Smoking related Flashcards
Nicotine dependence
- Def
- Risk factors
Def:
Treatable chronic relapsing disorder, characterized by cravings and compulsive use.
It is comparable to dependence caused by opiates, cocaine, or other illicit drugs
Risk factors:
Low incomes
Low level of education
Divorced/ Separated/ Widowed
Anxiety/ Depression
Parental smoking
Peer influence
Personality trait: impulsive, risk taking, sensation-seeking
Adverse childhood experiences
What are the withdrawal Sxs
Difficulty concentrating
Increased anxiety
Sadness
Anger
Frustration
Irritability
Insomnia
Usu peaks at day 2, then diminish within a week
Legalities relating to Smoking Bill
Previously known as The Control of Tobacco Product and Smoking Bill 2022, was tabled in parliament by then health minister Khairil Jamaluddin.
The bill was renamed The Control of Smoking Products for Public Health Bill 2023, unfortunately was not able to be tabled and debated for second time in Oct 2023.
The gist of the bill:
- Also known as the generational endgame law (GEG).
- Prohibits smoking on individuals born in 2007 and onwards, aimed at protecting their health and lives
- Penalises the sale of tobacco & targeted generation smokers,
- banned possession of tobacco products and
- gave police search powers (inc. warrantless home searches, access to electronic passwords, and bag and body searches), but amendments have been made.
- Also allows vape liquids to be regulated and checked in laboratories
Follow up required after starting smoking cessation program
Arrange f/up
Soon after quit date (within 1w)
Weekly (2-3m)
Monthly (4-6m)
How to assess severity of addiction?
1) Number of cigs/day
2) Time To First Cigarette (TTFC) = Time from waking to smoking the first cigarette
3) Fagerstrom Test - to Ax for nicotine dependence
Score:
1-2: may not need nicotine replacement therapy (NRT)
3-4: single NRT could be offered
≥5: offer combined NRT
Algorithm for Rx of tobacco use disorder
5 A’s:
1. Ask about smoking
2. Advice to quit
3. Assess willingness to quit
4. Assist in quit attempt – STAR
Set quit date: within 2w (reduce # of cig before)
Tell COC
Anticipate challenges
Remove tobacco products
5. Arrange f/up
Soon after quit date (within 1w)
Weekly (2-3m)
Monthly (4-6m)
Interventions that increase quit smoking
Telephone counselling can increase success irrespective of smoker’s motivation
Text-messaging programs
Financial incentives
Adjunctives:
Advice to make home & work environments smoke-free spaces
Self-help booklets
Websites
Smartphone app
Enlistment of social support
Pharmacological Rx for smoking cessation
Nicotine based – e.g. nicotine replacement therapies (NRT) with patch, gum, lozenges & inhalator
Non-nicotine based – e.g. varenicline, SR bupropion, nortriptyline
Choice of therapy depends on efficacy, safety, suitability and cost
Treat acute withdrawal, limits cravings, reduces relapse risk, more than counselling
Nicotine replacement therapy
Appropriate first line Rx: patches, gum, lozenges, inhalers, nasal spray
Increases likelihood of sustained quitting by 50-60%
Patch:
Max strength patch (21mg nicotine) provides steady state plasma nicotine concentration of ~50% of concentration from 20cig/d inadequate suppression from withdrawal need short-acting NRT
Other strength: Start with 21mg for 6w, 14mg for 2w, then 7mg for 2w (at least 8w Rx)
Gum: 2mg (<20cig/d), 4mg (≥20cig/d). 1 piece Q1-2H, at least 1-3m
Caution: use in immediate (1-2w) post MI, arrhythmia, worsening angina
SE: mild skin reaction from patch (top steroid cream)
Varenicline
Appropriate first line therapy
A partial nicotine receptor agonist
Dose: 0.5mg OD (D1-3), 0.5mg BD (D4-7), then 1mg BD
Start 1-2w pre-quit date, for 12w +/- 12w (in successful pt)
Caution: not to be used in pregnancy (Cat C)
SE: exac of depression, dizziness, nausea, headache, insomnia, abnormal dreams, may alter pharmacokinetic & dynamic of other meds inc insulin/warfarin) adjust dose.
For patients who have successfully stopped smoking at the
end of 12 weeks, an additional course of 12 weeks treatment
with 1 mg twice daily may be considered.
No data are available on the efficacy of an additional 12
weeks course of treatment for patients who do not succeed
in stopping smoking during initial therapy or who relapse
after treatment
Bupropion SR
Appropriate as first line
Increases quitting by 52-71%
Dose: 150mg OM (3d), the 150mg BD (for 7-12w post quit date). Start 1-2w pre-quit date. Maintenance: 150mg BD up to 6m
Caution: FDA Cat C in pregnancy, Cat B in lactating women
CI: seizure
SE: insomnia, dry mouth
Doses of meds used in smoking cessation
What about pts who are unwilling to quit?
Motivational interviewing (MI)
Recognise possible causes of unwillingness:
Lack of info on harmful effe
Relapse prevention
1) Minimal practice:
Congratulate ANY success and strong encouragement
D.E.A.D technique
Delay – deliberate delay smoking by doing something else
Escape – from any situation/ environment that induce smoking
Avoid
Distract – do something else (e.g. relaxation technique, housework)
Discussion re health benefits, problems encountered & medication effectiveness and side effects
2) Intensive practice:
Individualised intervention in behaviour modification via counselling and monitoring
Address specific problems, e.g. lack of support, negative mood, withdrawal Sxs, weight gain & smoking relapse
Problems that may occur & solutions
Smoking cessation Rx in specific population
