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CDM Exam 3 > Tobacco Cessation > Flashcards

Tobacco Cessation Flashcards

1
Q

The 5 As

A 
Ask 
Advise
Assess
Assist
Arrange
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2
Q

Ask

A

about tobacco use; with a tone that conveys sensitivity, concern and is non-judgmental

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3
Q

Advise

A

tobacco users to quit (clear, strong, personalized)

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4
Q

Assess

A

readiness to make a quit attempt

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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

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6
Q

Arrange

A

follow up care

more sessions, higher estimated quit rate

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7
Q

Weight gain

A

discourage strict dieting while quitting

pharmacotherapy can help with weight gain (Bupropion SR or nicotine gum/lozenges)

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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.

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9
Q

Alcohol and socialization

A

Explore alternative ways to socialize

Avoid going to a bar

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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

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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

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12
Q

Cigarettes are sold

A

in packs (20 cigarettes/pack)

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13
Q

Total nicotine content, per cigarette:

A

Average 13.5 mg (range, 11.9 to 14.5 mg)

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14
Q

Smoker’s nicotine yield, per cigarette:

A

Approximately 1 to 2 mg

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15
Q

ELECTRONIC CIGARETTES

A

Generally similar in appearance to cigarettes, cigars, pipes, or pens

battery operated

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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
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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

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18
Q

E cigs Indoor air pollution

A

E-cigarettes are not emission-free

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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
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20
Q

nicotine absorption in acidic media

A

Ionized –> poorly absorbed across membranes

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21
Q

nicotine absorption in alkaline media

A

Nonionized –> well absorbed across membranes

At physiologic pH (7.4), ~31% of nicotine is nonionized

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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

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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

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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.

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25
Q

CNS

A

Pleasure
Arousal, enhanced vigilance
Improved task performance
Anxiety relief

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26
Q

Cardiovascular system

A 
increase Heart rate
increase Cardiac output
increase Blood pressure
Coronary vasoconstriction
Cutaneous vasoconstriction
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27
Q

Other pharmacodynamics

A

Appetite suppression
Increased metabolic rate
Skeletal muscle relaxation

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28
Q

effects of nicotine

A

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)

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29
Q

Tobacco users maintain a minimum serum nicotine concentration in order to

A

Prevent withdrawal symptoms
Maintain pleasure/arousal
Modulate mood

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30
Q

Users self-titrate nicotine intake by

A

Smoking/dipping more frequently
Smoking more intensely
Obstructing vents on low-nicotine brand cigarettes

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31
Q

individual factors contributing to tobacco use

A

Sociodemographics
Genetic predisposition
Coexisting medical conditions

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32
Q

pharmacological factors contributing to tobacco use

A

Alleviation of withdrawal symptoms
Weight control
Pleasure, mood modulation

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33
Q

environmental factors contributing to tobacco use

A

Tobacco advertising
Conditioned stimuli
Social interactions

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34
Q

Drugs may have a decreased effect due to induction of

A

CYP1A2

Bendamustine, haloperidol, caffeine, Theophylline

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35
Q

Caffeine effects

A

Nicotine withdrawal effects might be enhanced by increased caffeine levels

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36
Q

Smokers who use combined hormonal contraceptives have an increased risk of serious cardiovascular adverse effects:

A

Stroke
Myocardial infarction
Thromboembolism

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37
Q

smoking ___ decrease the efficacy of hormonal contraceptives

A

DOES NOT

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38
Q

Non pharm methods

A

Cold Turkey

Unassisted tapering

Assisted tapering

Formal Cessation programs

Acupuncture therapy

Hypnotherapy

Massage

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39
Q

Tobacco quitlines

A

Tobacco cessation counseling, provided at no cost via telephone to all Americans

4-6 sessions

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40
Q

Pharmacotherapy is not recommended for

A

pregnant smokers
smokeless tobacco users
individuals smoking <10 per day
Adolescents

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41
Q

Nicotine polacrilex gum

A

Nicorette (OTC)

Generic nicotine gum (OTC)

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42
Q

Nicotine lozenge

A

Nicorette (OTC)

Generic nicotine lozenge (OTC)

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43
Q

Nicotine transdermal patch

A 
NicoDerm CQ (OTC)
Generic nicotine patches (OTC)
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44
Q

