L4. Smoking Cessation

tobacco cessation:

- tobacco use is the leading preventable cause of disease and death

- of the interventions that affect patients with ____, smoking cessation iis of highest significance

- smoking and second hand smoke are modifiable risk factors and triggers for the development and exacerbations of ___

- smoking cessation counseling is not routinely offered but can help

- on average _____ attempts are necessary for patient ot wuit successfully

COPD

asthma

seven

a usual pack of cigarettes contains ___ cigarettes

20

pack years is a measure of how much you have smoked

--> pack year history = ___________

cigarette packs/day x number of years smoked

so if you smoke 1 pack a day and have smoked for 8 years your pack history would be 8

if you have smoked half a pack for 30 years what is your pack year?

15 pack years

the higher your pack years the higher your ____ risk and ___ risk

COPD and lung cancer risk

pack years often used in determining ____ and ____ risk but is not full proof

example: USPTF recommends yearly low dose CT screening parients 50-80 years old if ____ pack year history of smoking and currently smoke or quit within 15 years

cancer; heart disease; 20 pack years

pack year hisotry can be used when designing _____ pharmacotherapy regimens

smoking cessation

when looking at willingness to quit what are the 5 A's (5 step strategy for smoking cessation program)

1. ASK about tobacco use

2. ADVICE tobacco users to quit

3. ASSESS readiness to make a quit attempt

4. ASSIST with the quit attempt *

5. ARRANGE follow up care

what stage of change is most notable for pharmacists

preparation (ready)

ready to give up but needs help in finding the appropriate strategy or treatment

stages of change

1. precontemplation (not ready)

- does not believe problem exists and no interest in giving up

2. contemplation (getting ready)

- recognize a problem exists and considers giving up or engaging in treatment

3. preparation (ready)

- ready to give up but needs help in finding appropriate strategy for treatment

4. maintenance (sticking ot it)

- stops smoking and integrates this change into lifestyle

5. relapse (learning)

- smoked again

what are the 5 Rs we can use to increase motivation to quit

Relvance- talor advice and dicussion to each patient

Risks- outline irsks of continued smoking

Rewards- outline benefits of quitting

Roadblocks- identify barriers to quitting

Repeition- repeat messages at every visit

what scoring can be used to assess a patients dependence on cigarettes

Fagerstrom Score

what fagerstrom score determine which dependence?

1-2 = low dependence

3-4 = low to moderate dependence

5-7 = moderate dependence

8+ = high dependence

exception to medication treatment:

weight risks vs benefit and consider behavioral counseling alone initially

- pregnancy woman

- adolescents - souldnt be smoking

- smokeless tobacco users (chewing tobacco- harder conversion)

- light smokers (< 10 cigs per day) - treat different

what are the 3 groups of pharmacologic options?

1. buproprion SR

2. Varenicline

3. Nicotine Replacement Therapy (NRT)

what form must buproprion be in

SR

Buproprion SR

- MOA: enhances ____ and ___ release --> leading to reduced ____ and other withdrawal symtpoms

- start when?

enhances noradrenergic and dopamine release --> leading to reduced cravings and other withdrawal symtpoms

start before quit date

Varenicline is more effective than ___ as ___

varenicline is more effective than biproprion as monotherpay

Varenicline

- MOA: partial A4b2 nicotine recetor agonist --> leads to ____________ while blocking ability of _______ to bind --> relieves withdrawal symtoms and inhbits surges of doapmine responsible for redinforcement and reward with smoking

low level stimulation of receptor while blocking ability of nicotine to bind

when should we start varenicline?

- abstinence rate: 21.8-33.5%

before quit date

what do many people not use correctly or a ____ enough dose intiially?

nicotine replacement therapy (NRT)

- many do not use correctly or high wnough doses initially

what are our options for NRT ?

nicotine transdermal patch OTC

nicotine gum OTC

nicotine lozenfe OTC

nicotine nasal spray

nicotine inhaler was disocntinued in late 2023

if an agent worked before for a patient then ____

then use this again

prior success may be hekpful in a subsequent quit attempt

what is first line smoking cessation therapy?

