Smoking Cessation (2.8) Flashcards
What does inhaling smoke from a cigarette lead to? How does nicotine dependence arise?
Inhaling smoke from a cigartte leads to:
- Arterial nicotine levels increase markedly within 15 seconds
- Bolus nicotine activates the brain award system by increasing dopamine levels
- Transient activation of the reward system is followed by a fall in nicotine levels into a state of withdrawal
- Which is relieved by the next cigarette….. the cycle continues
Nicotine dependence arises from the asssoication:
- of the rituals and sensory inputs
- with repeated stimualtion
- and relief of withdrawal by taking more nicotine
What does smoking increase the risk of?
- Lung cancer
- Leukaemia and other cancers - mouth, pharynx, larynx, oesophagus, stomach, pancreas,cervic, kindey, ureter and bladder
- Increase risk of heart disease: stroke, MI, IMHD and anuerysm
- Lung diseases: chronic bronchitis, pneumonia, emphysema and 90% of COPD exacerbates asthma
- Eye problems, including cataracts and age-related macular degneration
- Wound infections and delayed healing
- Osteporosis
- Stomach ulcers
- Hair loss
- Male impotence
- Gum disease - loss of teeth
- Affects the skin, sagging and wrinkling
What doess smoking during pregnanacy increase the risk of? And in children, what is the increased risk?
Smoking during pregnancy increases the risk of:
- Miscarriage
- Premature birth
- Low birth weight infant
ENVIRONMENTAL TOBACCO SMOKE, in children increased the risk of:
- Respiratory infections
- Middle ear infections
- Meningococcal infections
- Astha attacks
- SIDS
What is the benefit of quitting?
See attached image
What are some of the symptoms of quitting smoking?
- Nicotine withdrawal symptoms - 80^% of smokers
- Worst within the first 2-3 weeks
- Most sx’s will pass <2 weeks but can last upto 4 weeks
- Associations that cauase a person to think about smoking can persist for years
DSM-IV criteria for Nicotine withdrawal
Craving plus any 4 of the following:
- Depressed mood
- Insomnia
- Irritabliity, frustration, anger
- Anxiety
- Difficulty in concentration
- Restlessness
- Decreased heart rate
- Increased appetite or weight gain
What is the stages of change in smoking
- Pre-contemplation (not ready) –> unconcerned about smoking and not seriously thinking about quitting in the next 6 months
- Contemplatation (unsure) –> aware of need to quit and considering qutting within next 6 months
- Preparation (ready) –> planning to quit within the next 30 days
- Action –> has quit smoking within last 6 months. This is when risk of relapse is highest
- Maintanence –> Quit over 6 months ago. The person’s non-smoking behaviour is established and the threat of smoking gradually diminishes
- Relapse –> Has started smoking again
See attached image of pharmacis action
What is the 5A framework that pharmaicst can apply for smoking intervention
Ask
- Identify currrent and previous smokers, smoking history and motivation
Assess
- Interest in qutting
- Barriers to quitting
- Level of nicotine dependence
- Quitting history
- High risk situation
Advice
- Provide clear, brief and non-judgemental advice to quit
- Address the three domains (nicotine dependence, habit, physiological aspects of smoking)
Assist
- Quit services
- Pharmacotherapy (OTC. prescription medications)
- Address barriers to quitting e.g. stress, weight gain, negative emotions, lack of support
Arrange
- Follow-up
- Support
What is the Fagerstrom test?
A test used to assess nicotine dependence through asking 6 qestions
- 0-2 very low dependence
- 5 medium dependence
- 8+ very high dependence
Assessment may be time consuming and may not always be practical in a community pharmacy setting
What are the three questions to ask to determine nicotine dependence? What are some of the dependence levels
- Minutes after waking to first cigarette
- Number of cigarettes per day
- Craving and withdrawal symptoms in previous quit attempts
Dependence level:
High: waking at night to smoke, or smoke within 5 mins of waking, smoke >30 cigarettes per day
Moderate: smoke within 30 mins of waking, 20-30 cigarettes per day
Low to moderate: not needing to smoke within the first 30mins of smoking, smoke 10-20 cigarettes per day
Low: not needing to smoke within the first hour of waking, smoke <10 cigarettes per day
What are some questions to ask and what is the reasoning behind these questions?
What are some triggers for referral for smoking cessation
PATIENT REQUESTS NICOTINE REPLACEMENT THERAPY (NRT), REFER IF:
- CVD, DIABETES, HEPATIC or RENAL impairment
> NRT may be used but because of potential risks, persons doctor should be involved in the process
- Pregnant
> For women unable to quit on their own, NRT may be recommended: doctor must be consulted
- <12 years of age
- If NRT is contraindicated or unsuitable and the person wishes to use an anti-smoking prescription medicine
- Several unsucessful attemps at quitting smoking
Why is Nicotine replacement therapy (NRT) used?
