Self Care : Smoking Cessation

Statistics:

______ ________ is LEADING cause of precentable disease, disability, and death in the US

In the US, smoking is responsible for approximately 1 in _____ of all deaths annually

In 2021 28.3 million adults smoked cigarretes 13.1% were ____ and 10.1% were_____

more than ____ million americans are living with a disease CAUSED by smoking

Smokers die ____ years earlier than

Cigarrete causes >480,000 deaths per year in the US ; more ethan 41,000 from SECOND HAND smoke —> 1 in ___ deaths anually and ______ deaths DAILY

ciggarette smokingm

1 in 5 deaths annually

13.1 = men 10.1= women

16 millon

10 years earlier

1 in 5 anually 1,300 everyday

________ are most commonly used amonged youth

1.21 million (7% of high schoolers)

410,000 (3.5% of middle schoolers)

Are these numbers decreasing?

e-ciggarettes

YES they are decreasing

What are some trends in smoking? who is most effected?

men

65 or less

non hispanic

rural area

lower socioeconomic class

uninsured/ medicaid

low education

LGBT persons

dissability

serious + psychological stress

What are some chronic diseases that are seen in smokers?

• age related macular degeneration

• congenital defects — maternal smoking / orafacial CLEFTS

• tuberculosis

• diabertes

• ectopic pregnancy

• male sexual erictile dysfunction

• rheumatoid arthritis immune function

Beyond

• cancers

• cardiovascular disease

• pulmonary diseases

• reproductive effectives

what are some other health consequences you may see in smokers?

• cataracts

• osteoperosis

• peridontis (gum infection)

• erectile dysfunction

• diabetes

What is the MOST common cause of death due to smoking?

Cardiovascular + Metabolic Disease

Rank comorbidities from greatest number of deaths to fewest for smoking

1. GREATEST = metbaolic + cardiovascular diseases

2. lung

3. respiratory

4. secondhand smoke

5. other cancers

6. perinatal (from mom)

what is a severe consequence of second hand smoke?

stroke

In march 2020 FDA finalized “

“Required Warning for CIgarrete Packages and Advertisements Rule”

what was made mandatory to include on ciggarette packages?

• warning statements

• COLOR images

Which act in 2009, prohibitied characterizing falvors in ciggarettes?

In 2022 FDA also added

• prohibition of methol flavor

• prohibition of flavor in ciggars

family smoking prevention and tabacco control act

Cigarrete Prices/ Economic Impact

• Pack of 20 ciggaretes costs

  • ____ in missouri

  • ______ in New Yprk

The annual smoking cost in 2018 for smoking was $600 billion, what do these costs include?

• misouri = $5.35

• new york = $11.06

smoking cost includes

• healthcare

• loss of productivity from smoking related illness

• premature death from smoking

• premature death from second hand smoking

true/ false: the SINGLE MOST EFFECTIVE way to reduce consumption of ciggareetes is to INCREASE price of tabacco products

true

for every 10% increase in price will lead to a ___% decrease in ciggarete consumption

7% decrease

Which of the following are health consequences of smoking?

• cancer

• stroke

• diabetes

• cataracts

all of the above

true/ false: there is a benefit to quitting smoking REGARDLESS of age and and how long you have been smoking

TRUE

What improvements would you start seeing within these time spans when quitting smoking?

• minutes

• 24 hours

minues = decreased heartrate

24 hours = nicotine level in blood drops to 0

What improvements would you start seeing within these time spans when quitting smoking?

• 1 to 12 months

• 1-2 years

• 3 to 6 years

• 1 to 12 months = decreased couging and shortness of breath

• 1-2 years = SHARP decrease in risk of heart attack

• 3 to 6 years = added risk of coronary heart disease drops by HALF

What improvements would you start seeing within these time spans when quitting smoking?

• 5 to 10 years

• 10 years

• 15 years

• 20 years

• 5 to 10 years = DECREASED RISK OF STROKE

• 10 years = LUNG CANCER drops by HALF

• 15 years = CORONARY HEART DISEASE drops close to that of a non-smoker

• 20 years = risk of several CANCERS drops by half or close to that of a non-smoker

What are the inhaled tabacco products?

• cigarretes

• cigar

• pipe

• hookah

• bidis

Cigarettes (Inahled):

• sold in packs of ___ ciggaretes

• How many mg of nicotine are in each cigarette, and how much reaches the system?

• Are low-yield cigarettes less harmful than regular cigarettes

• 20

• each cig = 10-15 mg (systemic = 1-2 mg)

• Low yield cigarettes are NOT less harmful

What is the tar yield of the following cigarettes?

