Smoking Cessation Flashcards
What makes cigarette smoking so addictive?
Rapid delivery of nicotine to the mesolimbic reward pathway
Short half life of nicotine (60-90 min) forces repeated administration
What drug enzyme does smoking impact (causes many drug interactions with)?
Inducer of CYP1A2
Good for keep in mind for patients who quit smoking
Is reduction in smoking provide health benefits?
No, but it is associated with subsequent successful quitting
What are the “5 A’s Approach” to smoking cessation?
Ask
Advise
Assess
Assist
Arrange
What non-pharms can be recommended for smoking cesssation?
Behavioural therapy for 8-24 weeks has been shown to be effective at follow-up at 6 months
Long-term remission >1 year following single course of therapy was only in small number of patients
What non-pharm choices have no clear evidence for long-term efficacy?
Hypnosis
Acupuncture
Acupressure
Laser therapy
What are 5 evidence-based steps required to successfully quit?
1) Set a target quit date
2) Getting professional help
3) Social support
4) Medications to quit smoking
5) Problem solving methods of counselling
Is abruptly stopping on quit day or gradual reduction associated with better quit rate?
Both have comparable quit rates
There is a dose-response relationship between _________ and quit success.
Counselling
When should pharmacotherapy be added to patient’s smoking cessation plan?
If patients smoke more than 10 cigarettes per day
When is a contraindication to pharmacotherapy?
Adolescents (no benefit over behavioural approaches)
What is first line for smoking cessation?
Good to note that varenicline and bupropion is not actually considered second-line.
However, Health Canada has advised prescribers to consider giving:
Nicotine replacement therapy (NRT) prior to prescribing bupropion and varenicline.
What does American Thoracic Society suggest as first-line smoking cessation therapy?
Varenicline (higher quit rates than bupropion and single forms of NRT)
Especially if patient is uninterested, unwilling, or not ready to set a quit date to achieve smoking cessation
What can you combine with the nicotine patches to act as boluses to help control cravings?
As-needed gum, inhaler, lozenges, mouth spray
What two forms of nicotine add-on therapy is not available in Canada?
Nicotine nasal spray
Sublingual tablets
What is the standard duration of therapy for NRT?
8-12 weeks
Even though that is the standard duration, it is often insufficient in facilitating abstinence. How long can you extend the use of NRT to?
24 weeks
What is the max number of weeks you can extend NRT use to?
24 weeks
No additional benefit past that
NRT is relatively safe. When do we need to be cautious?
Extreme exercise can increase nicotine absorption
OK to keep on for mild to moderate exercise.
Remove patch if vigorous exercise.
Apply after exercise and limit to upper body to reduce risk of excess absorption.
Which smoking cessation drugs are only available by prescription?
Bupropion and varenicline
What drug class is varenicline?
Alpha4 beta2-nicotinic receptor partial agonist
What is on the boxed warning of varenicline product monograph?
Caution and monitor for mood changes and thoughts of harm to self or others (reports of neuropsychiatric side effects)
For patients with a history of past and current psychiatric illness, use varenicline with caution
Subsequent studies show that risk is much lower than anticipated but still monitor
What is another concern with varenicline use?
Potential cardiovascular risk
Exercise caution before initiating varenicline in patients with cardiovascular concerns
What drug class is bupropion?
Dopamine, norepinephrine and serotonin reuptake blocker
Bupropion combined with ________ is more effective than bupropion alone, but only if started at the same time (not as add-on therapy).
NRT
What are some side effects we need to watch out for with bupropion?
Agitation type reactions
Mood or behavioural changes
Thoughts of self harm
What are actual second line pharmacotherapies?
Have evidence for efficacy but not officially indicated
Clonidine
Nortriptyline
When would nortriptyline come into play?
When first line options are unaffordable or have not worked
When would clonidine come into play?
Good for if patient has coexisting hypertension where appropriate.
Caution with postural hypotension
What is a natural health product that is advertised for smoking cessation. Is it effective?
Cytisine (Cravv)
Non-inferior to NRT
What drug class is cytisine?
Partial nicotine agonist
Do you need a prescription for cytisine?
No
How is cytisine dosed?
Initial: 9 mg/day (divided in 6 doses)
Taper until 1.5mg (approximately day 21-25)
When should the quit attempt be made?
Fifth day after starting the medication
When do we initiate combo therapy for smoking cessation?
Monotherapy is preferred but if unsuccessful, can try initiating combo therapy.
What are electronic delivery systems?
E-cigarettes
- battery powered mechanism that heats and vaporizes a liquid mixture that contains nicotine and mimics cigarette behaviour
What is Health Canada’s stance on EDS?
Does not recommend due to lack of safety in regard to exposure to vaporized propylene glycol
What is a possibly bothersome side effect of smoking cessation for patients?
Post-smoking cessation weight gain
Does smoking cessation with pharmacotherapy affect the change in body weight?
No, they are both associated with changes in body weight.
However, smoking cessation with pharmacotherapy is associated with less weight gain.
Of the three different pharmacotherapies, which associated with the least weight gain?
Bupropion due to its anorexiant properties
When does post cessation weight gain occur the most?
First 3 months of quitting
4-5kg at 12 months
What are some tips we can suggest to help patients minimize food cravings that can cause weight gain?
Eat low calorie snacks such as carrots, celery sticks, and/or using sugar free candy and gum.
Encourage physical activity as well.
What drug interactions are associated with smoking cessation?
Smoking induces CYP1A2 enzyme. Smoking cessation can lead to higher doses of drugs such as caffeine, clozapine, diazepam, estrogen, fluvoxamine, methadone, nifedipine , olanzapine, rasagiline, theophylline, trifluoperazine, warfarin
What are adverse effects associated with smoking and pregnancy?
Intrauterine growth retardation, increased risk of sudden infant death syndrome, reduction in amount of breast milk
Pregnancy is the one of the best times to promote smoking cessation. Quitting at anytime during pregnancy is associated with improved birth outcomes. True/False?
True
Are there any risks with stopping cold-turkey while pregnant?
No
Is pharmacotherapy like varenicline and bupropion safe for pregnancy?
No
What would be a more acceptable pharmacotherapy option if patient needs in pregnancy?
NRT, but still lack of concrete evidence and efficacy in pregnancy. Start with lowest dose if needed (gum)
Behavioural therapy preferred
If we must use NRT therapy in pregnancy, what is the recommended dosing and formulation?
Gum for 8-12 weeks with the goal of quitting.
Reserve the transdermal patch for heavily dependent people who smoke and do not respond to gum.
If using patch, remove after 16 hrs (bedtime) to reduce fetal nicotine exposure.
How long should you stop smoking prior to conception if possible?
At least 3 months for male to allow for sufficient time to replace abnormal sperm (major cause of infertility)
When does bupropion come into play during pregnancy?
Only if patient has diagnosis of depression
However, there is a higher risk of congenital malformation
Which therapies are safe in breastfeeding?
NRT and bupropion
Varenicline (no safety data)
Continued breastfeeding is associated with delayed relapse in quit smoking. What non-pharms can we recommend to limit baby from smoke exposure during breastfeeding?
Smoke outdoors
Don’t smoke before or during breastfeeding
Chang clothing and hand wash
If patients often have slips while on medications, what can we recommend?
Continue on medication for at least 4 weeks
