Tobacco Cessation

Question 1

5 “As”:

Answer 1

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

Question 2

Medications should be encouraged for…

Answer 2

all patients attempting to quit, except when medically contraindicated

Question 3

Women ≥ 35 y/o who smoke should not…

Answer 3

take estrogen-containing oral contraceptives due to an increased risk of CV events

Question 4

Behavioral counseling alone is recommended for:

Answer 4

• pregnant women
• adolescents
• smokeless tobacco users (ex. chewing tobacco)
• “light” smokers using < 10 cigarettes/day

Question 5

Smokers age 19-64 should receive…

Answer 5

Pneumovax 23 and an annual influenza vaccine

Question 6

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.

Answer 6

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.

Question 7

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.

Answer 7

6-16 cartridges daily for up 12 weeks, then taper frequency of use over 6-12 weeks (use up to 6 months)

Question 8

nicotine nasal spray (Nicotrol NS) Rx. Fastest delivery and is useful for rapid relief of withdrawal symptoms; has the highest risk of dependence.

Answer 8

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

Question 9

Combo therapy with patch + short-acting NRT or burpropion…

Answer 9

is the most effective

Question 10

Gum and lozenge

Answer 10

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

Question 11

nicotine polacrilex gum (Nicrorette, others) OTC

Answer 11

• 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

Question 12

nicotine lozenge (Nicorette, Nicorette Mini) OTC

Answer 12

• 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

Question 13

gum or lozenge

Answer 13

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

Question 14

NRT Warnings and S/Es

Answer 14

• 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

Question 15

Bupropion blocks…

Answer 15

neuronal reuptake of dopamine and/or norepinephrine resulting in reduced cravings and other withdrawal symptoms

Question 16

Varenicline is a…

Answer 16

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.

Question 17

Bupropion SR (Zyban) tablet

Answer 17

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.

Question 18

Wellbutrin SR, Wellbutrin XL (for depression)

Answer 18

Aplenzin, bupropion IR, Forfivo XL

Question 19

Wellbutrin XL (Aplenzin)

Answer 19

for seasonal affective disorder (SAD)

Question 20

Bupropion BBW, C/Is, Warnings, SEs

Answer 20

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

Question 21

Bupropion Notes

Answer 21

• 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

Question 22

Varenicline (Chantix)

Answer 22

• 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

Question 23

Varenicline (Chantix) Warnings, SEs

Answer 23

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