Smoking Cessation Flashcards
What are some characteristics of the average smoker?
24 years old
14 cigs per day
lights up within 30 min of waking (reduces chances of quitting by 40%)
Are patients confident about the efficacy of NRT therapy in smoking cessation?
Somewhat
1/3 of smokers in Ontario do not think NRT therapy is effective
NRT is effective, and we need to deconstruct misconceptions
How many people start smoking?
10-15% of kids will become smoking adults
What are the two aspects of a smoking addiction?
- Physical (mood-altering effects)
- Behavioral/Social (ritual smoking, cigarette breaks)
What are toughest periods when trying to quit smoking?
First 2 days (irritability, anxiety, depression)
Does quitting smoking have an impact on weight?
Weight gain of up to 5kg is seen following discontinue of smoking
What are the Rules of 3 when it comes to smoking cessation?
3 minutes (the desire to smoke lasts 3 minutes, need to overcome this)
3 days (this is how long the physical symptoms of withdrawal last, but psychological effects remain)
3 weeks, months, years (full end of addiction, time period depends on each patient)
What are the effects of smoking on drug metabolism?
Nicotine increases levels of catecholamines, causing increased SNS activity. This results in increased metabolic rate
Aromatic hydrocarbons can affect enzyme induction (increased number of CYP enzymes, therefore reduced drug concentration)
Does smoking have significant drug interactions?
No, any impact is minimal. The impact is only seen in a few drugs like the following:
- Psychotropic agents
- Methadone
- Some oncology agents
What is the most common method for smoking cessation?
Cold turkey
How many people quit smoking in a given attempt?
10% after 1 year have successfully stopped smoking
What types of counselling are needed to support patients trying to stop smoking?
- Addictions counselling (not for pharmacists, refer to psychologists and therapists)
- Pharmacist counselling (drug and health advice)
Are nicotine vapes useful in smoking cessation?
No, vapes also deliver a quick hit like cigarettes
They do not reduce urge, simply shift patient from cigarettes to vaping
What is the efficacy of Lobelia plant in smoking cessation?
Not great (natural product)
It has an effect, but it is very minimal
How does silver acetate work in smoking cessation?
Mouthwashes and lozenges that have Silver acetate will cause a terrible after taste if patient starts smoking
What is the most common pharmacological delivery system for NRT?
Nicotine gum
How does nicotine gum work in smoking cessation?
Slower nicotine hit (absorption via bucal route)
Just enough to provide urge control, but not enough to get hooked on the gum
How should a patient chew nicotine gum?
Release rate is controlled by chewing (do not chew all at once)
Chew a few moments until peppery taste, then cycle of bite, bite, park for up to 30 minutes
What is the effect of coffee and acidic drinks on the efficacy of nicorette gum?
These drinks affect mouth pH, which affects rate of buccal absorption
Can a wrong dose for nicorette gum be selected (2mg or 4mg)?
Not really, patients will adjust how much they chew
What are the two approaches to nicorette gum dosing?
- PRN (used when urge hits, not optimal mimics cigarette use)
- Scheduled (defuse the next urge, breaks the connection between satisfaction associated with smoking, preferred approach)
What are side effects of nicorette gum?
Not very significant
Throat irritation, jaw fatigue, burping, nausea
Is it okay if a patient is smoking and chewing gum?
Not ideal, but this can help patients reduce the number of cigarettes they smoke.
Full discontinuation of cigarettes can be done later
What is the advantage of transdermal (patch) nicotine?
It can provide a baseline nicotine concentration (apply once every 24h)
How should a transdermal nicotine patch be applied?
Locate hairless site on upper body, outer upper arm, hip
Change daily at same time (do not reuse site for 7 days)
What is the benefit of transdermal nicotine patches on smoking right after waking?
prevents onset of urge to smoke right after waking due to constant delivery of nicotine all night
When should transdermal nicotine patches be weaned down to lower doses?
- Eliminate dependency
- Allow for behavioural changes
- Patient becomes more aware of cessation benefits
- Get over stress associated from trying to stop smoking
What is the effect of adding NRT therapy to patients that are trying to quit smoking in a given attempt?
NRT therapy doubles the likelihood of success for a given attempt (20%)
How can different types of NRT therapy be combined?
