Tobacco Cessation Flashcards
Tobacco is the leading cause of…
known preventable death
Smoking causes more deaths per year than all of the following combined:
- HIV
- Illegal drug use
- alcohol use
- motor vehicle accidents
- firearm-related incidents
Smoking increases the risk of…
- coronary heart disease x2-4
- stroke x2-4
- lung cancer in men x25 and women x25.7
Smoking can cause cancer in…
almost anywhere in the body
Smoking during pregnancy can lead to…
- preterm delivery
- stillbirth
- LBW
- SIDS
- ectopic pregnancy
- orofacial clefts in infants
Correlated factors for smoking:
- 25-44 YO
- non-hispanic american Indians/Alaskan natives
- lower education levels
- < federal poverty level
- differs by state (WV has highest and UT has lowest)
- mental illness
Second-hand smoke increases the risk of…
- SIDS
- respiratory infections
- ear infections
- severe asthma
- slowed lung growth
Marketing regulation of 1965:
federal cigarette labeling and advertising act
- surgeon general’s warning on cigarette packaging
Marketing regulation of 1971:
broadcast advertising banned
Marketing regulation of 1990:
cigarette ban on flights and interstate busses
What happened in 1994?
Mississippi filed lawsuit
- big tobacco for Medicaid costs
- first of 22 states to file suit
Marketing regulation of 1995:
President Clinton announced FDA to regulate sales and advertising to minors
T/F: cigarettes are the only marketed consumable product, that when used persistently, will kill half or more of its users
T
On June 18, 2021, the US will…
change packaging
- warnings prominently on packaging
In 2021, warning labels in the US will…
- occupy top 50% of package area on the front and back
- at least 20% of advertisements
How can nicotine can induce and sustain chemical dependence?
- psychoactive effects
- used in highly controlled or compulsive manner
- reinforce behavioral patterns
Pharmacologic process of smoking is similar to…
- heroin
- cocaine
Pathophysiology of smoking:
stimulates mesolimbic dopaminergic system in midbrain
- dopamine reward pathway
- induces pleasant or rewarding effects
- promotes continued use
Cigarette smoke has an EPA of…
class A carcinogen - no safe level of exposure for humans
Cigarette smoke has a complex mixture of…
- nitrogen
- CO
- ammonia
- hydrogen cyanide
- benzene
- nicotine
Nicotine:
- distilled when burned
- carried in tar droplets to small airways
- absorbed into arterial circulation
- readily penetrates CNS
Effects of nicotine on brain:
- decreased appetite
- decreased anxiety and tension
- increased mood
Effects of nicotine on heart:
- increases heart rate
- increases blood pressure
Nicotine will affect:
- brain
- heart
- endocrine
- nervous
- metabolic
Chronic users of smoking:
- develop tolerance to nicotine
- abrupt cessation triggers withdrawal
Withdrawal symptoms:
- irritability, frustration, anger
- anxiety, depression
- loss of concentration
- insomnia, restlessness
- cravings
- impaired performance
- constipation
- dizziness
Timeline of withdrawal symptoms:
- manifest 1-2 days
- peak in 1 week
- dissipates 2-4 weeks
- appetite and weight gain may persist for > 6 months
Drug interactions:
- increased toxicity of some drugs
- CYPP450 enzyme inducer
- caffeine exposure increased 56%
Significant drug interactions w/…
combination hormonal contraceptives
- increased clotting risk
- increased risk of CV effects
- greater risk if > 35 YO/ > 15 cigs a day
Primary treatment goal for smoking:
complete, long term abstinence from all nicotine products
Treatment goals for smoking:
- help patients quit tobacco
- prevent relapse
- utilize appropriate pharmacotherapy and counseling
General approach to quitting:
- no treatment (cold turkey)
- tobacco cessation counseling
- pharmacotherapy
What percentage of quitters fail by going cold turkey?