Nicotine inhaler

A

Nicotrol (Rx)

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45
Q

Nicotine nasal spray

A

Nicotrol NS (Rx)

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46
Q

Bupropion SR

A

Generic (Rx)

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47
Q

Varenicline

A

Chantix (Rx)

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48
Q

Nicotine replacement therapy

A

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

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49
Q

Nicotine replacement therapy precautions

A

Patients with underlying cardiovascular disease:

Recent myocardial infarction (within past 2 weeks)

Serious arrhythmias

Serious or worsening angina

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50
Q

Nicotine gum

A

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

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51
Q

Nicotine Lozenge

A

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

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52
Q

Use the 2 mg gum/lozenge:

A

If first cigarette of the day is smoked more than 30 minutes after waking

53
Q

Use the 4 mg gum/lozenge:

A

If first cigarette of the day is smoked within 30 minutes of waking

54
Q

Gum/Lozenge schedule

A

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
Q

Do not use more than ___ pieces of gum or ___ lozenges per day

A

24 –> gum

20 –> lozenges

56
Q

directions for use with gum

A

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
Q

directions for use with lozenges

A

Place in mouth and allow to dissolve slowly

no chewing or swallowing

58
Q

Lozenges will dissolve completely in about

A

20-30 minutes

59
Q

Do NOT eat or drink for __ minutes BEFORE or while using the nicotine gum or lozenge.

A

15

60
Q

The effectiveness of the nicotine gum/lozenge may be reduced by some foods and beverages:

A

Coffee
Wine
Juices
Soft drinks

61
Q

Chewing the lozenge or using incorrect gum chewing technique can cause excessive and rapid release of nicotine, resulting in:

A

Lightheadedness/dizziness
Nausea and vomiting
Hiccups
Irritation of throat and mouth

62
Q

Adverse effects of nicotine gum and lozenge:

A

Mouth and throat irritation
Hiccups
Gastrointestinal complaints (dyspepsia, nausea)

63
Q

Adverse effects associated with JUST nicotine gum:

A

Jaw muscle ache

May stick to dental work

64
Q

advantages of gum/lozenge

A

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
Q

disadvantages of gum/lozenge

A

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
Q

transdermal nicotine patch

A

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
Q

NicoDerm CQ light smoker dose

A 
<10 cigarettes/day
Step 2 (14 mg x 6 weeks)
Step 3 (7 mg x 2 weeks)
68
Q

NicoDerm CQ heavy smoker dose

A 
>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
Q

Generic patch light smoker dose

A 
<10 cigarettes/day
Step 2 (14 mg x 6 weeks)
Step 3 (7 mg x 2 weeks)
70
Q

Generic patch heavy smoker dose

A 
>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
Q

Patch directions

A

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
Q

After applying patch

A

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
Q

Patch pt education

A

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
Q

Patch ADR

A

Irritation at the patch application site (generally within the first hour)
Mild itching
Burning
Tingling

Sleep disturbances
Abnormal or vivid dreams
Insomnia

75
Q

Advantages of patch

A

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
Q

Disadvantage of patch

A

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
Q

Nicotine inhaler consists of

A

Mouthpiece

Cartridge with porous plug containing 10 mg nicotine and 1 mg menthol

78
Q

Delivers __ mg nicotine vapor, absorbed across buccal mucosa

A

4

79
Q

inhaler directions for use

A

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
Q

Inhaling nicotine inhaler

A

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
Q

Inhaler ADR

A

Mild irritation of the mouth or throat
Cough
Hiccups
Gastrointestinal complaints (dyspepsia, nausea)

82
Q

Do NOT eat or drink for minutes BEFORE or while using the nicotine inhaler.