• regular/full flavor

• light

• ultra-light

• 15mg +

• 6-15mg

• 1-6mg

roll of tabacco wrapped in lead tabacco of in s subtance that contains tabacco

3 major types = large, little, and cigarillos

DOESNT GO INTO LUNGS—> higher risk for ORAL cancers

cigars

A water pipe used to smoke specifically made tobacco that comes in different flavors

Similar health risks to smoking, including cancers,

hookah

inhaled: a mixture consiting of tabacco, cloves, and other additives

kretek or clove ciggarette

inaled: often reusable and consists of a bowl, stem, and mouthpeice

• tabacco is placed into a bowl and lit

• smoke is inhaled through the stem and mouthpeice

pipe

What are forms of smokeless tabacco?

chew

snus

snuff

what are some risks of smokless tabacoo?

(chew, snus, snuff)

Cancer (oral + esophageal +pancreas)

Oral disease (leukoplakia + gum disease + tooth decay+ loss)

Reproductive risks

does smokless tabbaco have LESS of a risk of developing cancer than smoking?

NO smokless tabacco has HIGHER risk of developing cancer

Smokless Nicotine: Oral nicotine pouches

• over 800 million products !

• how many mg of nicotine are included per pouch? is this more or less than ciggarettes?

• in youth the pouches can inhibit _______ and ______ as well as increase the risk of anxiety + depression

• EARLY use of nicotine increases chance of _______ and _______

• ______ irritation + ________ disease

• 1.5-12 mg of nicotine (this is MORE than cigarettes)

• attention + learning

• addiction and dependence

• gum irritation + periodontal disease (similar to smokeless tobacco)

what does ENDS stand for?

is there a higher relevance in men or women?

what age group is most impacted?

is prevelence higher in LGBTQ?

electronic nicotine deliver systems

men

18-24 years old

yes

what can be found in the aerosol of ENDs (e-nictoine)?

Why do people think they are safer even when they have all of these?

• nicotine

• propylene glycol

• carcinogens

• acrolein

• diacetyl

• diethylene glycol

• heavy metals such as nickel, tin, and lead

• ultrafine particles that can be inhaled deep into the lungs

People think they are safer b/c they DONT have TAR

Are ENDs less harmful than other ciggaretes since they dont have tar?

NO

what is the moa of nicotine?

are effects dose dependent?

cholinergic agonist

YES the higher dose you take the more you will need next time to acheive the same result

effects of nicotine (cholinergic agonsit):

• central and peripheral nervous system _____ and _____

• respiratory ________

• skeletal muscle ________

• _______ released by the adrenal medulla

• ______ appetitie and ________ metabolic rate

• peripheral vaso_________

• _______ blood pressure, heartrate, cardiac output, and oxygen consumption

• stimulation AND depression

• respiratiory STIMULATION

• relaxation

• catecholamine release

• supressed apetitie and increased metabolic rate

• constriction

• increased BP, HR< oxygen consumption

What are the steps of nicotine moa?

1. ______ alertness and cognitive stimulation of the CEREBRAL CORTEXT

2. stimualtes ______ center in the LIMBIC system of the brain

3. repititve exposure —>

1. increased

2. reward

3. nueroadaptation

Nicotine PK/PD:

• Where is nicotine well absorbed?

• more readily absorbed in _____ environemnt

• does nicotine pass the placenta and breast milk?

• halflife = 1-4 hours. Does the halflife change with repeated exposure?

• Respiratory tract, mucosal surface, skin, and intestines

• More absorbed in an alkaline environment

• YES

• YES half-life decreases w/ repeated exposure —> increased frequency of smoking

Cigarrete smoking induces which enzyme?

This would accelerate the metabolism of which medications?

CYP 1A2

increase metabolism of

• caffeine

• clozapine

• olanzapine

• ropinirole

• tizanidine

ciggaretes combinined with ____ _______ may increase the risk of serious cardiovascular adverse effects

oral contrceptives

What are some nicotine symptoms?

How long after a quit attempt would you start to experience symptoms?

1-2 days after attempt (LET PATIENTS KNOW)

• irritability

• depressed mood or anxiety

• difficulty concentrating

• insomnia

• restlessness

• increased apetitie

• cravings

What are the two compents of dependence?

Which would be medicated vs. which should be approached with behavioral change programs?

1. psychological (addiction) —> medications

2. behavioral (habit) —> behavior change program

Is the fgerstrom test for nicotine dependence necessary for diagnosis?

NO but it hleps to accessc nictoine dependence

What are the 5 As of counseling?