95%
Tobacco cessation counseling helps…
- increases odds of quitting
- longer and more frequent beneficial
Pharmacotherapy will help…
increases odds of quitting
What is the best approach for quitting smoking?
counseling and pharmacotherapy
Exclusions for self treatment:
- serious heart disease
- irregular heartbeat
- uncontrolled HTN
- pregnancy
- breastfeeding
- < 18
- active PUD
Comprehensive counseling has the 5A’s. What are they?
- ask patients if they use tobacco
- advise users to quit
- assess readiness to quit
- assist patients to quit
- arrange follow up care
Info about asking patients about tobacco use:
- routine component of care
- consider asking about secondhand smoke
- “do you ever smoke or use any type of tobacco?”
Info about advising patients about tobacco use:
- clear, strong, and personalized
- sensitive and convey concern
- “strongly encourage you to quit”
Info about assessing patients for tobacco use:
- not all patients are ready to quit when approached
- “what are your thoughts about quitting?”
- “something you are willing to do in the next month?
Classifications for assessing patients for quitting:
- not ready to quit in next month
- ready to quit in next month
- recent quitter in past 6 months
- former user > 6 months ago
Info about assisting patients with quitting:
- be empathetic
- acknowledge quitting is challenge
- goal is to maximize success
- encourage counseling and medication
Info about arranging follow up with patients who are quitting:
- multiple counseling interactions are preferred
- follow up is crucial
Intervals of following up with recent quitter:
- week 1
- month 1
- periodically after
Better quitting success comes from…
more and longer contacts
Precontemplation counseling:
- always ask permission first
- use open-ended questions
- motivational interviewing
Counseling:
- group and individual is effective
- self-help material alone is not effective
Most successful tips for quitting:
- social support
- problem-solving training
- stress management
- relapse prevention
- > 4 sessions
- > 10 minute sessions
Motivational interviewing techniques:
- develop discrepancy
- express empathy
- amplify ambivalence
- roll w/ resistance
- support self-efficacy
Motivational interviewing:
- always ask permission first
- use open-ending questions
Info about developing discrepancy:
- patient is smoking and knows it’s harmful
- can’t acknowledge that quitting is important
- will tend not to want to talk about it, so try to have honest discussion
Techniques of how to develop discrepancy:
- readiness ruler
- decisional matrix
How to express empathy:
- understand patient’s POV
- people want to feel understood
- no judgement zone
How to amplify ambivalence:
- explore two sides of thought to amplify ambivalence
- help bring quitting to forefront of patient’s mind
Rolling w/ resistance:
- avoid “righting reflex”
- humans resist change
Techniques for rolling with resistance:
- ask permission
- offer advice
- emphasize choice
- elicit response
- voice confidence
How to support efficacy:
- many lack confidence to change (want to increase it)
- maintain positive tones b/c patients will lean toward negative
Reminders for helping people quit:
- stay positive
- don’t be judgmental
- utilize motivational interviewing
- remember how difficult it is for patients
T/F: some pharmacological agents double quit rates
F, all agents double quit rates
What are the 7 FDA approved first-line agents?
