Tobacco cessation Flashcards
Tobacco use causes what percent of all lung cancer deaths in men and women?
- 90%
What is the pathophys of nicotine addiction?
- nicotine is a highly addictive drug in tobacco
- the cravings can begin within days of the first use
- nicotine stimulates brain nicotinic cholinergic receptors releasing dopamine and other neurotransmitters in the brain’s reward center
- nicotine activates the brain’s reward system during pleasurable activities similar to that of addictive drugs
Acute effects of tobacco use?
- increases HR, BP, and RR
- increases energy
- increased ability to concentrate
- ability to overcome fatigue
What are the chronic effects of tobacco use?
- yellow stains of teeth and fingers
- skin is drier and more wrinkled
- hair is thinner
Withdrawals from tobacco use?
- anxiety
- difficulty concentrating
- sleep disruption
What are the medical conditions related to tobacco?
- smoking causes a large range of health conditions: CVD stroke COPD: emphysema, chronic bronchitis pregnancy (low birth weight) bone and tissue health affects teeth and gums delayed wound healing
Why is tobacco use a RF for CVD and stroke?
- raises TGs
- lowers HDL
- damage cells that line blood vessels
- causes thickening and narrowing of blood vessels
- causes clots to form
How does tobacco use lead to COPD?
- poisons in cigarette smoke can weaken lungs’ defense against infections, narrow air passages, causes swelling in air tubes and destroys air sacs
What effects does tobacco use have on pregnancy?
- damage sperm and ED
- premature birth
- birth defects: cleft palate
- SIDs
What effects does tobacco use have on bone and tissues?
- osteoporosis
- delayed bone healing after fracture
- gum disease
Why are different types of cancers related to tobacco use?
- smoking itself can cause cancer and it also blocks your body from fighting it
- poisons in tobacco smoke weaken the body’s immune system to fight off the cancer cells
- poisons in tobacco smoke can damage a cell’s DNA causing the cell to begin to grow out of control and create a cancerous tumor
What cancers are related to smoking?
- almost all cancers in the body
- mouth, nose, throat
- larynx
- trachea
- esophagus
- lungs
- stomach
- pancreas
- liver
- kidneys and ureters
- bladder
- colon and rectum
- cervix
- bone marrow and blood (leukemia)
What cancers are linked to smokeless tobacco?
- esophagus
- mouth and throat
- pancreas
What are the 3 types of smokeless tobacco?
- chewing tobacco: loose leaf or plug tobacco, nicotine is absorbed through the mouth tissue
- snuff: finely ground tobacco in cans or pouches, nicotine is absorbed through the mouth tissue, dry snuff in powder form is used by sniffing or inhaling the powder up the nose
- snus: from Sweden and Norway. commonly packaged in small pouches. Has fewer tobacco specific nitrosamines (TSNAs) that are known to cause cancer
Who usually uses smokeless tobacco?
- about 3.5% of people 12 and older
- more high school students use compared to young adults
- the route is different, but the nicotine addiction is the same
What are the harmful health effects of smokeless tobacco?
- mouth, tongue, cheek, gum and throat cancer
- esophageal, stomach, and pancreatic cancer
- increased risk of heart disease and stroke
- leukoplakia
Who uses e-cigs?
- increase use in adults, high school and middle school kids since 2010
- most are current smokers
- most report purpose of use is for smoking cessation
How does an e-cig work?
- contains a battery that activates a heating device, atomizing liquid nicotine inside a cartridge and producing a vapor that is inhaled
First gen ECs?
- cigalikes
- disposable
- re-chargeable with pre filled cartridges
Second gen ECs?
-refillable with liquids
3rd gen ECs?
- mods
- able to adjust atomizer - burn liquid hotter - get more nicotine out
What are the components of an E-cig?
- liquid components: nicotine (Not followed by FDA) propylene glycol/glycerol flavorings other components - vapor: little is known about health effect
What are the public health concerns about E-cigs?
- appeal to youth
- reverse changing social norms about acceptability of cigarette smoking
How should you counsel a pt on use of ECs?
