Smoking Cessation Flashcards
What questions should you ask to determine nicotine dependence?
1) PPD history
2) how soon after waking do you have the first cigarette (more dependent smokers smoke within first 30 minutes of waking)
3) have you tried quitting before
What are symptoms of nicotine withdrawal?
dysphoric/depressed mood; insomnia; irritability/frustration; difficulty concentrating; anxiety; restlessness; increased appetite or weight gain
How should we address triggers?
Many smokers associate tobacco with environmental triggers like morning coffee, alcoholic drink, end of meal. NEedto anticipate them and find ways to overcome them (avoid trigger exposure, engage in other activities, elicit a support system)
When should follow-up contacts be arranged?
Within the first week of quitting and within the first month
What is the behavioral therapy that can be offered to patients?
specialty clinic; smoking cessation program; office-based supplemented by free telephone counseling (1-800-QUIT-NOW)
What is a good pharmacologic choice for patients concerned about weight gain?
buproprion
Should buproprion be used in patients with bipolar disorder?
No, it may trigger mania.
But it can be used in MDD and schizophrenia
Becaue it requires long-term management, you can think of tobacco dependence as a
chronic illness
How do help the patient make a quit date?
- -Quit date shoudl be within 2 weeks
- -tell family, friends, coworkers
- -anticipate challenges, particularly during first few weeks (including nicotine withdrawal symptoms)
- -remove tobacco products from environment
How do you help with the problem of other smokers in the household?
Ask if there are other smokers! Encourage them to quit with or not smoke in the presence
What should you say to encourage hte patient and provide intra-treatment social support?
“My office staff and I are available to assist you”
Should patient start cutting down on smoking before quit date?
Doesn’t matter. no difference in overall abstinence
What if the patient is worried about gaining weight?
Maintain on pharmacotherapy known to delay weight gain (buproprion), nicotine replacemetn pharmacotherapies like gum, especially; reassure that weight gain is common and is self-limiting
If patient not ready to quit, what do you do?
Assess patient’s perspective of risks and benefits of continuing to smoke
Ask patient what he likes and does not like about smoking
What about smoking reduction versus complete cessation?
No bueno! 2 prospective cohort studies have shown that even those that reduce smoking by at least 50 percent had no change in all-cause mortality, whereas those who quit smoking completely did have a decrased risk of all-cause mortality
What if patient wants to relapse and asks about smoking a puff?
emphasize that even a puff will increase urges and make quitting more difficult
What are the 7 first-ine agents for tobacco cessation?
1) transdermal nicotine patch (long-acting, but takes a while to peak…vs cigs that deliver immediately)
2) nicotine gum (shorter acting)
3) nicotine lozenge (shorter acting)
4) nicotine inhaler (shorter acting; REQUIRES PRESCRIPTION)
5) nicotine nasal spray (REQUIRES PRESCRIPTION)
6) buproprion
7) chantix
What is the goal of NRT?
to provide nicotine to a smoker without using tobacco, relieving nicotine withdrawal symptosm as the smoker breaks the bheavior of cig smoking. Avoids exposure to carbon monoxide that reduces oxygen delivery, oxidant gases that are atherogenic, and tars that are carcinogenic
How long should NRT continue?
2-3 months, or longer for patients with high rate of relapse
Can patients become addicted to the nicotine in NRT?
it could, but it’s rare: the dose of icotine is smaller and the delivery is slower, which prevents dependence
What doses of nicotine patches are given to patients?
If they smoke >10 cigs/ day,
21 mg/day for 6 weeks, 14 mg/day for two weeks, 7mg/day for 2 weeks.
If <10 cigs/day, then 14 mg/day for 6 weeks and 7 mg/day for 2 weeks
How do you use the patch?
One patch each morning to a non-hairy skin site. Removed and replaced with a new patch in the next morning. Patch site should be rotated daily to avoid skin irritation
If the patch is left on overnight, what can happen? How is that solved?
Insomnia and vivid dreams. Can be minimized by removing the patch at bedtime. Plasma levels of nicotine will reach baseline again 30mins after reapplication, and patient can use gum/lozenge while waiting for nicotine patch to take effect
How much nicotine gum should patients use?
If >25 cigs/d (1 pack), 4 mg
If <25 cigs/d, 2 mg
How much gum can patietns chew?
Smokers can chew one piece of gum every 1-2 hours over 6 weeks, with a gradual reduction over a second six weeks, for a total duration of three months
Why is it important to learn how to chew nicotine gum properly?
If the gum is chewed too rapidly, nicotine is released before it can be absorbed by the buccal mucosa. Nicotine absorbed by the GI tract is ineffective and it can cause gastric and esophageal irritation. Chew and park!
Why should coffee and carbonated drinks be avoided before and during gum use?
Acidic beverages lower oral pH, causing nicotine to ionize and reducing absorption
What are side effects of nicotine gum?
usually the result of overly vigorous chewing = nausea, vomiting, abdominal pain, constipation, hiccups, headache, excess salivation, sore jaw, mouth irritation
Who should avoid using nicotine gum?
TMJ disease, poor dentition, those who use dental appliances. These people can use lozenges
How is the lozenge used?
placed in mouth and allowed to dissolve for 30 minutes. One lozenge every 1-2 hours for 6 weeks (up to 20 lozenges per day); then gradual reduction over the next 6 weeks
What dose of lozenge should be used?
If patient smokes within 30 minutes of awakening, 4 mg lozenge
all others = 2mg
How do you use the nicotine inhaler?
6-16 cartridges/day for 6-12 weeks with reduction over the next 6-12 weeks
What are the pros and cons of nicotine inhaler?
pros: addresses physical dependence and the behavioral/sensory aspects of smoking
cons: localized irritation of mouth/throat; can cause bronchospasm so don’t use in smokers with a history of severe airway reactivity
How do you use nicotine nasal spray?
produces peak of nicotine 10 minutes after use; maximum dose is 10 sprays per hour or 80/day.
Nasal irritation, sneezing, tearing
What is the “patch plus” regimen?
Long-acting NRT (patch) with short-acting NRT to help control cravings and withdrawl symptoms during the day PRN
How do you use buproprion for patients?
Start a week before quitting with 150mg/d for 3 days, then 150 mg BID afterwards. Continue for 12 weeks
What are side effects of buproprion?
insomnia, agitation, dry mouth, HA, SEIZURE!
In whom is buproprion contraindicated?
- -history of seizure or predisposition to seize
- -bipolar
How does chantix work?
1) partial agonist, reducing symptoms of nicotine withdrawal
2) since it binds the receptor with high affinity, it blocks nicotine in tobacco smoke from biding to the receptor, reducing the rewarding aspects of cig smoking
How do you dose chantix?
0.5 daily for 3 days, then 0.5 mg BID for 4 days. THEN SMOKER QUITS. Then 1 mg BID for the rest of a 12 week course. Continue for 6 months total!
Take with food and full glass of water!
What do you have to check before you start chantix?
Renal function!!
What are the side effects of chantix?
neuropsychiatric and cardiovascular side effects (advise them to monitor for ischemia, etc!)
