smoking cessation

5 A's

• Ask about tobacco use

• Advise to quit

• Assess readiness to quit

• Assist with quit attempt

• Arrange follow up

What patients have exceptions to drug TX? (3) **

• Pregnant

• Adolescents

• Light smokers (<10 cig/day)

What CYP does smoking target?

CYP450 1A2 inducers

Smoking DDI with patients who quit (2)

• Increase theophylline dose

• Increase warfarin dose

What medication should be avoided in female smokers?

Estrogen containing OC in patients ≥35 years old due to increased risk of CV disease

Vaccinations in smokers aged 19-49 (2)

• Pneumococcal

• Influenza

Preferred TX for smoking cessation **

• Combination NRT with LA patch and SA gum/lozenge

• Varencicline monotherapy

NRT examples (4)

• Patch (NicoDerm CQ)

• Gum (Nicorette)

• Lozenge (Nicorette Mini)

• Nasal spray RX

How many cigarettes in a pack haha

20

Pack per year equation

(# cigs packs per day) x (# of years smoked)

NICOTINE PATCH DOSING

>10 cig/day:

• 21 mg/day x 6W

• 14 mg/day x2W

• 7 mg/day x2W

≤10 cig/day

• 14 mg/day x 6W

• 7 mg/day x2W

GUM/LOZ DOSING

≤30 min after waking

• 4 mg q1-2hr x6W

• 4 mg q2-4hr x 3W

• 4 mg q4-8hr x 3W

>30 min after waking

• 2 mg q1-2hr x 6W

• 2 mg q2-4hr x 3W

• 2 mg q4-8hr x 3W

What patients should NRT be avoided in? (2)

• CV: post-MI, arrhythmias, angina

• Pregnancy and adolescents

What medication should be avoided in COPD/Asthma?

Nasal spray

Main NRT adverse effect (1)

Insomnia

Main adverse effects with patch? (2)

• Vivid dreams

• Skin irritation

The FDA prohibits sale of nicotine products to patients < ____ years and identification is required to purchase.

<21 years old

Should the nicotine patch be removed prior to MRI?

YES

Can you eat/drink when using loz/gym?

NO - do not eat/drink 15 min before or during use

Gum & loz (sugar free): ___ mg strength can reduce or delay weight gain

4 mg

Buproprion MOA

Blocks neuronal reuptake of dopamine and norepinephrine

BUPROPION SR dosing **

• Start 1-2 weeks prior to quit to allow time to reach steady state before stopping smoking

• SR: 150 mg QAM x 3D, then 150 mg BID

- Take first dose upon waking and 2nd dose at least 8 hours after first dose

• Max dose: 300 mg/day

Bupropion BW

Increased risk of suicidal thinking and behavior in children, adolescents, and young adults taking antidepressants

Bupropion Contraindications (5)

• Seizures

• Anorexia/bulimia

• MAOI

• Linezolid

• Methylene blue

Bupropion adverse effects (5)

• Serious neuropsych events

• Dry mouth

• Insomnia

• Tremors

• Weight loss

Varenicline MOA

Partial neuronal alpha-4/beta-2 nicotinic receptor agonist

Start 1 week before quit date

A. Bupropion

B. Varenicline

B. Varenicline

Start 1-2 weeks before quit date

A. Bupropion

B. Varenicline

A. Bupropion

Varenicline adverse effects (6)

• Serious neuropyschiatric events

• Seizures

• Nausea

• Insomnia

• Vivid dreams

• Headache

PATCH COUNSELING

• Press patch on clean skin for ~10 sec

• Wear for 24 hours

• If vivid dreams occur, remove the patch prior to bedtime and apply a new one in the AM

• Fold sticky ends together and put in trash can with lid

• Wash hands before and after

• Rotate patch site

• NEVER cut patch

• Never wear more than 1 patch at a time

Nicotine GUM counseling

• Chew slowly until there is a tingle or peppery flavor in the mouth

• Park it between the cheek & gum

• When the tingle or flavor goes away, chew the gum again slowly until it returns, then park again

• Repeat until most of the flavor is gone (~30 min)

• Do not eat/drink for 15 min before or during use

Nasal spray counseling

• Tilt head back slightly

• Spray once in each nostril while breathing through the mouth

• Do not sniff, swallow, or inhale through the

• Can cause sneezy, coughing, watery eyes, runny nose, and a hot peppery feeling in the back of the throat

Which NRT is prescription only

Nicotine spray