Tobacco Cessation Flashcards
1
Q
The 5 As
A
Ask Advise Assess Assist Arrange
2
Q
Ask
A
about tobacco use; with a tone that conveys sensitivity, concern and is non-judgmental
3
Q
Advise
A
tobacco users to quit (clear, strong, personalized)
4
Q
Assess
A
readiness to make a quit attempt
5
Q
Assist
A
with the quit attempt
Not ready to quit: enhance motivation (the 5 R’s)
Ready to quit: design a treatment plan
Recently quit: relapse prevention
6
Q
Arrange
A
follow up care
more sessions, higher estimated quit rate
7
Q
Weight gain
A
discourage strict dieting while quitting
pharmacotherapy can help with weight gain (Bupropion SR or nicotine gum/lozenges)
8
Q
withdrawal symptoms
A
Most pass within 2–4 weeks after quitting
Cravings can last longer, up to several months or years
Most symptoms manifest within the first 1–2 days, peak within the first week, and subside within 2–4 weeks.
9
Q
Alcohol and socialization
A
Explore alternative ways to socialize
Avoid going to a bar
10
Q
Smoking after meals
A
Immediately get up from the table
Brush teeth
While doing so, look in the mirror and confirm commitment to quitting—”I can do this!”
Take a short walk
Call a supportive friend
11
Q
Boredom
A
Always carry a book/newspaper/crossword puzzle
Plan ahead, avoiding long periods of inactivity
Learn to enjoy doing nothing from time to time; rethink the belief that it’s necessary to always be doing something
Restart an old hobby or start to exercise
12
Q
Cigarettes are sold
A
in packs (20 cigarettes/pack)
13
Q
Total nicotine content, per cigarette:
A
Average 13.5 mg (range, 11.9 to 14.5 mg)
14
Q
Smoker’s nicotine yield, per cigarette:
A
Approximately 1 to 2 mg
15
Q
ELECTRONIC CIGARETTES
A
Generally similar in appearance to cigarettes, cigars, pipes, or pens
battery operated
16
Q
e cigs components
A
Power source Rechargeable or disposable battery Cartridge containing liquid solution Propylene glycol Glycerin Flavorings (tobacco, fruit, chocolate, mint, cola, candy, etc.) Nicotine (0-36 mg/mL) Electronic atomizer/vaporizer Heating element vaporizes liquid at temperatures 65-120 °C
17
Q
E cigs health risks
A
Propylene glycol may cause respiratory irritation and increase the risk for asthma
Glycerin may cause lipoid pneumonia on inhalation
Nicotine is highly addictive and can be harmful
Carcinogenic substances are found in some aerosols
second hand
18
Q
E cigs Indoor air pollution
A
E-cigarettes are not emission-free
19
Q
During vaping sessions, compounds and particles emitted into the indoor air include
A
Propylene glycol Glycerin Heavy metals Nicotine Flavoring agents Polycyclic aromatic hydrocarbons
20
Q
nicotine absorption in acidic media
A
Ionized –> poorly absorbed across membranes
21
Q
nicotine absorption in alkaline media
A
Nonionized –> well absorbed across membranes
At physiologic pH (7.4), ~31% of nicotine is nonionized
22
Q
buccal mucosa acidic vs alkaline media
A
acidic media (limited absorption): cigarettes
Alkaline media (significant media): pipes, cigars, spit tobacco, oral nicotine products
23
Q
skin and GI tract
A
nicotine is absorbed through the skin
well absorbed through small intestine but low bioavailability due to 1st pass hepatic metabolism
24
Q
lung
A
Nicotine is “distilled” from burning tobacco and carried in tar droplets.
Nicotine is rapidly absorbed across respiratory epithelium.
Lung pH = 7.4
Large alveolar surface area
Extensive capillary system in lung
Approximately 1 mg of nicotine is absorbed from each cigarette.
