Smoking Cessation Flashcards
Why are pharmacies useful for tobacco cessation?
-Accessible
-Mediations are safe and effective
-Team with tobacco quitline
What is the tobacco quitline?
1-800-QUIT NOW
What percent of smokers want to quit?
68%
What percent of smokers tried to quit in the last year?
55%
What is tobacco use and how should it be treated as?
Tobacco use is an ADDICTION and it should be treated as a CHRONIC MEDICAL ISSUE
Patients with what disease states have the most to benefit from quitting?
-Cardiovascular disease
-Respiratory disorders
-Diabetes
-Cancer
-Pregnancy + lactation
-Mental health
What are the two parts of tobacco dependence?
-Physiological
-Behavioral
What makes up the physiological component of tobacco dependence AND how do we treat it?
The addiction to nicotine
Treatment: medications for cessation
What makes up the behavioral component of tobacco dependence and how do we treat it?
The habit of using tobacco
Treatment: behavior change program
Which part of tobacco dependence do we manage first?
Physiological
What neurotransmitter is involved in the pleasure that people get from cigarettes?
Dopamine
How long does it take for nicotine to reach the brain?
10-20 seconds
What is the half-life of nicotine?
2 hours
What is the time course of nicotine withdrawal symptoms?
Manifest in first 1-2 days
Peak within first week
Subside within 2-4 weeks
The following are medical conditions caused by exposure to nicotine:
A. COPD
B. Infertility in women
C. Cerebrovascular disease
D. None of the above
D
**nicotine is the addictive component of tobacco products, but it does NOT cause the ill health effects of tobacco use
What is the current predominant of tobacco use?
A. E-cigarettes
B. Smokeless tobacco
C. Cigarettes
D. Cigars, cigarillos, filtered little cigars
C. cigarettes
What affect does help from a clinician have on the odds of quitting?
Odds of quitting doubles
What are the five A’s of smoking cessation?
Ask (about tobacco use)
Advise (tobacco users to quit)
Assess (readiness to quit)
Assist (with the quit attempt)
Arrange (follow-up care)
What are the 5 R’s to use to motivate a patient when they are not ready to quit?
-Relevance
-Risks
-Rewards
-Roadblocks
-Repetition
Does smoking relieve stress?
No
-smokers confuse the relief of withdrawal with the feeling of relaxation
What are the three steps in brief counseling?
Ask-Advise-Refer
Are brief interventions effective?
Yes
Most health-care providers and most patients are familiar with tobacco quitline services. True or False
False
How many attempts will the quitline make to reach out to a patient?
5
What are the first-line therapies for smoking cessation?
-Nicotine gum
-Nicotine lozenge
-Transdermal nicotine patch
-Nicotine oral inhaler
-Nicotine nasal spray
-Bupropion SR tablets
-Varenicline tablets
How are nicotine gum/lozenges dosed?
Based on the patient’s first cigarette of the day
What are the directions to use nicotine gum?
- Chew slowly
- Stop chewing at first sign of peppery taste or tingling
- Park between cheek and gum
- Chew again when peppery taste or tingle fades
How often are nicotine patches dosed?
Once daily
What is a con that is specific to nicotine patches?
Cannot be titrated
Can a patient take both varenicline and bupropion?
YES
*there is no drug-drug interaction between the two
How often are bupropion and varenicline dosed?
Twice daily
When is bupropion initiated?
1-2 weeks before quit date
What dose of bupropion is available?
150mg
What else may bupropion treat besides smoking cessation?
May be beneficial in patients with depression
What are some concerns associated with taking bupropion?
-Seizure risk increased
-Many contraindications
-Monitor patients for neuropsychiatric symptoms
-Do not use in patients with history of eating disorders
What is the dosing of varenicline?
0.5 and 1 mg
When is varenicline initiated?
1 week before quit date
Which of the two medications (bupropion or varenicline) is the most effective agent to use as a monotherapy?
Varenicline
How should varenicline be taken?
After eating and with a full glass of water
-decreases nausea risk
What adverse effects are associated with varenicline?
-Nausea
-Sleep disturbances/ Insomnia
-Monitor for neuropsychiatric symptoms
***Expensive
Which of the two medications is LESS expensive: bupropion or varenicline?
Bupropion
What is the varenicline FIXED QUIT approach?
Set quit date for 1 week after starting varenicline
-Continue treatment for 12 weeks
What is the varenicline FLEXIBLE QUIT approach?
Start varenicline and pick quit date between 8 to 35 days from treatment initiation
-Continue treatment for 12 weeks
What is the varenicline GRADUAL QUIT approach?
-Start taking varenicline and reduce smoking by 50% within first 4 weeks. Then an additional 50% in next 4 weeks. Then complete abstinence by 12 weeks
Which of the following smoking cessation medications has a boxed warning for serious neuropsychiatric side effects?
