Smoking Cessation

Smoking increases the risk of

• coronary heart disease 2-4x

• stroke 2-4x

• lung cancer in men 25x

• lung cancer in women 25.7x

causes cancer almost anywhere in the body

smoking during pregnancy causes

• preterm delivery

• stillbirth

• low birth weight

• SIDS

• ectopic pregnancy

• orofacial clefts in infants

correlated factors

• 25-44 years old

• non-hispanic American Indians/alaskan natives

• lower education levels

• < federal poverty level

• differs by state

• mental illness

Second hand smoke in infants increases risk of

• SIDS

• respiratory infections

• ear infections

• severe asthma

• slowed lung growth

marketing

cigarettes are the only marketed consumable products that, when used persistently, will kill half or more of its users

Dependence

• nicotine induce and sustain chemical dependence

  • psychoactive effects

  • used in highly controlled or compulsive manner

  • reinforce behavioral patterns

EPA

class A carcinogen

• no safe level of exposure for humans

• gaseous and particulate (tar)

nicotine

• distilled when burned

• carried in tar droplets to small airways

• absorbed into arterial circulation distributed throughout body

• reaches brain in seconds

nicotine effects

brain:

• decreases appetite, anxiety, tension

• increases mood

cardiovascular:

• increases heart rate, BP

withdrawal symptoms

• irritability, frustration, anger

• anxiety, depression

• loss of concentration

• impatience

• insomnia, restlessness

other:

• cravings

• impaired performance

• constipation

• dizziness

• cough

withdrawal timeline

• manifest in 1-2 days

• peak in 1 week

• dissipate 2-4 weeks

• appetite and weight gain may persist for >6 mo

drug interactions

• reduces therapeutic efficacy

• increased toxicity

• CYPP450 enzyme inducer

• caffeine exposure increased 56% (decrease caffeine during attempts to quit)

interacts with a hormonal contraceptive

• increases clotting risk

• increase of CV events

• greater risk if >35 yo or > 15 cig/day

cigarette smokers die ____

10 years earlier than non-smokers

approach to quiting

• no treatment

  • cold turkey

  • 95% of attempts fail

• tabacco cessation counseling

• pharmacotherapy

• counseling + pharmacotherapy

exclusions for self treatment

• serious heart disease, including recent MI, irregular heartbeat, severe angina

• uncontrolled HTN

• pregnancy

• breastfeeding

• < 18 yo

• Active PUD

5 A’s

• ask patients if they use tobacco

• advising users to quit

• assess readiness to quit

• assisting patients to quit

• arranging follow-up care

Ask

do you ever smoke or use any type of tobacco?

Advise

• clear, strong, and personalized

• sensitive and convey concern

I strongly encourage you to quit, and I want to help

Assess

• not all patients are ready to quit when approached

• classifications

  • not ready to quit in the next month

  • ready to quit in the next month

  • recent quitter in past 6 mo

  • former user > 6 mo ago

Assist

• be empathetic

• acknowledge quitting is a challenge

• encourage counseling and medication

2 steps:

• helping make decision to quit

• setting a quit date

Arrange

• multiple counseling interactions preferred (increase ability to abstain)

• follow up is crucial

  • week 1, month 1, periodically thereafter

  • manage AEs

  • behavioral tips

  • offer emotional support

pre-contemplation counseling

• always ask permission first

• use open-ended questions

• motivational interviewing

• 5 R’s popular in smoking cessation

Develop discrepancy

• patient is still smoking

  • know it is harmful

  • cannot acknowledge that quitting is important

• human tendency not to think about it

  • lead an honest discussion with patient

• readiness ruler

• decisional matrix

readiness ruler

helps focus the gap between where the person has been, and where they want to be

decisional matrix

essentially a pro/con list for fair meeting

express empathy

• understand patient’s point of view

• reflect on patient’s perspective

• NO judgement zone

amplify ambivalence

help bring quitting to the forefront of the patient’s mind

roll with resistance

• humans resist change

• avoid the righting reflex

support self efficacy

• many lack confidence to change

• maintain positive tones

pharmacotherapy for smoking cessation

• all agents double quit rates

first line agents:

• nicotine replacement therapy gum

• NRT lozenge

• NRT patches

• NRT inhaler

• NRT nasal spray

• sustained release bupropion

• varenicline

nicotine replacement therapy

MOA: stimulates the release of dopamine in the CNS

• reduces symptoms of withdrawal

• allows focus on behavior change

• no exposure to carcinogens

lower, slower, and less variable plasma levels

AE: headache, insomnia, abnormal dreams

NRT counseling

• do not use tobacco products while taking NRT

  • AE may occur: nausea, vomiting, hyper-salivation, perspiring, abdominal pain, dizziness, weakness, palpitations

NRT gum/lozenge

2mg < 30 mins after waking

4 mg > 30 mins after waking

• various flavors

• available in mini formulations

• MOA: buffering agent helps absorption in buccal mucosa

dosing: time to first cigarette

peak: 30 mins

duration: 2-3 hrs

AE: unpleasant taste, mouth irritation, jaw soreness, hyper salivation, hiccups, dyspepsia

NRT gum use

• chew and park method

  • chew slowly several times

  • stop after you feel a peppery sensation

  • park gum between cheek and gums

• when taste/tingles dissipates resume chewing

• repeat, rotating parking locations

• gum last about 30 mins

• do not exceed 24 pieces/day

NRT lozenge use

• place in mouth and let dissolve

  • stangdard lozenge about 20-30 mins

  • mini lozenge about 10 mins

• warm, tingling sensation

• do not chew or swallow

• rotate in mouth

• do not exceed 20 lozenges/day

NRT patch

7mg, 14 mg, 21 mg

• deliver continuous, low levels of nicotine

  • 1 patch = 24 hours

> 10 cigs per day:

• 21 mg/day for 4 weeks

• 14 mg/day for 2 weeks

• 7 mg/day for 2 weeks

< 10 cigs per day:

• 14mg/day for 6 weeks

• 7mg/day for 2 weeks

AE: local skin irritation, sleep disturbances (remove patch at night)

How to use NRT patch

• apply to clean, dry, hairless area

  • same time per day

• potate patch site

• apply firm pressure for 10 seconds

• apply for no more than 24 hours

• do not cut patches

• may shower and swim

• keep out of reach of children and pets

E-cig risks

• decision making nad impulse control in teens

• attention and leanring in teens

• addiction

• mood disorders

• aerosol related lung damage

• fires and explosions

Youth epidemic tied to vitamin E

Individuals with MI, serious arrhythmias, serious or worsening angina pectoris

use NRT with medical supervision

pregnancy/lactation

refer

individuals less than 18 yo

refer