- not approved by FDA
- probably less harmful than conventional cigs
- if smokers want to use E cigs to quit, up to provider to support use
Second hand smoke exposure rates?
- 88 million nonsmokers exposed 07-08
- today: half of children b/t ages 3-18 are exposed regularly
- body begins to metabolize nicotine from the smoke, producing a byproduct called cottoning, which can be measured by testing saliva, urine or blood for cotinine
What are the effects of secondhand smoke on children?
- ear infections
- asthma attacks
- respiratory sxs
- resp. infections
- SIDs
What are the effects of secondhand smoke on adults?
- CVD: increases risk 25-30%
- causes around 34000 heart disease death annually
- lung cancer: increases risk 20-30% - causes more than 7300 lung cancer deaths annually
What are the goals of nicotine replacement therapies? (NRT)
- goal is to provide nicotine to a smoker w/o using tobacco while a smoker tries to break the habit
- the use of long acting NRT in combo with a short acting NRT is preferred
- initial dosing is based on the number of cigarettes smoked daily
- NRT is recommended for 2-3 months after smoking cessation
- NRT products can be used while the smoker is still smoking
What NRT products are available?
- 3 OTC products:
patch, gum and lozenge - 2 Rx:
nasal spray, and oral inhaler
Describe the transdermal nicotine patch?
(OTC)
- provides the most continuous nicotine delivery
- patch provides a 16 and 24 hour release
16 hr: usually helps for light average smoker
24 hr: helps with morning cravings
- doses available: 21, 14, and 7
- light smokers: less than 10 cigs/day - should start on quit day and start with 14 mg/day strength for 6 weeks, followed by 7 mg/day for 2 weeks
- heavy smokers: more than 10 cigs a day - should start on quit day with 21 mg/day for 6 weeks followed by 14 for 2 weeks and then 7 mg/day for 2 weeks
What are the SEs of the transdermal nicotine patch?
- skin irritation (most common)
- dizziness
- nausea
- sleep problems and unusual dream
- HA
- muscle aches and stiffness
- SE if patch is too strong:
tachycardia, nausea and overstimulated
What are the short acting NRT agents?
- nicotine gum
- lozenge
- nasal spray
- inhaler
- these should be used in combo with the patch to help control nicotine cravings and withdrawal sxs
Describe the nicotine gume (OTC)?
- most common short acting NRT used
- chewing the gum releases nicotine that is absorbed through the oral mucosa
- doses available: 2 mg for light smokers
and 4 mg: for those that smoke more than 25 cigs a day - chew one piece of gum every 1-2 hours for 6 weeks with gradual reduction over the next 6 weeks for a total duration of 3 months
- chew and park method and then repeat for 30 minutes
What are the SEs of nicotine gum?
- Nausea
- vomiting
- abdominal pain
- constipation
- hiccups (air in the stomach)
Describe the nicotine lozenge (OTC)?
- place in mouth and it dissolves over 30 minutes
- doses:
2 mg for most smokers
4 mg for smokers who smoke within 30 min after waking - use one lozenge q 1-2 hours for 6 weeks with gradual reduction over the next 6 weeks
- max dose is 5 lozenges every 6 hours or 20 lozenges per day
- good for pts that cant chew gum (bad jaw, or dentition)
SEs of lozenges?
- mouth irritation
- hiccups
- N/V
Describe the nasal spray (Rx)?
- delivers nicotine directly to the nasal mucosa where it is absorbed
- 1 or 2 sprays/hr for about 3 months with a max dose of 10 sprays/hr for 80 sprays a day
- each spray contains about 0.5 mg of nicotine
SEs of nasal spray?
- nasal irritation
- runny nose
- watery eyes
- b/c of SEs limits use (caution use in asthma, nasal polyps, any sensitivity in Upper respiratory tract)
Describe oral inhalers (Rx)?