A. Bupropion SR
B. Varenicline
C. A and B
D. None of the above
D
*boxed warnings for both medications have been removed
How many hours apart must bupropion be dosed?
8 hours
Which of the following is TRUE regarding use of bupropion SR for smoking cessation?
A. Its use is contraindicated in pregnant women
B. The doses must be spaced at least 10 hours apart
C. Its effectiveness is comparable to varenicline
D. Insomnia is a common side effect
D. Insomnia is a common side effect
For most patients, nicotine withdrawal symptoms will generally subside within how long after quitting?
A. 24-48 hours
B. 7-10 days
C. 2-4 weeks
D. 2-4 months
C. 2-4 weeks
How are nicotine gum and lozenges dosed based on when a patient has their first cigarette of the day?
If first cigarette smoked is > 30 minutes after waking:
-Use 2 mg gum or lozenge
If first cigarette smoked is < 30 minutes after waking:
-Use 4 mg gum or lozenge
Which of the following is the most appropriate combination therapy dosing for a patient who smokes one pack of cigarettes/day and smokes his first cigarette within 20 minutes of waking?
A. 21 mg patch daily + 4 mg nicotine lozenge every 1-2h while awake
B. 21 mg patch daily + 4mg nicotine lozenge every 1-2h as needed
C. 21 mg patch + 14 mg patch daily
D. 4 mg nicotine lozenge four times daily + nicotine nasal spray every 1-2h while awake
B
How may the constituents of tobacco smoke affect the metabolism of other drugs?
It may enhance the metabolism of the drugs
When should drug interactions with smoking be considered?
When a patient starts smoking, quits smoking, or markedly alters their levels of smoking
What are some common drugs that have a decreased affect due to interactions with tobacco smoke and what is the basis of these interactions?
Tobacco smoke induces CYP1A2
Drugs with decreased effect:
-Caffeine
-Clozapine
-Olanzapine
-Irinotecan
*mental health drugs
Which enzyme is induced by tobacco smoke and causes drugs to be metabolized faster?
CYP1A2
How should caffeine be adjusted when quitting?
Decrease caffeine intake by 50% and limit it especially after early afternoon
What interaction is possible for patients who take hormonal contraceptives and also smoke?
-Increased risk of severe cardiovascular adverse effects
**This interaction does NOT decrease efficacy of hormonal contraceptives
What is the telephone number for the Indiana toll-free tobacco quitline?
A. 1-800 JUST QUIT
B. 1-800 QUIT NOW
C. 1-800 NO SMOKE
D. 1-800 NO BUTTS
C. 1-800-KETCHUP
B
What women are at a significantly elevated risk for developing cardiovascular adverse effects when they take birth control and smoke?
Women 35 years or older AND who smoke at least 15 cigarettes per day
A 38-year old woman taking combined hormonal contraceptives AND who smokes greater than ___ cigarettes per day is at a significant increased risk for thromboembolism, stroke, and myocardial infarction.
A. 5
B. 15
C. 20
D. 30
B
What is the standard dosing of varenicline?
Day 1-3: 0.5mg daily
Day 4-7: 0.5mg twice daily
Day 8 to end of treatment: 1mg twice daily
**Titrated to avoid GI effects
*Up to 12 week, option to continue treatment in select patients only
Which of the two smoking cessation drugs does NOT have a generic formulation available?
Varenicline
Which study showed that there are no significant differences in neuropsychiatric events in patients taking varenicline and bupropion vs placebo and that varenicline has the highest efficacy?
The “EAGLES” study
What affect may caffeine have on nicotine withdrawal effects?
Caffeine may make nicotine withdrawal symptoms worse
What are some common reasons for relapse?
-Chooses to use no medication
-Daily non-adherence undermines treatment effects
-Insufficient duration of overall therapy
Nicotine inhaled from tobacco smoke is estimated to reach the brain within:
A. <5 seconds
B. 10-20 seconds
C. 5-15 minutes
D. 1-2 hours
B. 10-20 seconds
ENDS use is MORE harmful than smoking cigarettes True or False?
FALSE
-evidence shows that it is less harmful
Should ENDS use be promoted as a safe alternative to smoking?
NO
According to data from clinical trials, which of the following is most effective for smoking cessation?
A. Bupropion SR
B. Electronic nicotine delivery systems
C. Nicotine replacement therapy
D. Varenicline
D. Varenicline
Which of the following statements is TRUE regarding electronic nicotine delivery systems?
A. ENDS are a safe alternative to cigarette smoking
B. ENDS have lower exposure to carcinogens and toxins than tobacco smoke
C. ENDS have a lower risk for nicotine dependence
D. ENDS are more effective for cessation than nicotine replacement therapy
B
What are the contraindications of bupropion?
-Seizure disorder
-Current or prior diagnosis of an eating disorder
-Abrupt discontinuation of alcohol, benzodiazepines, barbiturates, and antiepileptic drugs
-Use of MAO inhibitors
