smoking cessation therapy

T/F: nicotine is the addictive substance and the carcinogen

• false

  • nicotine = only the addictive substance

  • other ingredients in cigarettes = carcinogens

T/F: it takes ~7-10 quit attempts to quit successfully

• true

when do the benefits of quitting start?

• 20 minutes after quitting

what are the 5 “A”s 

• ASK → about tobacco use 

• ADVISE → all tobacco users to quit 

• ASSESS → readiness to quit 

• ASSIST → tobacco users with a quit plan 

• ARRANGE → follow-up visits 

if a person wants to quit, does that mean they are ready to quit?

• NO 

  • maybe other things in life that prevent readiness

T/F: increasing follow-up sessions also increases estimated quit rate

• true

how to calculate pack years?

• ( # of packs smoked/ day ) x # of years smoked

how many cigarettes are in a pack?

• 20 

what is the first question to assess from a patient for a smoking cessation consult?

• Are you ready to quit smoking / Do you want to quit smoking 

what are some important questions to ask a patient regarding their smoking? 

• Have you tried quitting in the past? 

• what kind of cigarettes do you smoke (filter/unfiltered) \

• what are their triggers ? 

what is important to find out before a therapy can be recommended?

• PMH (past medical history)

what are the 3 main treatment options?

1. behavior modification 

2. OTC pharmacological therapy 

3. prescription pharmacological therapy 

T/F: patients always know what their trigger is for smoking

• false 

  • different for every patient

  • some may not know 

what are ways to change habits?

1. clear home from tobacco related products 

2. clean house 

3. modify behaviors associated with smoking 

what are some withdrawal symptoms? 

• depression 

• insomnia 

• irritability

• anxiety

• restlessness

• weight gain

Tom has been smoking for the past 20 years. He currently smokes Marlboro light 100’s and is extremely interested in quitting smoking. He smokes his cigarette about 45 minutes after waking up in the morning, when he has his cup of coffee. He currently smokes approximately 30 cigarettes/day. What is Tom’s current pack year history?

a) 20 year pack history 

b) 30 year pack history 

c) 40 year pack history 

d) 50 pack-year history 

b) 30 year pack history

• 30 cigarettes/day = 1.5 packs/day

• 1.5 packs x 20 years = 30 

what options are found in nicotine replacement therapy (NRT) ?

• patch (OTC) 

• gum (OTC) 

• lozenge (OTC) 

• inhaler (RX) 

• nasal spray (RX)

when do you give a dose 2mg of nicotine gum?

• smoke your first cigarette more than 30 minutes after waking up 

when do you give a dose 4mg of nicotine gum?

• if you smoke your first cigarette within 30 minutes of waking up 

do you change doses while on nicotine gum? 

• does NOT change 

  • only intervals change

nicotine gum should not be used more than ____ pieces/day

• 24 

what is the dosage schedule for nicotine gum

• 1 piece every 1-2 hrs (week 1-6) 

• 1 piece every 1-4 hrs (week 7-9) 

• 1 piece every 4-8 hours (week 10-12)

when is the peak concentration for nicotine gum

~30 minutes after

what is the contraindication for nicotine gum ?

• active TMJ disease

what precautions should be used for nicotine gum

• dental work 

  • fillings, braces, dentures, crowns, etc

what is the correct way of using nicotine gum?

• “Chew and Park” method 

  • chew slowly 

  • stop chewing when you notice a tingle 

  • park gum between cheek and gum 

  • chew again when the taste or tingle fades

if a patient is using nicotine gum but reports of lightheadedness, nausea/vomiting, and irritation of the throat/mouth, what might it indicate? 

• patient is most likely chewing the nicotine gum all at once → excessive release of nicotine 

when do you chose a 2 mg lozenge for a patient?

• smoke first cigarette more than 30 minutes waking up 

  • same as gum 

when do you chose a 4 mg lozenge for a patient?

• smoke first cigarette within 30 minutes of waking up 

  • same as nicotine gum

what is the max number of lozenges in a day?

• not more than 20 lozenges/day 

  • not more than 5 lozenges in 6 hours

does nicotine gum or lozenges have a greater max of uses/day?

• gum = more max # 

  • lozenge = fully dissolve = full dose of nicotine 

  • gum = may not release full dose 

what is the dosage schedule for nicotine lozenge

• 1 piece every 1-2 hours (week 1-6) 

• 1 piece every 2-4 hours (week 7-9) 

• 1 piece every 4-8 hours (week 10-12)

T/F: lozenge can be chewed

• false

  • should NOT be chewed 

    • can cause adverse/unpleasant effects 

what is the proper administration technique for nicotine lozenge

• lozenge in mouth and allow it to dissolve SLOWLY (20-20 mins)

  • experience a warm, tingling sensation

• occasionally rotate lozenge to different areas

T/F: patient should place lozenge in the same place every time

• false

  • should occasionally rotate the lozenge to different areas

if a patient can not let the lozenge sit in their mouth, what is an alternative?