1st line: Varenicline or combination NRT (long acting + short acting) and are more effective than buproprion or single NRT

what should we use on patients with partial or failed repsonse to single therapy

combinations

(NRT + varencicline or buprorprion; varenicline + buproprion)

treatment considerations of tobacco cessation (if patients have these we lead towards one treatment over another)

weight gain

depression

dentures

asthma/COPD

skin conditions

seizures

if a patient gas weight gain use what

gum, lozenge, buproprion SR, varenicline (all delay weight gain)

if patient has depression use

burprioron SR

if patient has dentures avoid

gum

if patient has asthma/COPD avoid

inhaler or nasal spray

if patient has skin conditions

avoid patch

if patiend has seizures avoid

burprorion; varencicline

Varenicline adverse effects

nausea * (helps w weight loss),

sleep disturbances (insomnia/vivid dreams), constipation, flatulence, vomtiitng

what is the dosing like for varenicline?**

days 1-3: 0.5 mg po daily AFTER EATING WITH FULL GLASS OF WATER (helps with nausea)

days 4-7: 0.5 mg po bid

days 8- week 12: 1 mg BID

--> we slowly titrate dose to help with nausea

when do we begin varenicline ?**

start at least 1 week prior to quit date **

varenicline duration **

12 weeks with an ADDITIONAL 12 weeks for sucessful quitters

Varenicline clinical pearls

counseling: report changes in mood, thinking, behavior

can be used in combo with NRT agents and buproprion

Varenicline warnings/percautions

BBW removed in 2016 for neuropsychiatric symptoms like suciidal ideation, aggression, depression

- adjust dose for renal imapiremnt

- preganncy and breatfeeeding

- < 18

- monitor patients w severe/unstable CV

dont need

Bupropion SR BBW? CI? precautions?***

CI: seizures, eating disorders, MAO-I ****

BBW: neurosypchiatric symptoms (suicidal ideation, aggression, depression) ****

precautions: concomitant meds that lower seizure threshold, hepatic impairment, pregnancy and breastfeeding, ages < 18

Buproprion SR

- dosing/initiation?

- adverse effects: insomnia, dry mouth

150 mg per day for first 3 days, then 150 mg BID at least 8 hours apart, INITIATE AT LEAST 1 WEEK BEFORE QUIT DATE

Buproprion SR clinical pearls****

- consider if depression is a comborbity ***

- may blunt post-cessation weight gain ***

- avoid bedtime dosing with insomnia risk (take at 8 am or 4 pm) ***

- can combine

Nicotine Trandermal: warnings/percautions **

MI past 2 weeks

serious arrhythmias

unstabel or worsening angina

pregnancy or breast feeding

skin disorders (patch only)

nicotine transfermal adverse effects for ALL NRT? what is specific to just patch?

ALL NRT: headache, dizzy, nervous, dyspepsia

patch only: vivid dreams, skin irritation, insomnia ****

how do we dose nicotine transdermal?

dosing is based on number of cigs per day

nicotine transdermal --> explain

dosage = # of cigs per day

> 10 cigs per day: 21 mg.day for 4-6 weeks

<= 10 cigs/day: 14 mg/day for 6 weeks

what is the step down dosing like for nicotine transdermal patch?

> 10 cigs per day:

- 21 mg patch/day for 4-6 weeks, then 14 mg/day for 2 weeks, then 7 mg/day for 2 weeks

<= 10 cigs per day

- 14 mg patch/day for 6 weeks, then 7 mg/day for 2 weeks

wear for 24 hours a day and only remove at night only if it disrupts your sleep

nicotine transdermal clinical pearls

- highest adherence rate (15.7-23.4%)

- change patch daily upon awakening, recommend wearing 24 hours to start and remove at bedtime if sleep disturbances

- apply to clear dry, hairless, minimal perspiration area and rotate daily; least obvious to others, remove before MRI

what has the highest adherence rate of all NRT? and what is the rate

nicotine transdermal patch (15.7-23.4%)

nicotine lozenge dosage is based on what?

timing of first cigarette

nicotine lozenge dosing is based on timing of 1st cigarette

- what is the dosing? regimen? max lozenges?