1. Ask

2. Advice

3. Access

4. Assist

5. Arrange

What is the pharmacy patient care proccess (PPCP) and how they fall into the five As?

Collect = Ask

Asses = Assess

Plan = Assist

Implement = Assist

Follow Up: monitor + evaluate = Arrange

Advice doesn’t necessarily fall under a category

The first step of counseling in the five As is to ASK.

What are some questions you would you ask a patientq?

ASK about their tobacco or nicotine use?

how long?

How often?

How much?

you can bring up certain disease states that are worsened by tabacco help w/ motivation specific to the patient

Step 2 of 5As = advise

• should you try to persuade at this point?

• make this statmenet clear, strong, and __________

Not an opportunity to persuade

personalized

what is step 3 of the 5 As?

access thier readiness to quit —> this will inform how you assist

how would you asist a patient who is NOT ready to quit?

5 Rs

• relevance

• risks

• roadblocks

• rewards

• repitition

“ do you ever plan to quit? what would you have to change for you to decide to quit sooner?”

How would you assist a patient who is ready to quit?

design a treatment plan + STAR

Set a quit date

Tell loved ones
Anticipate challenges (make aware of withdrawl symptoms)
Remove tabacco from environment

How would you assist a patient that recently quit?

• prevent relapse

• further counseling

• medication refills

what is the last step of the 5 As?

How much more likely is a patient to quit if they have had more than 8 counseling sessions?

Arrange follow up care

24.7% more likeley

Motivational interviewing:

• develop _________ between clients goals or values and their current behavior

• avoid argument and ______ _______

• adjust to client ________ rather than opposing directly

• support self -______ and optimism

• discrepancy

• direct confrontation

• resistance

• efficacy

what are some resources to guide patients towards?

• formal cessation programs (Individualized or group)

• telephone quitlines (1-800-QUIT-NOW)

• smartphone: text QUITNOW to 333888

• apps: quitSTART or QuitGuide

• web based counseling

has the COMBINATION of counseling and medication been shown to be more effective than either alone?

YES

what are the FDA approved/ first line agents for pharamacologic therapies?

Comnbination of which two medications are more effective?

1. Nicotine replacement therapy (NRT)

2. Buproprion SR

3. Varenicicline

Combo of NRT + varenicline is more effective!

Which of the FDA approved therapies are over the counter vs prescription?

Buproprion SR = prescription

Varenicicline = prescription

Nicotine Replacement Therapy = OTC

What are examples of nicotine replacement therapy (NRT)?

• patch

• gum

• lozenge

• nasal spray

• inhaler

what are some precautions to have when patients are starting nicotine replacemnt therapy (NRT)?

• nicotine could potentially contribute to the worstening of CVD through its sympathomimetic properties

• do NOT introduce users to combustion products in cigarrete smoke that are involved in cardiovasculalr disease pathogensis

Nicotine Patch:

• Provides _______ release of nicotine

• Can it control long term cravings?

• Can it dimish the severity of breakthrough cravings?

CONTROLLED release

CAN controll long term cravings

CAN dimish severity of breakthrough cravings

Nicotine Patch Adminitration:

• Where are they applied?

• Should you rotate sites?

• How long can the patch be worn for?

• upper body or uper outer arm

• you CAN and SHOULD rotate sites

• patch can be worn for 16-24 hours

What are the three steps of nicotine patch dosing?

1. 21 mg/day

2. 14 mg/day

3. 7 mg/day

why is it a good idea to try to combine gum/lozenge with nicotine patches?

patch can help w/ withdrawl symptoms while

lozenge/gum can help w/ breakthrough cravings

what is the 8 week nocotine patch scheudle of a patient who is heavy smoker and takes more than 10 ciggareetes a day?

1-4 weeks = 21mg/ day

5-6 weeks = 14mg / day

7-8 weeks= 7 mg/day

what is the 8 week nocotine patch scheudle of a patient who is lighter smoker and takes 10 or LESS ciggarretes a day?

weeks 1-6: 14 mg / day

weeks 7-8: 7mg /day

What are some side effects of nictoine patches?

• skin irritation - can advise hydrocortisone

• vivid dreams - can advise to take off at night

• sleep disturbances

• headache

• dizziness / lightheadedneess

Nicotine Patch Counseling:

• how do you dispose of patch

• shoudl you wear more than one at a time?

• can you cut patches?

• can you wet the patches?

• do you HAVE to remove them before MRIs? why or why not?

• What can you do if you are experiecing vivid dreams?