• nicorette mini lozenge 

  • dissolves 3 times faster 

  • same dosing 

  • but might be more costly 

when is the gum/lozenge initiated for patients?

• on quit date

  • not recommended to start while still smoking

can the gum/lozenge be used on as needed basis?

• not recommended, should be on a scheduled basis 

  • minimize withdrawal symptoms 

  • if patient goes longer → patient can have cravings → relapse 

T/F: if the patient is on a gum or lozenge, and relapses, they should stop the therapy immediately

• false 

  • do NOT stop 

T/F: do not eat or drink anything (except water) 15 minutes before or while using the gum/lozange

• true

which of the following would be appropriate counseling points for use of the nicotine gum? 

a) explain that the maximum number of pieces of nicotine gum/day is 30 

b) patients should use the “chew and park” technique when using the nicotine gum 

c) there are no restrictions related to eating or drinking while using the nicotine gum 

d) A and B are both correct options

b) patients should use the “chew and park” technique when using the nicotine gum 

Tom has been smoking for the past 20 years. He currently smokes Marlboro light 100’s and is extremely interested in quitting smoking. He smokes his cigarette about 45 minutes after waking up in the morning, when he has his cup of coffee. He currently smokes approximately 30 cigarettes/day. which of the following NRT options would be appropriate to start Tom on today? Select all that apply.

a) nicotine lozenge 2 mg 

b) nicotine lozenge 4 mg 

c) nicotine gum 2 mg 

d) nicotine gum 4 mg 

e) nicotine lozenge 6 mg 

a) nicotine lozenge 2 mg 

c) nicotine gum 2 mg 

dosing for nicotine patch is based on what?

• based on # of cigarettes smoked/day 

  • greater or less than 10 cigarettes/day 

what is the dosing of the nicotine patient if a patient smokes more than 10 cigarettes/day

• step 1 = 21 mg for 6 weeks 

• step 2 = 14 mg for 2 weeks 

• step 3 = 7 mg for 2 weeks

what is the dosing of the nicotine patient if a patient smokes less than 10 cigarettes/day

• step 2 = 14 mg for 2 weeks 

• step 3 = 7 mg for 2 weeks

is the dosing schedule for nicotine patch strictly followed?

• does not need to be strict 

  • can be longer if needed

T/F: some literature suggests that using the nicotine patch for 24 weeks total increase long term abstinence rates

• true

what are precautions for nicotine patch

• allergies to adhesive tape

• avoid use in patients with dermatologic conditions 

  • may depend on where (ex. eczema) 

what are common adverse effects of nicotine patch?

• local skin irritation

  • itching, burning, redness

what are less common effects of the nicotine patch

• vivid or abnormal dreams, insomnia, HA 

  • NOT nightmares (might be good or bad) 

  • caution for patients with PTSD

what is the administration technique for the nicotine patch?

• apply patch → clean, dry, hairless area 

  • upper body/ outer part of arm 

• apply firm pressure for 10 seconds 

• wash hands after applying/removing patch 

• rotate application site every day

T/F: the nicotine patch should be places in the same place every day

• false \

  • rotate application site every day 

  • if not = irritation 

Can the nicotine patch be left on the skin for more than 24 hours

• no

T/F: nicotine patches can be cut to fit onto smaller areas

• false 

  • DO NOT CUT 

when is the nicotine patch started?

• begin on quit date 

  • 1st day = 1st day smoke free

which of the following dosing schedules would be appropriate for a patient who would like to initiate the nicotine patch and smokes 1 pack of cigarettes per day? 

a) 21 mg patch for 6 weeks, then 14 mg for 4 weeks, then 7 mg for 4 weeks 

b)  21 mg patch for 6 weeks, then 14 mg for 2 weeks, then 7 mg for 2 weeks 

c)  14 mg for 6 weeks, then 7 mg for 6 weeks 

d)  14 mg for 6 weeks, then 7 mg for 2 weeks 

b)  21 mg patch for 6 weeks, then 14 mg for 2 weeks, then 7 mg for 2 weeks 

what is the risk for nicotrol inhaler?

• can cause addiction to patient 

  • NO specific recommendations for tapering

T/F: patients SHOULD stop all nicotine intake while on NRT 

• true

T/F: sometimes pregnant patients take NRT 

• true 

  • NRT is better than smoking (“clean”, only nicotine)

  • risk vs benefit 

when is bupropion SA supposed to start?

