and convenience
adherence issues
script meds versus OTC
potential for ADR
possible drug interactions
Discuss NRT patches for smoking cessation
ADRs = headache, dizzy, vomiting, vivid dreams, skin irritation
Apply to non-hairy, clean and dry area of body, rotate each day
Good for high dependence smokers
Discuss NRT gum for smoking cessation
ADRs = headache, dizzy, N/V, irritation of throat/mouth, dyspepsia
Chew slowly until taste becomes strong/tingly, park in cheek for 30 mins
Discuss NRT inhaler for smoking cessation
used based on cravings
ADRs = cough, mouth/throat irritation, headache, dizzy, N/V
shallow puffs every 2 seconds or 4 deep puff per min
Discuss NRT oral film/strips for smoking cessation
ADRs = hiccups (and the others)
DO not chew or swallow, allow to dissolve
Quick acting
Discuss NRT lozenge for smoking cessation
Good for heavy dependence
ADRs = same as others
allow to dissolve, dont chew, last around 20-30 mins
Discuss NRT oral spray/mist for smoking cessation
ADRs = like others, burning lips, indigestion
Used prn, side of cheek or under tongue
Discuss the reasoning behind NRT dual therapy
Two NRT products are more effective
Patches = steady release
Oral forms = fast relief from cravings
When is dual NRT therapy recommended?
1st line for those who smoke and are nicotine dependent
Unable to quit using NRT monotherapy
experience cravings using NRT monotherapy
Discuss the mechanism of Varenicline
Nicotine receptor partial agonists
In absence of nicotine = reduces withdrawal and cravings
In presence of nicotine = blocks nicotine’s ability to bind with receptors (no pleasure)
There are changes in mood, behaviour, and suicidal thoughts
How and why is Varenicline’s dose titrated?
The dose is titrated due reduce the occurrence of nausea during the initial phases of treatment
Day 1-3 = 0.5 mg once daily
Day 4-7 = 0.5 mg twice daily
Day 8 onwards (11-23 wks) = 1 mg twice daily
What are some counselling points for varenicline?
Start taking at least a week before you stop smoking
swallow tablet whole, dont chew or crush
May feel nauseous when taking this, can take with food to help this
Monitor for unusual mood changes, behaviour disturbances, depression, or suicidal thoughts
Finishing this treatment, can cause temporary increases in cigarette craving, irritability, and insomnia –> use fast acting product on hand
follow up with Dr 2-3 wks after starting
Briefly discuss some properties of bupropion
Antagonist at nicotinic cholinergic receptor, reduced urge to smoke, improve symptoms of withdrawal
As effective as NRT but less effective than varenicline
Drug interactions with antidepressants due to inhibition of CYP2D6 and metabolised by CYP2B6
When should bupropion not be used?
Hx of seizures, anorexia/bulimia
CNS tumours
alcohol/benzodiazepines w/drawal, use with MAOi
What are some counselling points for bupropion use
Start taking at least a week before you stop smoking
Take in morning to minimise sleep disturbances
swallow tablets whole, do not crush or chew
Only drink small amounts of alcohol or avoid all together, inc risk of fits and other ADRs
Use alongside NRT to improve effectiveness
Use with caution in patients taking other drugs that lower seizure threshold (antipsychotics, antidepressants)
follow up with Dr 2-3 wks after starting
Which non-prescription drugs that aid smoking cessation are listed on the PBS?
Nicotine patches = aid to quitting for those in support/counselling programs, not available at same time as other subsidised patches
Oral forms of NRTs subsidised = gum and lozenges for use as sole PBs subsidised therapy (combination therapy not on PBS)
Under PBS = max 12 weeks of PBS-subsidised NRT available per 12 month period