- NRT gum
- NRT lozenge
- NRT patches
- NRT nasal spray
- sustained release buproprion
- varenicline
Nicotine replacement therapy (NRT) is…
FDA approved for cigarette cessation
MOA of NRT:
stimulates release of dopamine in the central NS
- non-tobacco source of nicotine
- reduces physiologic symptoms of withdrawal
- allows focus on behavior change
- no exposure to carcinogens
NRT has…
lower, slower, and less-variable plasma levels
General counseling for NRT:
- don’t use tobacco products w/ it
Adverse effects of nicotine:
- nausea
- vomiting
- hyper-salivation
- perspiring
- abdominal pain
- dizziness
- weakness
- palpitations
Adverse effects of NRT:
- headache
- insomnia
- abnormal dreams
Dosage of NRT gum/lozenge:
- 2mg - 4mg
- buffering agent helps absorption in buccal mucosa
- time to first cigarette (TTFC)
Peak effectiveness of NRT gum/lozenge:
30 minutes
Duration of NRT gum/lozenge:
2-3 hours
Strength selection for NRT gum/lozenge during 1st cigarette < 30 minutes after waking:
4 mg
Strength selection for NRT gum/lozenge during 1st cigarette > 30 minutes after waking:
2 mg
How to taper gum/lozenge:
- 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
Adverse effects of gum/lozenge:
- general NRT adverse effects
- unpleasant taste
- mouth irritation
- jaw soreness/fatigue
- hiccups
- dyspepsia
How to use the NRT gums:
- chew and park method
- gum lasts about 30 minutes
- don’t excess 24 pieces a day
What is the chew and park method:
- chew slowly several times
- stop chewing when you feel “peppery” sensation (around 15 chews)
- park gum between cheek and gum
- when tingling goes away, resume chewing
- rotate “parking” locations
Why do you rotate parking locations?
it reduces mouth irritation
NRT lozenge use:
- place in mouth and allow to dissolve
- warm, tingling sensation is normal
- don’t chew or swallow
- occasionally rotate in mouth to reduce irritation
- don’t excess 20 lozenges/day
Standard lozenges dissolve within…
20-30 minutes
Mini lozenges dissolve within…
10 minutes
NRT patch dosages:
7 mg, 14 mg, 21 mg
- based on # of cigarettes/day
NRT patches deliver…
continuous, low levels or nicotine
Each NRT patch lasts…
about 24 H
Composition of NRT patch:
- waterproof surface layer
- nicotine reservoir
- adhesive layer
- disposable protective liner
NRT patch dosing if one smokes > 10 cigarettes per day:
- 21 mg/day for 4 weeks
- 14 mg/day for 2 weeks
- 7 mg/day for 2 weeks
NRT patch dosing if one smokes < 10 cigarettes per day:
- 14 mg/day for 6 weeks
- 7 mg/day for 2 weeks
Adverse effects of NRT patch:
- local skin reactions at application site
- rotate application site
- change brands
- nonrx hydrocortisone cream
- sleep disturbances, so can remove patch at night
How to use NRT patch:
- apply to clean, dry, hairless area same time every day with firm pressure for about 10 seconds
- rotate application site
- apply for no more than 24 H
- don’t cut
- can shower and swim with it
How to choose therapy based on patient factors:
- comorbidities
- smoking habits
- gum difficult w/ dental work/dentures
How to choose therapy based on patient preferences:
- frequent vs infrequent dosing
- perceptions from past attempts
E-cigarettes are the most common…
teen “tobacco” product in the US b/c of availability, alluring ads, e-liquid flavor, and belief of safety over cigarettes
E-cigarettes risks:
- nicotine addiction
- mood disorders
- aerosol related lung damage
- affects attention and learning in teens
- affects decision making and impulse control in teens
US e-cigarettes regulations:
- 2016 FDA center for tobacco products (CTP), which is similar to tobacco regulations
In 2018, US surgeon general declared…
vaping is a youth epidemic
In 2020, FDA encourages…
smokers to switch to less harmful products such as e-cigarettes
- made it illegal to market to youth populations
People with CVD should…
- use NRT w/ caution because it can increase b.p. and h.r.
- use NRT w/ MD/DO supervision
Pregnant people should…
- look at risk/benefit
- NRT has a category D: fetal harm
- use NRT w/ MD/DO supervision
No FDA approved products for…
adolescents
Elderly people:
- same recommendations as adult population
- pharmacologic therapy and counseling
Stages of behavioral change:
- precontemplation
- contemplation
- preparation
- action
- maintenance
Precontemplation stage of behavioral change:
unaware of problem
Contemplation stage of behavioral change:
aware of problem and of desired behavioral change
Preparation stage of behavioral change:
intends to take action
Action stage of behavioral change:
practices desired behavior
Maintenance stage of behavioral change:
works to sustain behavioral change