• folding adhesive ends together

• DONT weat more than one (not common)

• DO NOT CUT PATCH

• patches CAN be wet—> can take in shower

• YES must remove before MRI because they have metal (will burn)

• if experiencing vivid dreams you can keep patch on for 16 hours instead of 24 hours

Nicotine Gum:

• provides an _______ release of nicotine to control craving

• contains ______ agents to enhance buccal absorption

• available in various flavors

• immediate release (unlike patch which is controlled release)

• buffering agents

what is the corrent method to chew gum?

1. chew gum slowly UNTIL it begins to tingle

2. once it tingles —> place gum between cheeks and gums UNTIL tingle goes away

3. repeat proccess until TINGLE IS GONE (30-60 minutes)

called CHEW AND PARK method

• should you chew fast or slow and why?

• how long should you “fast” before eating the gum?

chew slowky to prevent extensive release of nicotine —> indigestion, lightheadedness

dont eat for 15 minutes before chewing gum

Nictoine lozenge:

• ______ formulation

• provides _____ release of nictoitne to control cravings

• contains buffering agent ot enhance _____ ______ of niccotine

• available in flavors

• who is it best for?

• polacrilex formulation

• IMMEDIATE release

• buffering agent —> enhance buccal absoprtion of nicotine

• best for those who cant use gum due to

  • orthodontics

  • temporomandibular joint (TMJ)

  • social or proffesional situations

How should you take nictoine lozenges?
Can you chew or swallow?

Occasionally move the lozenge from one side to the other untile it is COMPLETELY disolved in ____-____ minutes

• place lozenge in mouth and allow it slowly dissolve

• DO NOT CHEW OR SWALLOW

• 20-30 minutes

What strengths do nicotine gum and lozenges come in?

How can you detemine whether a patient gets which dose?

2mg and 4mg

4mg is for patients who smoke first ciggarette within 30 minutes of waking

2mg is for patients who smoke first ciggarette AFTER 30 minutes of waking

what is the 12 week scheudle for nicotine gum/ lozenges?

• weeks 1-6 = 1 peice every 1-2 hours (12-24 peices a day)

• weeks 7-9 = 1 peice every 2-4 hours (6-12 peices a day)

• weeks 10-12 = 1 peice every 4-8 hours (3 - 6 pieces a day)

what is the MINIMUM amount of peices of gum r lozenges you would have to take daily in order to make a difference?

what is the MAXIMUM amount of gum you should chew a day

what is the MAXIMUM amount of lozenges you should have a day?

at least 9!

max gum = 24 peices

max lozenge = 20 peices

What are side effects of nicotine gum/lozenges?

1. dyspepsia

2. heartburn

3. hiccups

4. oral irritation

5. sore throat

6. jaw pain (gum)

what are some counseling points for the nictoine gum/lozenge:

• may delay _______ _______ associated w/ smoking cessation

  • due to administration (use for about ____ minutes and cannot eat/drink for ___ minutes before)

• can you use a second peice within the hour for strong or frequent cravings?

• may delay WEIGHT GAIN (good if patient worried about weight)

• use for 30 minutes and dont eat 15 minutes before taking lozenge/gum

• YES you can have a second peice after another BUT dont make it a habit since it can cause

  • hiccups

  • heartburn

  • nausea

Nicotine Nasal Spray:

• is it OTC or does it require prescription?

• what is the concentration?

• how much does each bottle contain?

• How many sprays in a bottle?

• who should you avoid use in?

• REQUIRE PRESCRIPTION

• 10mg/ml

• each bottlte has 10mL = 100mg

• one bottle = 200 sprays (each dose = 2 sprayes = 100 doses)

avoid use in patients with NASAL disorders or severe reactive airway disease

what are the steps to prime nicotine nasal spray?

1. get a tissue

2. point tip of bottle at tissue

3. press UP on buttom with thumb

4. pump into tissue until a fine spray is seen (up to 6-8 times)

DONT SPRAY INTO AIR —> it will get into your eye

Nictoine Nasal Spray Administration:

• Side effects will ______ in a few days for most people (LET PATIENT KNOW)

• use regularly for _____ _______

• press the circles on the _____ of the bottle then pull off cap

• ________ pump (6-8 times)

• what should you do if your nose is not clear at the time of administration?

• insert tip of bottle into nostril as _____ as is comfortable

• breath through ______! Spray ____ into each nostril

• LESSEN (tell patient it will get better w/ time)

• first week

• side

• prime

• blow it

• far

• breath through mouth first then speay once in EACH nostril

Nasal nicotine spray:

• what is the max recommended duration of treatment?

• what is the recommended dose per hour?

• what is the MAX dose per hour?

• what is max doses per day?

