Smoking Cessation

what does nicotine bind to?

ligand gated receptors to release dopamine

what is the 5A method?

1. relevance

2. risks

3. rewards

4. roadblocks

5. repetition

what is the assessment of tobacco dependence ?

heaviness smoking index

what combination of NRT is benefical ? and is it more effective than a single NRT? 

1 short 

1 long acting

yes 

OTC products 

nicotine gum 

lozenges

patches

Rx products

nasal sprays

inhalers

do nicotine patches need to be tapered?

no, it is optional

typical duration of nicotine patches

12 weeks but can be longer

delayed wt gain

gums

lozenges

they require frequent dosing 1-2 hrs

which dosage form compliance is the lowest? 

gums 

lozenges 

which dosage has the highest dependence?

spray

should the pt drink acidic liquid such as coffee?

what is the recommendation if the patient wanted a coffee?

no

smokers can use oral NRT before drinking there coffee

is bupropion first line?

yes

bupropion SR MOA

block neuronal uptake of dopamine

advantages of bupropion SR 

beneficial with pts with depression 

can use in combo with NRT PATCH 

delay weight gain 

is using bupropion SR + patch more beneficial than using bupropion alone?

yes

does SR bupropion have similar in efficacy to NRT?

yes

is effective in smokers with or without depression

bupropion SR disadvantages

increased risk of seizures

difficult sleeping

constipation

dry mouth

is varenicline first line? 

yes 

varenicline MOA

partial agonist at alpha-4 beta-2 nicotinic cholinergic receptor

is varenicline more effective in promoting smoking cessatioin than single NRT? 

yes 

are varenicline + nicotine patches well tolerated?

yes and is a option for smokers who do not suceed with the individual products alone

varenicline advantages

different mechanism for patients who have failed previous quit attempts

varenicline disadvantages

nausea - take with food

2nd line 

clonidine 

nortriptyline

clonidine AE

orthostatisis

sedation

nortriptyline

sedation

anticholinergic

cardiac toxicity

what should physicians do when pharmacotherapy is used with lighter smokers 10-15 cigs/day?

should consider reducing dose

can most therapies be used long term?

yes 

what do most minority patients use when they successfully quit smoking?

ad libitum NRT medications long term

did FDA approve the use of bupropion SR long-term medications?

yes

nicotine patch key pt counseling

if insomnia occurs / disturbing dreamers → remove

if 1st cig is <30 min what dose do you give the pt? 

4 mg 

if 1st cig is >30 what dose do you give?

2 mg

how long do you use nicotine lozenge?

>3 months

nicotine lozenge disadvantages

no food / drink use and during use

nicotine gum key pt counsel 

discard gum after 30 mins of use 

use 1 piece / hr 

nicotine gum disadvantages

damage dental work and difficult to use with dentures

when do you start varenicline?

1-4 weeks before quit date

when do you start bupropioon?

1-2 weeks before quit date