Smoking Cessation Flashcards
What we hope to do as pharmacists?
If you help a person quit smoking, way to go, you just added years to their life
If you don’t get them to quit right now, but you set the stage to eventually quit, that is still a huge success
Don’t get bogged down trying to get the ‘best’ method; simply trying something is likely close enough
What is a good move? What is hard about quitting?
You will see that combining a patch with a second form of NRT is often agood move
Pharmacists are sticklers for following the rules. But in the case of NRT cessation products, we can be flexible with dosing
Starting them on a product is just a small part of the equation. The behavioral aspects of smoking (and quitting) is where the real issues lie
Does smoking impact other meds?
Starting to smoke, or quitting, generally has little impact other medicines the person may be using (a few exceptions)
Is cultural tobacco connecected with addiction?
NO, tobacco use today, including inhaling has no connection with First Nations.
Aveerage SMoker Stats
- 24 years old, 14 cigs per day, lights up within 30 mins of waking
Why is lighting up 30 mins before wakening bad?
- Reduce the chances of quitting by 40%
Can one smoke on the patch?
People can smoke on the patch, if drop them down from 15 cigs to 7 cigs
SUCCESS (would rather have them not smoke on the patch)
Smokers trying to cut back tend to…..
Smokers trying to cut back on the number of cigs tend to take longer drags and hold the smoke longer
Squeeze the filter, more smoke gets in
Are smoking warnings effective?
No - Only one that had traction “look 30 at 16”
What are the aspects of an addiction?
Physical:
Mood altering
Instant reinforcement
Nicotine –> Dopamine
Behvaioural/Social:
Ritual of smoking
Morning coffeee
After meals
Cigarette breaks
Bar/friends
What days are the toughest to quit smoking?
- First. 2 days
Irritability, anxiety, depressed, diffuclty concentrating
- Weight gain - Approx. 5 kg (most within first 3 months)
What is the rule of 3”s?
3 minutes ‘nic fit’
3 days nic addiction
3 weeks psych addiction
Nicotines impact on Drug Metabolism
- Increase catecholamines –> Increase metabolic rate
- Aromatic hydrocrabones –> Increase metabolism through enzyme induction
- One of the effects may be a drop in blood level, however, re-establishes new blood level
If someone starts smoking, blood levels may
Drop
If someone stops smoking, blood levels may…
- levels rise as enzyme induction now normal (slower metabolism)
If a smoker continues to smoke while on a medication blood levels
No effect
Is there a big worry about drug levels? Which agents? What to do if worried?
- In general, minimal impact of drug tx
- Psychotropic agents, methadone, some oncology agents
- FAX MD re the chnage
What is a word we should avoid?
“FAILURE”
What is th emain method of cessation?
Cold turkey -nNeed willpower here
In regards to counselling, an important distinction is……
Addictions counselling vs Pharmacist counselling
Big difference!
Psychiatry –> Different
Pharmacist –> More of an advisor; cannot provide behvaioural changes
Should we be worried about scams?
Scams vs. legitimate
- If they act as. a crutch, great
- Device to fiddle with
Should e-cigs be used to quit?
No - Fast hit of nicotine, want slow delievery
Lobeila Plant
nicotine-like substance
- Historical –> pre-champix
Silver Acetate
Silver acetate + smoke –> Bitter taste
- Historical
Deterrent –> Tastes terrible
To quit one must have ________. If we are busy, we need to inform the pt of what?
Still need motivation
Product + “program”
IF you have NO time for the patient ….
READ THE FINE PACKAGE INSERT
Nicotine Gum Brands
Nicorette and Thrive
- 2 or 4 mg in gum resin
Nicotine Gum release. How long does it take to work?
- Just enough to take the edge off
- DO not chew fast, slow release prep 9controlled by chewing)
- BUCCAL DELIEVERY: want nicotine to hit mouth, absorbed (little lag), to the brain
- Gum takes 5-8 mins to work –> Morning smokers that lag time is important
Nicotine Gum Technique
BITE BITE –> PARK –> repeat for up to 30 min
- if smoker needs more, can go faster
- If smoker needs less, can go slower
- Chew until pepper taste
Nicotine GUm Interactions
-Coffee and acidic drinks slow abdorption
- SMoke with coffee, have gum before coffee
- Chew a bit more
Is 2 or 4 mg a big mistake if switched?
NO –> Chew what you need
- Under-dosing is a major issue
NRT Heart Attack
If have heart attack, 2 weeks after then NRT –> Second heart attack is common anyways
- What if they smoke in those 2 weeks –> Easy call for JT to use Nicorette
Two approaches to Gum:
One should have what for how long?
PRN - Use whenever urge hits but always playing ctach up
Scheduled: Defuses the next urge
Emergency supply likely needed for months
Wean Off: Follow package insert; hyowever, can be on for a long time
Nicotine Gum Side Effects
Throat Irritation
Burping/hiccups
Jaw fatigue
Nauseau
Can one become addicted to the gum?
Very hard, slow release prep
- Preferably do not want the smoking during gum use but if smoke less cigaretets than ok
Transdermal Nicotine Patch Design
- 114 mg of Nicotine, 21 mg over 24 hours to the
- 7 mg, 14 mg, 21 mg
Nicotine levels via smoking vs patch
Smoking fluctuates
Patch is constant
Patch SIte Application, switching sites?
upper body / outer upper arm / hip
clean / dry / non-hairy / healthy skin
showering is fine with it on
Don’t re-use a site within 7 days
Patch S/e
Local rxn –> redness, move it around
“How are you with band aids?”