• 3 months max treatment duration

• recomended 1-2 per hour (2- 4 sprays)

• max per hour = 5 doses (10 sprays)

• max per day = 40 doses (80 sprays)

what are some side effects of nasal sprays?

• nasal and throat irritation

• runny nose

• watering eyes

• sneezing

• coughing

a patient states he smokes 1 pack of cigarrettes per day and has his first ciggarrete 20 minutes after waking up which NRT would be dose appropriate recommendation?

4mg/ nicotine gum (bc/ less than 30 minutes)

21mg/ day nicotine patch (bc/ more than 10 ciggarettes a day - a pack is 20 ciggs)

4mg gum (12 weeks)

1-6 = 1-2 hours

7-9= 2-4 hours

10- 12 = 4-8 hours

21mg/ day patch (8 weeks)

1-4 = 21mg

5-6 = 14mg

7-8 = 7mg

After discussion with the patient they start nicotine patch 21mg/ Which side effects may they see?

• skin irritation

• dyspepsia

• coughing

• vivid dreams

• vivid dreams (can take off before sleep)

• skin irritation (can give hydrohortisone)

Bubroprion/ Zyban:

• what is the moa?

• blockes neuronal uptake of ______ and to a lesser extent _______

• reduces ________ and symptoms of _________

atypical antidepressent

blocks uptake of dopamine + norepinphrine

reduces cravings + symptoms of withdraw

What is the dosing of buproprion SR dosing?

• ______mg by mouth once daily for _____ days

• _______mg by mouth _____ a day

• how long is treatment?

• what is the max dose per day?

• 150mg by mouth once for 3 days THEN

• 150mg by mouth TWICE a day for rest of duration

• duration = 3-6 months

• max dose per day = 300mg/day (2x a day)

when is it recommended to start buproprion XR?

is there any tapering involved?

• 1-2 weeks prior to quit day

• NO tapering

what are CONTRAINDICATIONS to buproprion?

1. seizure disorder

2. abrupt discontinuation of alcohol, benzodiazepines, barbituates, antiepileptic drugs

3. hisotry of bulimia or anorexia nervosa

4. use of MAO inhibitor within previous 14 days

5. initiation in patients recieiving linezolid or methylene blue

what are some adverse effects of buproprion?

0 insomnia

headache

tachycardia

blurred vision

weight loss (delays weight gain from smoking cessation)

What was the black box warning on buproprion and when was it removed?

• changes in mood

• phsycosis, hallucination, paranoia, delusions

• sucidal ideation

BUT REMOVED IN 2016

Varenicicline/ Chantix:

• moa = ______ ________ receptor ________

• bind SELECTIVELY to ____-____ nicotinic acetylcholine receptors

• does it bind with a greater or less affinity compared to nicotine?

• does it decrease symptoms of withdrawl?

• patial nicotnic receptor agonist

• a4-B2 nicotinic acethylcholine receptors

• bind with GREATER affinity compared to nicotine

Varenicicline Dosing:

INITIAL DOSING:

• ______ mg by mouth ____ daily for ____ days THEN ___mg by mouth ______ daily for ____ days

MAINTENANCE DOSING:

• ___mg by mouth ____ daily

WHAT IS THE MAX DOSE?

RENAL DOSING:

• if crcl less than ______ = ___mg ___ daily

HOW LONG IS DURATION OF THERAPY?

inital dosing:

0.5mg by mouth once daily for 3 days (0.5mg) THEN

0.5mg by mouth TWICE a day for 4 days (1mg)

maintenance:

1 mg by mouth twice daily (2mg)

max dose = 2mg/day

renal dosing:

if crcl less than 30 then 0.5mg twice daily max dose (max 1 mg)

duration = 3 months —> can go on extra 3 months for some patients

What are the different variations of when to start vareniciline?

1. start ____ week BEFORE quit day

2. start varenicicline and establish quit day between says ___- ____

3. start vrenicicline and gradually reduce smoking with goal of cessation by week _____ of therapt and then continue for another ____ weeks with no smoking (slow quit)

1. 1 week before quitting

2. between days 8-35 after starting

3. gradually smoke less for 12 weeks then fully by next 12 weeks of therapy

What are some adverse effects of Varenicicline?

• sleep disturbance (insomnia + vivid dreams)

• nausea (TAKE W/ FOOD AND WATER TO MINIMIZE)

• irritability

• headache

What are some warnings/precautions of varenicicline?

old black box :

• CNS depression

• neuropsychiatric effects

somnambulisn (sleep walking)

increased risk of cardiovascular events

seizures

which study removed the black box warning off of varenicline and buproprion?

EAGLES study