Tobacco Cessation Flashcards
5 “As”:
1) Ask- about tobacco use
2) Advise- to quit
3) Assess- willingness to quit in the next month
4) Assist- with quitting w/in 2 weeks
5) Arrange- for follow up
Medications should be encouraged for…
all patients attempting to quit, except when medically contraindicated
Women ≥ 35 y/o who smoke should not…
take estrogen-containing oral contraceptives due to an increased risk of CV events
Behavioral counseling alone is recommended for:
- pregnant women
- adolescents
- smokeless tobacco users (ex. chewing tobacco)
- “light” smokers using < 10 cigarettes/day
Smokers age 19-64 should receive…
Pneumovax 23 and an annual influenza vaccine
Nicotine patch (NicoDerm CQ), OTC. Has highest adherence. Must remove before MRI. Avoid if the patient has dermatitis/skin conditions. Do not cut patch. Rotate sites.
Initial dose: If > 10 cigarettes/day: 21 mg patch
If ≤ 10 cigarettes/day: 14 mg patch
Weeks 1-6 start 21 mg, Weeks 7-8 (step down dose to 14 mg). Weeks 9-10 (step down to 7 mg). Apply to dry and relatively hairless area of the skin; press the patch firmly onto the skin for ~ 10 seconds. Wear for 24 hours. If vivid dreams or trouble sleeping occur, take off the patch before bedtime (after about 16 hours) and put on a new one in the AM. Throw out the patch by folding the sticky ends together, place back in the pouch and throw away in trash can with a lid. Wash hands after applying and removing.
Nicotine inhaler (Nicotrol Inhaler) Rx. Mimics the hand-to-mouth smoking action, providing a coping mechanism. Each cartridge provides about 20 minutes of active puffing and is only good for one day after opening. Clean the mouthpiece with soap/water regularly.
6-16 cartridges daily for up 12 weeks, then taper frequency of use over 6-12 weeks (use up to 6 months)
nicotine nasal spray (Nicotrol NS) Rx. Fastest delivery and is useful for rapid relief of withdrawal symptoms; has the highest risk of dependence.
Prime 6-8 times before first use; 1-2 times if not used within 24 hours. Tilt the head back slightly and spray in each nostril. Do not sniff, swallow or inhale through the nose.
1 dose= 1 spray in each nostril; use 1-2 drops/hr, PRN for symptom relief. Use up to 3 months.
Min: 8 doses/day; Max: 5 doses/hr or 40 doses/day
Combo therapy with patch + short-acting NRT or burpropion…
is the most effective
Gum and lozenge
Sugar-free; 4 mg strenth can reduce or delay weight gain; acidic beverages/foods decreases buccal absorption; do not eat/drink 15 minutes before or during use
nicotine polacrilex gum (Nicrorette, others) OTC
- Do not use if the patient has dentures
- Chew slowly until there is a tingle or peppery flavor in the mouth.
- When the tingle or flavor goes away, being chewing slowly again until it returns, then park the gum again.
- Repeat until most of the flavor or tingle is gone (~ 30 min)
- Do not eat or drink for 15 minutes before or during chewing.
- Min: 9 pieces/day during the first 6 weeks. Max: 24
pieces/day
nicotine lozenge (Nicorette, Nicorette Mini) OTC
- Do not eat or drink for 15 min before or during use.
- Do not chew or swallow. Allow to dissolve slowly.
- Move the lozenge from one side of the mouth to the other until completely dissolved (~20-30 min).
- May cause a warm or tingling sensation.
- Min: 9 pieces/day during the first 6 weeks
- Max: 20 pieces/day
gum or lozenge
Initial dose for gum or lozenge: 1st cig > 30 min upon waking: 2 mg 1st cig ≤ 30 min upon waking: 4 mg Weeks 1-6: 1 piece Q 1-2 hr Weeks 7-9: 1 piece Q 2-4 hr Weeks 10-12: 1 piece Q 4-8 hr
NRT Warnings and S/Es
- Warnings: Avoid in immediate post-MI period, life-threatening arrhythmias, severe or worsening angina and pregnancy
- Inhaler/nasal spray: avoid in asthma, COPD, and other chronic respiratory diseases
- SEs: headache, dizziness, nervousness, insomnia, dyspepsia. Patch- vivid dreams, skin irritation. Inhaler- mouth and throat irritation, cough, rhinitis. Nasal spray- nasal irritation, watery eyes, sneezing, transient changes in taste and smell
Bupropion blocks…
neuronal reuptake of dopamine and/or norepinephrine resulting in reduced cravings and other withdrawal symptoms
Varenicline is a…
partial neuronal alpha-4 beta-2 nicotinic receptor agonist. It causes low-level stimulation of the receptor while blocking the ability of nicotine to bind.
Bupropion SR (Zyban) tablet
Start at least 1 week before quit date. SR: 150 mg QAM for 3 days, then 150 mg BID. Max dose: 300 mg/day. Use up to 6 months.
Wellbutrin SR, Wellbutrin XL (for depression)
Aplenzin, bupropion IR, Forfivo XL
Wellbutrin XL (Aplenzin)
for seasonal affective disorder (SAD)
Bupropion BBW, C/Is, Warnings, SEs
BBW: Increased risk of suicidal thinking and behavior in children, adolescents, and young adults taking antidepressants
CIs: seizure disorder, history of anorexia/bulimia; with MAO inhibitors, linezolid or IV methylene blue; abrupt discontinuation of ethanol or sedatives
Warnings: serious neuropsychiatric events, activation of mania/hypomania, HTN, angle-closure glaucoma, rash
SEs: Dry mouth, insomnia, tremors, weight loss, agitation, anxiety, tachycardia, headache, sweating, N/V, constipation
Bupropion Notes
- Do not combine with other forms of bupropion
- delays weight gain
- to decrease insomnia, take the 1st dose upon waking up and the 2nd dose 8 hour after the 1st
- If no significant progress by week 7, consider stopping
Varenicline (Chantix)
- Do not combine with NRT.
- Start at least 1 week before quit date.
- Days 1-3: 0.5 mg daily
- Days 4-7: 0.5 mg BID
- Day 8 (quit date) and beyond: 1 mg BID
- CrCl <30 mL/min: 0.5 mg daily titrated to max 0.5 mg BID
- Use for 12 weeks; can use another 12 weeks to maintain success
Varenicline (Chantix) Warnings, SEs
Warnings: Serious neuropsychiatric events, seizures, increased effects of alcohol, sleepwalking, accidental injury (traffic accidents), CVD risk, hypersensitivity reactions
SEs: Nausea (~30%, dose-dependent), insomnia, abnormal dreams, headache, constipation, flatulence, vomiting