A

15

83
Q

Advantages of inhaler

A

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
Q

Disadvantages of inhaler

A

Need for frequent dosing can compromise adherence
Cartridges might be less effective in cold environments (≤60F)
Cost of treatment

85
Q

Nicotine nasal spray

A 
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
Q

Nasal spray dose and administration

A

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
Q

nasal spray direction for use

A

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
Q

Nasal spray what to expect (first week)

A 
Hot peppery feeling in back of throat or nose
Sneezing
Coughing
Watery eyes
Runny nose
89
Q

Nasal spray advantages

A

Can be titrated to rapidly manage withdrawal symptoms

Can be used in combination with other agents to manage situational urges

90
Q

nasal spray disadvantages

A

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
Q

Bupropion SR MOA

A

atypical antidepressant thought to affect levels of various brain neurotransmitters

Dopamine
Norepinephrine

92
Q

Bupropion SR clinical effects

A

decrease craving for cigarettes

decrease symptoms of nicotine withdrawal

93
Q

Bupropion absorption

A

Bioavailability: 5–20%

94
Q

Bupropion metabolism

A

Undergoes extensive hepatic metabolism (CYP2B6)

95
Q

Bupropion elimination

A

Urine (87%) and feces (10%)

96
Q

Bupropion 1/2 life

A

Bupropion (21 hours); metabolites (20–37 hours)

97
Q

Bupropion contraindications

A

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
Q

Bupropion should be used in caution in the following populations

A

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
Q

Bupropion precautions

A

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
Q

Bupropion SR: To ensure that therapeutic plasma levels of the drug are achieved, patients should begin therapy ___weeks PRIOR to their quit date.

A

1-2

101
Q

Bupropion SR dosing

A

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
Q

Bupropion ADR

A

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
Q

Bupropion advantages

A

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
Q

Bupropion SR disadvantages

A

Seizure risk is increased
Several contraindications and precautions preclude use in some patients
Patients should be monitored for neuropsychiatric symptoms

105
Q

VARENICLINE

A

Chantix

106
Q

VARENICLINE

A

Nonnicotine cessation aid
Partial nicotinic receptor agonist
Oral formulation

107
Q

VARENICLINE MOA

A

Binds with high affinity and selectivity at a4b2 neuronal nicotinic acetylcholine receptors
Stimulates low-level agonist activity
Competitively inhibits binding of nicotine

108
Q

Varenicline clinical effects

A

decrease symptoms of nicotine withdrawal

Blocks dopaminergic stimulation responsible for reinforcement & reward associated with smoking

109
Q

varenicline absorption

A

Virtually complete (~90%) after oral administration; not affected by food

110
Q

varenicline metabolism

A

Undergoes minimal metabolism

111
Q

varenicline elimination

A

Primarily renal through glomerular filtration and active tubular secretion; 92% excreted unchanged in urine

112
Q

Varenicline 1/2 life

A

24 hours

113
Q

Varenicline warnings

A

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
Q

In some patients, use of varenicline has been associated with:

A 
Seizures
Enhanced effects of alcohol
Accidental injury
Cardiovascular events
Somnambulism 
Angioedema and hypersensitivity reactions
Serious skin reactions
115
Q

Patients should begin therapy __ week PRIOR to their

quit date. The dose is gradually increased to minimize treatment-related nausea and insomnia

A

1

116
Q

Varenicline dose

A

day 1-3 = 0.5mg qd
day 4-7 0.5 mg bid
day 8-end 1 mg bid

117
Q

FIXED QUIT approach

A

Set quit date for 1 week after starting varenicline

Continue treatment for 12 weeks

118
Q

FLEXIBLE QUIT approach

A

Start taking varenicline and pick a quit date between 8 to 35 days from treatment initiation
Continue treatment for 12 weeks

119
Q

GRADUAL QUIT approach

A

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
Q

Varenicline ADR

A 
Common adverse effects include the following:
Nausea
Insomnia
Abnormal dreams
Headache
Less common adverse effects:
Gastrointestinal (flatulence, constipation)
Taste alteration
121
Q

Varenicline pt edu

A

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
Q

Varenicline advantages

A

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
Q

Disadvantages of Varenicline

A

cost

Patients should be monitored for potential neuropsychiatric symptoms

124
Q

highest long term quit rate

A

Varenicline

125
Q

lowest long term quit rate

A

patch

126
Q

combination therapy

A

can combine patch with gum, inhaler, lozenge, nasal spray

Can combine bupropion SR and patch

127
Q

Strong evidence that combination NRT and varenicline are more effective than bupropion SR or NRT monotherapy

A

Important to remember

128
Q

Combination dosing

A

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
Q

3 key factors of adherence

A

Correct strength of medication

Taken daily, according to a fixed schedule

Taken for the full duration of therapy

CDM Exam 3 (8 decks)

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