More than doubles quit rates compared with controls
- Replaces some of the nicotine from cigarettes, but without the constituents found in tobacco smoke
- Delivers nicotine slowly –> minimum addictive potential
- Still stimulates nicotinic receptors in the brain (causing release of dopamin), leads to a reduction in physical nicotine withdrawal symptoms
- Allows smokers to focus on psychosocial aspects of quitting smoking
Best results achieved when combined with behavioural advice and follow up
- NRT is available as patches (transdermal), gum, inhaler, lozener, film, SL microtabs and liquid spray (oral mucosa)
- All current NRT products rely on systemic venous absorption and therefore achieve lower nicotine levels over a period of
> Minutes (gums, lozenges, film, inhaler, SL tablet, SL liquid)
> Or hours (patches)
TGA approved indications for NRT:
- smoking cessation (immediate) as single or combination therapy
- Use in the smoking reduction (over the age of 18)
For Nicotine Transdermal Patches;
A) How does it work?
B) Dose
C) How to use
D) Adverse effects/side effects
A)
- Designed to release nicotine slowly through skin absorption, blood concentrations of nicotine rise over several hours
- Produces a skin reservoir, absorption continues for upto 2 hours after patch is remvoed
- Often better tolerated and easier to use than gum
- Comes in 16hour and 24hour patches –> no difference in effectiveness due to duration of patch
- Appropriate dose of nicotine/patch will depend on level of dependence and stage of quitting
B)
Low to moderate dependence
- Apply 1 patch/day of either 14mg/24 hours or 10-15mg/15 hours
- Stop within 12 weeks
- Can either stop abruptly of gradually taper down dose
Moderate to high dependence
- Apply 1 patch/day of either 21mg/24hours or 15-25mg/16 hours
- Stop use within 12 weeks
- Can either stop abruptly or gradually taper down dose
Patches are not recommended for those who smoke less than 10 cigarettes a day
C)
- Aply patch to clean dry non-hairy skin on the upper part of body or arm
- Should be left in place for either 16 or 24 hours depending on the patch
- Use a different site each day to avoid skin irritation. skin sites should not be reused for at least a week
D)
- If skin irritation occurs (due to a reaction to the patch adhesive, or to the effect of nictoine) can be treated with hydrocortisone cream
- Sleep disturbances = most common ADR esp vivid dreaming, does not seem to affect success rates (use 16 hour patches )
- Used patches should be disposed of carefully –> contain traces of nicotine –> dangerous if swallowed by small children or pets
For Nicotine Gum;
A) How does it work?
B) Dose
C) How to sub-divide into patient groups
D) How to use
A)
- Nicotine is readily and rapidly absorbed through the oral mucosa
- Oral gratification of the gum can help some smokers
- Not suitable for those with dentures or other complicated dental work, oral or pharyngeal inflammation
B)
- 2mg/piece
- 4mg/piece
C)
Moderate nicotine dependence
- Usually 8-12 pieces of the 2mg gum daily
- Cut down number of pieces chewed each day then cease
High nicotine dependence
- Usually 6-10 pieces of the 4mg gum daily
- Avoid >1 piece per hour
- After 4-8 weeks, reduce to 2mg, then, stop or taper use over a further 4 weeks then cease
> Max of 40 mg of chewed gum per day
> Treatment should be stopped when the dose is reduced to one to two pieces of gum a day
D)
- Chewing technique is important
- Chew 1 piece of gum slowly when urge to smoke is felt
- Bite gum about 10 times until bitter taste becomes strong/tingling sensation felt
- Place gum between chicken and upper gum until tingling subsides
- Then chew again
- Each piece will last about 30 mins (then no more tangling)
- Use at regular intervals at least 6 times a da
- Avoid acidic beverages for 15 mins before, and during use
- Excessive chewing causes salivation –> indigestion
For Nicotine Lozenges;
A) How does it work?
B) Dose
C) How to sub-divide into patient groups
D) How to use
A)
- Nicotine absorption occurs through the oral mucosa and allows for acute onset
B)
- Nicabate Lozenge 2mg and 4mg
- Nicabete minis 1.5mg and 4mg
- Nicorette Cooldrops 2mg and 4mg
C)
Low to moderae nicotine dependence
- Eg smoke after 30 mins waking < 20/day
- Use 1.5mg or 2mg lozenge
Moderate to high nicotine dependence
- smoke within 30 mins of waking or > 20/day
- Use 4mg lozenge
D)
- Let lozenge dissolve in mouth
- Try not to bite or swallow
- May take up to 30 mins to dissolve completely
- Try not to eat or drink during this time
- Same strength is used throughout the treatment