Use patch scheduled + an active form PRN (gum most often used)
- Passive form: patch (provides baseline nicotine)
- Active forms: gum, lozenge, inhaler, mist (used to control burst of smoking urge)
How do nicotine inhalers work?
Puffing sensation stays intact (cig-like)
Buccal absorption (do not deeply inhale into lungs)
What are the directions for nicotine inhaler use?
Patient should use whatever works to control their urges
How are nicotine lozenges used?
Park in cheek between hits (like gum)
Use for about 30 min
1mg = one cigarette
Dose according to smoking habits
Slowly taper frequency of use over a period of months
How are mini-lozenges different from regular nicotine lozenges?
Dissolves 3x faster (within a few minutes)
How is the Quick-mist nicotine used?
Spray into mouth for buccal absorption (not towards back of throat)
Effect seen within 60 seconds (shortest lag time out of all of the NRT therapy options)
Do not eat or drink for 15 min
What drug class does bupropion belong in?
Anti-depressant
Big therapeutic jump from NRTs
What is the efficacy of bupropion in smoking cessation?
Good (20% success rate on its own)
Anti-depressants like bupropion can reduce cravings
How should bupropion be started?
continue smoking + 150mg OD bupropion for seven days, then stop smoking and continue bupropion
What are some common side effects of bupropion?
- Dry mouth
- Insomnia
- Reduced weight gain
- Dermal reactions
What is the likelihood of bupropion-induced siezures?
0.1% at 300mg
0.4% at 300-450mg
Incidence is higher for patients with seizure history (MDs will not start these patients on bupropion)
What are some reccomendations to reduce seizure risk?
Divide daily dose into BID (separate by 8 hours, and last dose should not be near bed time)
What is the most common pharmacological agent used in for smoking cessation?
Varenicline (partial nicotine agonist=some of the hit is experienced)
Slower dopamine release vs. nictotine activation of receptor
What happens if the patient smokes while on varencline?
Varencline has greater affinity for receptor, so nicotine is not able to bind to the receptor. Therefore, smoking while on varencline has no effect on the release of dopamine
How to start varencline?
Slowly titrate dose over a course of a week to 1mg BID, but continnue to smoke.
Discontinue smoking between day 7 and 14
Is the varencline+NRT combination valuable?
No, the NRT will not be able to bind to the receptor because varencline is already a partial agonist
No additional value for NRT
What is cytisine (Cravv)?
It is a plant-derived version of varenicline
considered useful, JT is sceptical
What factors should be considered when reccomending an agent for smoking cessation?
- Health status (derm, TMJ, heartburn, cardio)
- Quit history
- Dependency (early morning cravings, hand-mouth ritual)
- Product use history (expectations)
- Patient preferences (ease of use, control of nicotine intake, concerns about weight gain)
- Cost (drugs can get expensive, but so is maintaining a smoking habit)
What is the guideline for NRT use following heart disease?
Do not use within 2 weeks of a heart disease event/symptoms
Can preganant women use NRT?
There is no safe NRT dose during pregnancy, as it can cause harm to fetus, but it is safer than smoking
Should NRT be stopped after 3 months of therapy?
No, NRT can be used as long as the patient would like to take
Can a patch and other types of NRT, be used together?
No, the guidelines requset physicians and pharmacists to not combine the two
Are pharmacological agents responsible for the lion’s share of avoiding smoking urges?
No, motivation is likely the most important part
Cessation aids play a smaller, but still important role
What are the stages of change in smoking cessation?
- Precontemplation (they are not even thinking of changing)
- Contemplation (They are now thinking about the situation
- Preparation (patient prepared to be a non-smoker)
- Action (actually implement changes)
- Maintenance
What are the three underlying addictions in smoking?
- Behavioural addiction: (more important than the physical (drug) addiction, ex. i like how the smoke feels in my mouth)
- Physical addiction
- Social addiction
Why do we give patient’s a period of time before they decide to quit smoking officially?
- Eliminate your dependency on nicotine
- Replace smoking with other activities
- Become more aware of the benefits of treatment
Are there any failures in attempts to quit smoking?
No, every attempt is movement towards the right outcome