• begin 1-2 weeks BEFORE quitting

what is the dosage for bupropion SA (zyban)

• 150 mg for 3 days, then increase to 150 mg twice daily 

• continue therapy for at least 7-12 weeks 

• consider for up to 6 months post-quit 

what is the MOA for bupropion SA

• blocks re-uptake of NE and DA

T/F:Bupropion XR can be an option for smoking cessation

• false \

  • Bupropion SA is used for smoking cessation 

what are contraindications for bupropion SA use 

• history of seizures 

  • lowers seizure threshold (increases risk of seizures) 

• cranial trauma (greater risk for seizures) 

• be wary for patient already on a well-maintained antidepressant medication 

what are medications that lower seizure threshold, and should NOT be used with bupropion SA

• tramadol

• antipsychotics

• theophylline 

if a patient is on gabapentin, can they be put on bupropion SR?

• depends 

  • gabapentin for nerve pain = okay 

  • gabapentin for seizures/epilepsy = NOT okay

what is the MOA for varenicline?

• partial nicotine receptor agonist 

  • stimulates low level agonist activity 

  • competitively inhibits binding of nicotine 

T/F; chantix blocks nicotine from binding and blocks dopaminergic stimulation responsible fore reinforcement and reward associated with smoking

• true

when is varenicline started?

• while still smoking

  • 1 week prior to quit date

what is the dosage schedule for chantix?

• white tablet

  • 1 tablet (0.5 mg) qd = Day 1-3

  • 1 tablet (0.5 mg) bid (morning, evening) qd = day 4-7 

• blue tablet 

  • 1 tablet bid (morning, evening) = weeks 2-12

what is a common side effect of varenicline?

• GI upset 

  • constipation, flatulence, nausea, vomiting

• trouble sleeping

  • vivid dreams

list the 3 types of varenicline quit approaches 

1. fixed 

2. flexible

3. gradual

fixed quit approach (varenicline)

• quit date = 1 week before quitting 

• treatment = 12 weeks 

flexible quit approach (varenicline)

• start varenicline → quit date = 8-35 days from treatment initiation 

• continue treatment for 12 weeks

gradual quit approach (varenicline)

• start varenicline + reduce smoking by 50% within first 4 weeks 

• additional 50% reduce in the next 4 weeks 

• continue until abstinence by 12 weeks 

  • 24 WEEKS TOTAL

T/F: the blackbox warning for chantix was removed in 2016

• true 

  • no evidence of more frequent neuropsychiatric effects w/ varenicline 

T/F: there is an increased CV risk in patients with CV disease when using varenicline 

• false 

  • NO INCREASED RISK 

  • safe in patients with stable CVD 

increased intoxicating effects of alcohol in patients taking

a) bupropion SA

b) varenicline 

c) nicotine patch 

d) nicotine lozenge

b) varenicline 

SATA: worsening effects of seizures in patients taking

a) bupropion SA

b) varenicline 

c) nicotine patch 

d) nicotine lozenge

a) bupropion SA

b) varenicline 

Chantix should be used with caution in patients with :

• seizure disorder/at risk 

• chronic alcohol use ]

• inpatient with acute coronary syndrome

what is the treatment period for varenicline

• AT LEAST 12 weeks 

  • additional 12 weeks = higher rates of continuous abstinence 

what is the recommended first line options

• varenicline OR 

• combination NRT (ex. nicotine patch PLUS lozenge or gum) 

what is the recommended second line option?

• Bupropion 

• single use NRT 

T/F: combination bupropion and NRT is more effective than either agent alone 

• true 

what is the least recommended therapy for smoking cessation?

• nicotine inhaler + nasal spray 

T/F: varenicline + NRT and varenicline + bupropion are other combinations available 

• true

laboratory data suggests that what substance found in THC-containing e-cigarette or vaping products is strongly linked to issues associated with lung illness? 

• vitamin E acetate 

A patient has been taking bupropion SR 150 mg twice daily for 8 weeks but has not been able to reduce his daily cigarette use or make a quit attempt. He asks for your advice. What is the best recommendation?

1. Increase the dose to 300 mg twice daily.

2. Keep taking the bupropion and add varenicline to the regimen.

3. Continue the medication for at least another 4 weeks to see an effect.

4. Discontinue the bupropion, as it is unlikely to be effective for him.

4. Discontinue the bupropion, as it is unlikely to be effective for him.

• bupropion: "If no clinical benefit noted after 7 weeks; D/C medication".

A 65-year-old male with a history of severe chronic kidney disease (CrCl 25 mL/min) wants to discuss prescription smoking cessation options. Which medication requires special precaution and potential dose adjustment in this patient?

1. Nicotine Patch

2. Varenicline

3. Bupropion SR

4. Nicotine Lozenge

2. Varenicline

• "Use with caution in patients with significant kidney disease (CrCl <30mL/min)"