25
CNS
Pleasure
Arousal, enhanced vigilance
Improved task performance
Anxiety relief
26
Cardiovascular system
```
increase Heart rate
increase Cardiac output
increase Blood pressure
Coronary vasoconstriction
Cutaneous vasoconstriction
```
27
Other pharmacodynamics
Appetite suppression
Increased metabolic rate
Skeletal muscle relaxation
28
effects of nicotine
Dopamine (Pleasure, appetite suppression)
Norepinephrine (Arousal, appetite suppression)
Acetylcholine (Arousal, cognitive enhancement)
Glutamate (learning, memory enhancement)
Serotonin (mood, appetite suppression)
b-Endorphin (reduction of anxiety and tension)
GABA (reduction of anxiety and tension)
29
Tobacco users maintain a minimum serum nicotine concentration in order to
Prevent withdrawal symptoms
Maintain pleasure/arousal
Modulate mood
30
Users self-titrate nicotine intake by
Smoking/dipping more frequently
Smoking more intensely
Obstructing vents on low-nicotine brand cigarettes
31
individual factors contributing to tobacco use
Sociodemographics
Genetic predisposition
Coexisting medical conditions
32
pharmacological factors contributing to tobacco use
Alleviation of withdrawal symptoms
Weight control
Pleasure, mood modulation
33
environmental factors contributing to tobacco use
Tobacco advertising
Conditioned stimuli
Social interactions
34
Drugs may have a decreased effect due to induction of
CYP1A2
Bendamustine, haloperidol, caffeine, Theophylline
35
Caffeine effects
Nicotine withdrawal effects might be enhanced by increased caffeine levels
36
Smokers who use combined hormonal contraceptives have an increased risk of serious cardiovascular adverse effects:
Stroke
Myocardial infarction
Thromboembolism
37
smoking ___ decrease the efficacy of hormonal contraceptives
DOES NOT
38
Non pharm methods
Cold Turkey
Unassisted tapering
Assisted tapering
Formal Cessation programs
Acupuncture therapy
Hypnotherapy
Massage
39
Tobacco quitlines
Tobacco cessation counseling, provided at no cost via telephone to all Americans
4-6 sessions
40
Pharmacotherapy is not recommended for
pregnant smokers
smokeless tobacco users
individuals smoking <10 per day
Adolescents
41
Nicotine polacrilex gum
Nicorette (OTC)
| Generic nicotine gum (OTC)
42
Nicotine lozenge
Nicorette (OTC)
| Generic nicotine lozenge (OTC)
43
Nicotine transdermal patch
```
NicoDerm CQ (OTC)
Generic nicotine patches (OTC)
```
44
Nicotine inhaler
Nicotrol (Rx)
45
Nicotine nasal spray
Nicotrol NS (Rx)
46
Bupropion SR
Generic (Rx)
47
Varenicline
Chantix (Rx)
48
Nicotine replacement therapy
Reduces physical withdrawal from nicotine
Eliminates the immediate, reinforcing effects of nicotine that is rapidly absorbed via tobacco smoke
Allows patient to focus on behavioral and psychological aspects of tobacco cessation
49
Nicotine replacement therapy precautions
Patients with underlying cardiovascular disease:
Recent myocardial infarction (within past 2 weeks)
Serious arrhythmias
Serious or worsening angina
50
Nicotine gum
Resin complex
Nicotine
Polacrilin
Sugar-free chewing gum base
Contains buffering agents to enhance buccal absorption of nicotine
Available: 2 mg, 4 mg; original, cinnamon, fruit, and mint (various) flavors
51
Nicotine Lozenge
Nicotine polacrilex formulation
Delivers ~25% more nicotine than equivalent gum dose
Sugar-free mint, cherry flavors
Contains buffering agents to enhance buccal absorption of nicotine
Available: 2 mg, 4 mg
52
Use the 2 mg gum/lozenge:
If first cigarette of the day is smoked more than 30 minutes after waking
53
Use the 4 mg gum/lozenge:
If first cigarette of the day is smoked within 30 minutes of waking
54
Gum/Lozenge schedule
weeks 1-6 = 1 piece q 1-2 h
weeks 7-9 = 1 piece q 2-4 h
weeks 10-12 = 1 piece q 4-8 h
55
Do not use more than ___ pieces of gum or ___ lozenges per day
24 --> gum
| 20 --> lozenges
56
directions for use with gum
chew slowly
stop at first sign of peppery taste or tingling sensation
park between cheek and gum
chew again when taste or tingle fade
57
directions for use with lozenges
Place in mouth and allow to dissolve slowly
no chewing or swallowing
58
Lozenges will dissolve completely in about
20-30 minutes
59
Do NOT eat or drink for __ minutes BEFORE or while using the nicotine gum or lozenge.