- consist of nicotine cartridge and a thin plastic tube that mimics a cigarette
- smoker inhales puffs on the tube and produces a vapor of nicotine that is absorbed in the mucosa of the mouth so it gives the sensation of the cigarette
- downfall: easier to get e-cig, most expensive of NRTs, vapor rarely reaches the lungs
SEs of oral inhalers?
- coughing
- mouth or throat irritation
- upset stomach
What 2 medical therapies are available for tobacco cessation?
- varenicline (chantix)
- Bupropion (wellbutrin, zyban)
MOA of Varenicline?
- agonizes and blocks alpha-4-beta-2 nicotine acetylcholine receptors
- works in 2 ways:
1. binds to and produces partial stimulation of alpha-4 beta 2 nicotine receptor, thereby reducing nicotine withdrawal - since the drug binds to alpha 4 beta 2 it blocks nicotine from binding to the receptor reducing the pleasure reward
SEs of varenicline?
- Nausea (low dose and titrating up will reduce nausea)
- constipation
- sleep disturbance
- unusual dreams
What are the 2 main concerns of Varenicline?
- neuropsychiatric SEs:
risk of suicide (BBW) so monitor smokers with depression - Cardiovascular SEs:
may have higher risk of MI or stroke
Administration of varenicline?
- start 0.5 mg daily for 3 days
- 0.5 mg 2x for 4 days
- 1 mg 2x daily for rest of 12 week therapy
MOA of Bupropion?
- unknown, thought to act by enhancing CNS noradrenergic and dopaminergic release
- may benefit smokers who are concerned about post cessation wt gain
- considered 1st line therapy for smokers with schizophrenia
- CI for smokers with seizure disorder
SEs of bupropion?
- insomnia
- dry mouth
- HAs
Administration of Bupropion?
- start 1-2 weeks prior to stop date
- 150 mg/day for 3 days
- then 150 mg 2x a day for 12 weeks
How much more likely are smokers going to quit when they see a provider that advises on cessation?
- 1.6x more likely to quit
- providers must ask about smoking history
- advise smokers to quit
- assist smoker with plan to stop
- determine smokers desire: 5 stages of change and 5 As for assessing tobacco use and quitting
What are the 5 stages of change?
- step 1: pre-contemplation
- step 2: contemplation (thinking about quitting but not quite ready)
- step 3: preparation (set a quit date)
- stage 4: action
- stage 5: maintenance
What are the 5 As?
- ask
- advise
- assess
- assist
- arrange
What are some useful strategies for cessation?
- get rid of ashtrays
- drink a lot of water
- avoid smoke filled places
- track money saved
- exercise
- eat healthy, avoid alcohol
- reflect on why you want to quit
- call a friend or support line
- think of yourself as a non-smoker
What are alternative cessation therapies?
- hypnosis
- acupuncture
- behavioral therapy
- motivational therapy
What is nicotine withdrawal? sxs?
- usually begins 30 minutes after the last use of tobacco
- sxs will usually peak in 2-3 days
- sxs will usually subside over the next 3-4 weeks, however some smokers it may take a couple of months
sxs: intense craving for nicotine, tingling in the hands and feet, sweating, nausea, HAs, and feeling irritable
What are the health benefits of smoking cessation?
- within 20 minutes: BP, HR and peripheral circulation improve
- in 24 hrs CO levels drop
- within 48 hrs nicotine is eliminated and taste and smell improve
- 2-12 weeks lung fxn can improve 30%
- 3-9 months: SOB and coughing decrease
- 1 year: risk of MI reduced 50%
- 10 years: risk of lung cancer: reduced by 50%
How do you calculate pack years?
- packs smoked per day x years smoked
- or (number of cigs a day/20)x number of years smoked
What groups have highest rates of tobacco use?
- american indians and alaska natives
Health conditions linked to tobacco use?
- CV
- COPD/cancer
- pregnancy complications
smokeless tobacco is most prevalent in which age group?
- kids
Second hand smoke effects on children?
- infections
- asthma
What is first line medical therapy for tobacco cessation?
Varenicline (Chantix) - **suicide risk