Headache, insomnia, nauseai (or just withdrawal sx)
Nightmares/dreams
–> Take 24 hour patch off at night vs 16 hour patch (hard to find) –> less impact on those who smoke upon wakening
Step Down Tx
- Not worried –> Follow pt
- If not ready, maybe behavioural change shave not occured
- FLexible algorithm
A person is ready to drop wean off the patch when:
eliminate dependency
allow for behavior changes
become aware of cessation benefits
get over stress from trying to quit
What is the suces srate of all NRT’s?
- 1/10 will succeed (10%), NRT increases it to 20%
What are the active forms of nRT? They are also refrred to as….
“Rescue methods” –> PRN use with patch to cover emergencies
Gum, lozenge, inhaler, mist
Passive form (baseline level) NRT
PATCH
Inahler Effectiveness and Absorption
puffing sensation stays intact (cig-like)
buccal absorption again (not pulmonary)
Inhaler Directions
6 min, max 12 carts/day
- Low level directions, get in ball park
Lozenges Choosing a Strength:
Nicorette: 2, 4 mg
Thrive: 1,2 mg
- Does not matter, suck on it more or less
Lozenge technique
Suck –> Until nicotine flavour is strong
Rest –> Cheek until taste fades
Repeat –> 30 mins
Mini-Lozenges Difference from lozenges. Strength?
Dissolves 3x faster
Lasts about 10 min
Move from side-to-side prn
2 / 4 mg
Quick Mist Directions
sprayed into mouth (but not towards back of throat)some effect within 60 seconds
‘hold’ spray in mouth few seconds + don’t inhale
don’t eat or drink for about 15 min
Fastest delivery system
Quick-mist
Bupropion:
- Two strengths: SR and XL
Does bupropion only work for depressed people:
Depression more common in smokers
Quitting is difficult until depression is dealt with
It works in the non-depressed too
How does bupropion work?
Antidepressants seem to reduce cravings
↑ NA and ↑ DA via uptake blockage (noradrenaline, doapmuine)
STILL NEED WILLPOWER
Bupropion Does and Schedule
- 150 mg bid SR (max) (switch to bid on day 4)
- Keep on smoking for first week, day 7 go cold turkey, can add on nRT at any point
Bupropion s/e, di
S/e:
Dry mouth, insomnia, decraesed weight, derm
DI: MAOI’s, seizure disorders
DOsing interval Bupropion
Sr: Want > 8 hour seperation, and last dose not near bedtime
Bupropion Effectiveness:
Bupropion: 20%
With NRT: 30%
Other anti-depressants
Notriptylline
SSRI’s
Varencilline (CHampix) MOA:
- Partial nicotine agonist
- Some hit of nicotine, get enough dopamine to wave off withdrawal
- Also blocks nicoitne from smoke from binding
Dosing of CHampix
0.5 mg OD (1-3), 0.5 mg BID(4-7), 1 mg BID (8)
- Titration helps decrease nausaeu
- STop smoking for day 7 to 14
Does champix with NRT make sense?
NO
Champix S/e
Nauseau, abnormal dreams, constipation, drowsiness
- Increase sucicide risk?????
Cytistine
- OTC cap
- Plant-derived
Considered useful - Varencilline-like
Slecting an agent: Ask about:
Ask about their smoking habit
(# cigs overall, how early in day, after meals, etc)
Number of quit attempts
tried what to date?
what seemed to help (however small)?
In regards to slecting an agent one should consider:
Pt’s expectations and bring them to reality
Weight gain Smoking Cessation
1 cigarette burns about 10 calories
If a quitter does not change any eating habits, they will likely gain - about 3-4 kg
Can one use NRT while on zyban (bupropion)? Champix?
YES
Champix No –> Does not makes ense
Champix and Zyban Combo?
Makes people a bit more nervous
- A possibility –> More s/e
- Shown some value for sure and sometimes no value - evidence lacking
Preganncy and NRT
There is NO safe dose of nicotine during pregnancy.NRT, although potentially harmful to the fetus, is safer than smoking
GO WITH QUICK RELEASE OVER PATCH
Treatment with NRT DUration:
Withdrawal symptoms vary minute by minute, hour byhour, day by day.
Treatment should be flexible enough to put more control in the hands of the smoker. Smokers should vary their approach according to their needs.
Continue with NRT as long as need be
What is the patch maximum per day?
- 84 mg
What is the main thing needed for peopl to quit?
BEHAVIOUR CHANGES –> MOTIVATION
Make behaviour harder to do –> Make new behaviour easier to do
Steps of Behaviour CHange:
Pre-contemplation (I love to smoke, see not benefits of quitting)
Contemplation
Preparartion (turning point)
Action
Maintenance (now se ebenefits, what was i thinking?”
Smoking is how many addictions:
3
Behavioural, Physical, Social
need time to:
eliminate your dependency on nicotine
replace smoking with other activities
become aware of the benefits
Pharmacists need to know:
WHY PEOPLE SMOKE
- Plan for cravings
Cravings last how long? what to do?
Last 3 mins
The 4 D’s
- DO something else
- Delay
Deep breathing
Drink water
Tips for cravings
- Tell family about attempt
remove ashtrays
Reward yourself
Quit Day Technique
brush your teeth, then smoke right away (GROSS)
change brands
use your other hand
change seating in the house
try cutting down; smoke only half the cig postpone lighting for a few minutes
emptying ashtrays (or put butts in a jar)
put cigs in a different spot (house, car, etc)
- 2 WEEKS
Smokers Cough
often worse in morning
minimal sputum at first, becomes productive
~40% of smokers have one
arts to decline after ~3 months