15
60
The effectiveness of the nicotine gum/lozenge may be reduced by some foods and beverages:
Coffee
Wine
Juices
Soft drinks
61
Chewing the lozenge or using incorrect gum chewing technique can cause excessive and rapid release of nicotine, resulting in:
Lightheadedness/dizziness
Nausea and vomiting
Hiccups
Irritation of throat and mouth
62
Adverse effects of nicotine gum and lozenge:
Mouth and throat irritation
Hiccups
Gastrointestinal complaints (dyspepsia, nausea)
63
Adverse effects associated with JUST nicotine gum:
Jaw muscle ache
| May stick to dental work
64
advantages of gum/lozenge
Might serve as an oral substitute for tobacco
Might delay weight gain
Can be titrated to manage withdrawal symptoms
Can be used in combination with other agents to manage situational urges
Relatively inexpensive
65
disadvantages of gum/lozenge
Need for frequent dosing can compromise adherence
Gastrointestinal adverse effects (nausea, hiccups, and dyspepsia) may be bothersome
Specific to nicotine gum:
Might be problematic for patients with significant dental work
Proper chewing technique is necessary for effectiveness and to minimize adverse effects
Chewing might not be acceptable or desirable for some patients
66
transdermal nicotine patch
Continuous (24-hour) nicotine delivery system
Nicotine is well absorbed across the skin
Transdermal delivery to systemic circulation avoids hepatic first-pass metabolism
Plasma nicotine levels are lower and fluctuate less than with smoking
67
NicoDerm CQ light smoker dose
```
<10 cigarettes/day
Step 2 (14 mg x 6 weeks)
Step 3 (7 mg x 2 weeks)
```
68
NicoDerm CQ heavy smoker dose
```
>10 cigarettes/day
Step 1 (21 mg x 6 weeks)
Step 2 (14 mg x 2 weeks)
Step 3 (7 mg x 2 weeks)
```
69
Generic patch light smoker dose
```
<10 cigarettes/day
Step 2 (14 mg x 6 weeks)
Step 3 (7 mg x 2 weeks)
```
70
Generic patch heavy smoker dose
```
>10 cigarettes/day
Step 1 (21 mg x 4 weeks)
Step 2 (14 mg x 2 weeks)
Step 3 (7 mg x 2 weeks)
```
71
Patch directions
Choose an area of skin on the upper body or upper outer part of the arm
Make sure skin is clean, dry, hairless, and not irritated
Apply patch to different area each day
Do not use same area again for at least 1 week
72
After applying patch
Wash hands: Nicotine on hands can get into eyes or nose and cause stinging or redness
Do not leave patch on skin for more than 24 hours—doing so may lead to skin irritation
Adhesive remaining on skin may be removed with rubbing alcohol or acetone
Dispose of used patch by folding it onto itself, completely covering adhesive area
73
Patch pt education
Water will not harm the nicotine patch if it is applied correctly; patients may bathe, swim, shower, or exercise while wearing the patch
Do not cut patches to adjust dose
Keep new and used patches out of the reach of children and pets
Remove patch before MRI procedures
74
Patch ADR
Irritation at the patch application site (generally within the first hour)
Mild itching
Burning
Tingling
Sleep disturbances
Abnormal or vivid dreams
Insomnia
75
Advantages of patch
Once-daily dosing associated with fewer adherence problems
Of all NRT products, its use is least obvious to others
Can be used in combination with other agents; delivers consistent nicotine levels over 24 hrs
Relatively inexpensive
76
Disadvantage of patch
When used as monotherapy, cannot be titrated to acutely manage withdrawal symptoms
Not recommended for use by patients with dermatologic conditions (e.g., psoriasis, eczema, atopic dermatitis)
77
Nicotine inhaler consists of
Mouthpiece
| Cartridge with porous plug containing 10 mg nicotine and 1 mg menthol
78
Delivers __ mg nicotine vapor, absorbed across buccal mucosa
4
79
inhaler directions for use
Press nicotine cartridge firmly into bottom of mouthpiece until it pops down into place
Line up the markings on the mouthpiece again and push the two pieces back together so they fit tightly
Twist top to misalign marks and secure unit
80
Inhaling nicotine inhaler
During inhalation, nicotine is vaporized and absorbed across oropharyngeal mucosa
Inhale into back of throat or puff in short breaths
Nicotine in cartridges is depleted after about 20 minutes of active puffing
81
Inhaler ADR
Mild irritation of the mouth or throat
Cough
Hiccups
Gastrointestinal complaints (dyspepsia, nausea)
82
Do NOT eat or drink for minutes BEFORE or while using the nicotine inhaler.