smoke first cigarette <= 30 minutes of waking: 4 mg strength-delays weight gain

smoke first cigarette > 30 mins of waking: 2 mg strength

Fixed dose for 6 weeks then taper slowly over 3 months

- weeks 1-6: one lozenge every 1-2 hours

- weeks 7-9: one lozenge every 2-4 hours

- weeks 10-12: one lozenge every 4-8 hours

- use at least 9 lozenges/day for the first 6 weeks if monotherapy, max 20 lozenges per day

Nicotine lozenge dosing is based on the timing of first cigarette

- if first cigarette is smoked within 30 minutes of waking: 4 mg strength- delays weight gain

- if smoke first cigarette later than 30 mins of waking: 2 mg strength

- fixed dose for _____ and then taper slowly over _____ (can consider 6 mo maintenance)

fixed dose for 6 weeks; taper slowly over 3 months

nicotine lozenge dosin g

- first cirgarette smoked within 30 minutes of waking: 4 mg lozenge

- first cigarette smoked later than 30 minutes of waking: 2 mg

- fixed dosing for 6 weeks, then taper slowly over 3 months

- week 1-6: _____

- week 7-9: ____

- week 10-12: _____

- use at least _____ per day for the first 6 weeks if _____, max is _____ per day

week 1-6: one lozenge every 1-2 hours

week 7-9: one lozenge every 2-4 hours

week 10-12: one lozenge every 4-8 hours

use at least 9 lozenges per day for the first 6 weeks if monotherapy, max is 20 lozenges per day

what is the max number of lozenges per day we can use

20 lozenges per day

Nicotine gum warnings/precautions: **

temporomanidibular joint disease (gum only) ****

all NRT: MI in past 2 weeks, serious arrhythmias, unstabel or worsening angina, pregnancy or breast feeding, adolescents < 18

nicotine gum adverse effects **

mouth/jaw soreness **

dyspepsia **

hiccups, hypersalivation: if incorrect techniquw: lightheadedness, nausea, throat and mouth irritation

how do we determine dosing for nicotine gum?

timing of first cigarrette or number of cigarettes per day

< 25 cigs/day or first cig > 30 mins of waking: 2 mg strength

> 25 cigs/day or first cig <= 30 mins of waking: 4 mg strength

what is the method for use of nicotine gum

*chew and park*

chew until taste and then park in gum

when using nicotine gum we "chew and park" 1 piece of gum should be taken with urge to smoke and can use up to ______ in _____

24 pieces in 24 hours ***

max

what is the dosing regimen like for nicotine gum?

fixed dose for 6 weeks then taper slowly for 3 months

- weeks 1-6: chew 1 piece every 1-2 hours; at least 9 pieces per day if monotherapy

- weeks 7-9: chew 1 piece every 2-4 hours

- weeks 10-12: chew 1 piece of hum every 4-8 hours

each piece can last up to 30 minutes or until flavor is gone

nicotine gum dosing

- fixed dose for ___ and slow taper for ____

- at weeks ____: should have at least ____ per day if ___

fixed dose for 6 weeks and slow taper over 3 months

- at weeks 1-6: should have at least 9 pieces per day if monoterhapy

with a patch we always recommend gum/lozenge so it can be used for ____

breakthrough symtpoms

nicotine nasal spray is not often used but what is a side effect particular to it?

reactive airway disease or nasal conditions

we can refer patients to ___ where they can test "QUIT" to a number and receive medications including ___, ____, and ____

eligibility to recieve counseling: age 14+, readiness, PA reisdent

eligibility for medication: age ___, complete medical screening questions

QUITLINE

nicotine gum, nicotine lozenge, nicotine patch

must be 18 to receive medication

electronic cigarettes

- due to health concerts e cigarettes are ___ recommended for smoking cessation

- if using use as a tool to ____ smoking all all together (aka switching from cigarettes to e cigarettes is _____)

- nicotine content varies between products

- ____ and other damaging chemicals can be present in e cigarette vapors

- e cigarettes are NOT recommend

- used as a tool to quit smoking (aka switching from cigs to e cigs is NOT SAFER)

- carcinogens

what is flavored air that can help with oral fixation that is also not a great option?

QuitGo Inhaler