15
83
Advantages of inhaler
Might serve as an oral substitute for tobacco
Can be titrated to manage withdrawal symptoms
Mimics the hand-to-mouth ritual of smoking
Can be used in combination with other agents to manage situational urges
84
Disadvantages of inhaler
Need for frequent dosing can compromise adherence
Cartridges might be less effective in cold environments (≤60F)
Cost of treatment
85
Nicotine nasal spray
```
Aqueous solution of nicotine in a 10-ml spray bottle
Each metered dose actuation delivers
-->50 mcL spray
-->0.5 mg nicotine
~100 doses/bottle
Rapid absorption across nasal mucosa
```
86
Nasal spray dose and administration
One dose = 1 mg nicotine
(2 sprays, one 0.5 mg spray in each nostril)
Start with 1–2 doses per hour
Increase as needed to maximum dosage of 5 doses per hour or 40 mg (80 sprays; ~½ bottle) daily
At least 8 doses daily for the first 6–8 weeks
Termination:
Gradual tapering over an additional 4–6 weeks
Recommended maximum duration of therapy is 3 months
87
nasal spray direction for use
Prime the pump (before first use)
Re-prime (1–2 sprays) if spray not used for 24 hours
Blow nose (if not clear)
Tilt head back slightly and insert tip of bottle into nostril as far as comfortable
Breathe through mouth, and spray once in each nostril
Do not sniff or inhale while spraying
88
Nasal spray what to expect (first week)
```
Hot peppery feeling in back of throat or nose
Sneezing
Coughing
Watery eyes
Runny nose
```
89
Nasal spray advantages
Can be titrated to rapidly manage withdrawal symptoms
| Can be used in combination with other agents to manage situational urges
90
nasal spray disadvantages
Need for frequent dosing can compromise adherence
Nasal administration might not be acceptable/desirable for some patients; nasal irritation often problematic
Not recommended for use by patients with chronic nasal disorders or severe reactive airway disease
Cost of treatment
91
Bupropion SR MOA
atypical antidepressant thought to affect levels of various brain neurotransmitters
Dopamine
Norepinephrine
92
Bupropion SR clinical effects
decrease craving for cigarettes
| decrease symptoms of nicotine withdrawal
93
Bupropion absorption
Bioavailability: 5–20%
94
Bupropion metabolism
Undergoes extensive hepatic metabolism (CYP2B6)
95
Bupropion elimination
Urine (87%) and feces (10%)
96
Bupropion 1/2 life
Bupropion (21 hours); metabolites (20–37 hours)
97
Bupropion contraindications
Patients with a seizure disorder
Patients with a current or prior diagnosis of bulimia or anorexia nervosa
Patients undergoing abrupt discontinuation of alcohol, benzodiazepines, barbiturates and antiepileptic drugs
Patients taking MAO inhibitors (within 14 days of initiating or discontinuing therapy)
98
Bupropion should be used in caution in the following populations
Patients with an elevated risk for seizures, including:
Severe head injury
Concomitant use of medications that lower the seizure threshold (e.g., other bupropion products, antipsychotics, tricyclic antidepressants, theophylline)
Severe hepatic impairment
Patients with underlying neuropsychiatric conditions
99
Bupropion precautions
Neuropsychiatric symptoms and suicide risk
Changes in mood (including depression and mania)
Psychosis/hallucinations/paranoia/delusions
Homicidal ideation
Aggression/hostility/anxiety/panic
Suicidal ideation, suicide attempt, completed suicide
100
Bupropion SR: To ensure that therapeutic plasma levels of the drug are achieved, patients should begin therapy ___weeks PRIOR to their quit date.
1-2
101
Bupropion SR dosing
Initial treatment
150 mg po q AM for 3 days
Then…
150 mg po bid for 7–12 weeks
Doses must be administered at least 8 hours apart
Tapering not necessary when discontinuing therapy
102
Bupropion ADR
Common adverse effects include the following:
Insomnia (avoid bedtime dosing)
Dry mouth
Nausea
```
Less common but reported effects:
Anxiety/difficulty concentrating
Constipation
Tremor
Skin rash
```
103
Bupropion advantages
Oral dosing is simple and associated with fewer adherence problems
Might delay weight gain
Bupropion might be beneficial in patients with depression
Can be used in combination with NRT agents
Relatively inexpensive (generic formulations)
104
Bupropion SR disadvantages
Seizure risk is increased
Several contraindications and precautions preclude use in some patients
Patients should be monitored for neuropsychiatric symptoms
105
VARENICLINE
Chantix
106
VARENICLINE
Nonnicotine cessation aid
Partial nicotinic receptor agonist
Oral formulation
107
VARENICLINE MOA
Binds with high affinity and selectivity at a4b2 neuronal nicotinic acetylcholine receptors
Stimulates low-level agonist activity
Competitively inhibits binding of nicotine
108
Varenicline clinical effects
decrease symptoms of nicotine withdrawal
| Blocks dopaminergic stimulation responsible for reinforcement & reward associated with smoking
109
varenicline absorption
Virtually complete (~90%) after oral administration; not affected by food
110
varenicline metabolism
Undergoes minimal metabolism
111
varenicline elimination
Primarily renal through glomerular filtration and active tubular secretion; 92% excreted unchanged in urine
112
Varenicline 1/2 life
24 hours
113
Varenicline warnings
Neuropsychiatric symptoms and suicide risk
Changes in mood (including depression and mania)
Psychosis/hallucinations/paranoia/delusions
Homicidal ideation
Aggression/hostility/anxiety/panic
Suicidal ideation, suicide attempt, completed suicide
114
In some patients, use of varenicline has been associated with:
```
Seizures
Enhanced effects of alcohol
Accidental injury
Cardiovascular events
Somnambulism
Angioedema and hypersensitivity reactions
Serious skin reactions
```
115
Patients should begin therapy __ week PRIOR to their
| quit date. The dose is gradually increased to minimize treatment-related nausea and insomnia
1
116
Varenicline dose
day 1-3 = 0.5mg qd
day 4-7 0.5 mg bid
day 8-end 1 mg bid
117
FIXED QUIT approach
Set quit date for 1 week after starting varenicline
| Continue treatment for 12 weeks
118
FLEXIBLE QUIT approach
Start taking varenicline and pick a quit date between 8 to 35 days from treatment initiation
Continue treatment for 12 weeks
119
GRADUAL QUIT approach
Start taking varenicline and reduce smoking by 50% within the first 4 weeks, an additional 50% in the next 4 weeks, and continue until complete abstinence by 12 weeks
120
Varenicline ADR
```
Common adverse effects include the following:
Nausea
Insomnia
Abnormal dreams
Headache
Less common adverse effects:
Gastrointestinal (flatulence, constipation)
Taste alteration
```
121
Varenicline pt edu
Doses should be taken after eating, with a full glass of water
Nausea and insomnia are usually temporary side effects
If symptoms persist, notify your health care provider
May experience vivid, unusual or strange dreams during treatment
Use caution driving, drinking alcohol, and operating machinery until effects of quitting smoking with varenicline are known
122
Varenicline advantages
Oral dosing is simple and associated with fewer adherence problems
Offers a different mechanism of action for persons who have failed other agents
Most effective agent for cessation when used as monotherapy
123
Disadvantages of Varenicline
cost
Patients should be monitored for potential neuropsychiatric symptoms
124
highest long term quit rate
Varenicline
125
lowest long term quit rate
patch
126
combination therapy
can combine patch with gum, inhaler, lozenge, nasal spray
Can combine bupropion SR and patch
127
Strong evidence that combination NRT and varenicline are more effective than bupropion SR or NRT monotherapy
Important to remember
128
Combination dosing
Nicotine patch
Dose: 21 mg/day x 4–6 wks --> 14 mg/day x 2 wks --> 7 mg/day x 2 wks
PLUS
Nicotine gum or lozenge (2 mg/4 mg; based on TTFC)
Dose: Use 1 piece q 1–2 hours as needed (use at least 4-5/day)
OR
Nicotine inhaler (10 mg cartridge; delivers 4 mg nicotine vapor)
Dose: Use 1 cartridge q 1–2 hours as needed
OR
Nicotine nasal spray (0.5 mg/spray)
Dose: Use 1 spray in each nostril q 1–2 hours as needed
129
3 key factors of adherence
Correct strength of medication
Taken daily, according to a fixed schedule
Taken for the full duration of therapy
