Smoking Cessation

T/F: Tobacco use is the largest preventable cause of death and disease in the US.

True

T/F: Adults with mental illness or substance use disorder consume 40% of all cigarettes smoked in the US.

True

Ages: 24-44 years old and 45-64 are highest smokers

What percentage of current smokers smoke daily?

75%

Which of the following are community characteristics for increased risk of smoking addiction? (select all that apply)

A. Higher education

B. Lower household income

C. Under insured

D. Lower education

B. Lower household income

C. Under insured

D. Lower education

Nicotine product use trends

Drop in 2020= popcorn lungs

Pathophys of nicotine

Nicotinic acetylcholine receptor agonist= increases the release of neurotransmitters = stimulant at low doses by activating reward system

*Stimulant at low doses, neuronal depression at high doses*

Absorption of nicotine

lungs, oral mucosa, GI mucosa, and skin & metabolized via the lung and liver

T/F: smoke (combustion of tobacco) drives drug-drug interactions due to chemicals in cigarette and other forms of tobacco

True

Metabolite is cotinine(great biomarker for nicotine use/exposure)

T/F: Smoking is an independent risk factor for coronary heart disease, cerebrovascular disease and total atherosclerotic cardiovascular disease

True

Immediate cardiac consequences associated with nicotine use

1. Acute increase in HR (10-15 bpm)

2. Increased BP (5-10 mmHg)

3. Increased myocardial activity, constriction of cardiovascular beds in skin and coronary arteries, dilating cardiovascular beds in skeletal muscle)

4. Increased cardiovascular disease profile

Concentration-dependent cough and airway obstruction

Nicotine and its related effects can trigger a concentration-dependent cough and airway obstruction by stimulating afferent nerve endings in the bronchial mucosa. This can result in symptoms such as nocturnal chest tightness and increased bronchial hyperactivity

more = worse effect

Benefits to quitting smoking

Foundations of Comprehensive Treatment

1. Behavioral counseling

2. Pharmacotherapy: medications significantly improve quit success rates

T/F: Behavioral counseling is not recommended in all smokers.

False; recommended in all smokers.

Exclusion criteria for smoking cessation pharmacotherapy?

1. Smoke less than 10 cigarettes/day: NRT only?

2. Age < 18 (needs Rx): parents must pick up

3. Pregnant women must weigh the risk versus benefits and safety

4. Contraindications to pharmacotherapy

First-line pharmacotherapy for smoking cessation

1. Nicotine replacement therapy (NRT): gums, lozenges, patches, sprays, inhalers

2. Antidepressant: Buproprion 150 mg BID

3. Nicotinic receptor partial agonist (Varenicline (Chantix))

Nicotine Replacement Therapy

1. Gums

2. Lozenges

3. Transdermal Patch

4. Nasal spray: Rx only and rarely use

5. Inhaler: Rx only and rarely used

Rational for NRT

1. Mimics action of nicotine on receptors= reduce craving= allows patient to focus of behavioral and psychological aspects of cessation

2. Delays weight gain

3. Slower, less variable, and more sustainable nicotine concentrations (refer to pic)

4. Reduces withdrawal

5. Less addicting than cigarettes

NRT still appropriate for people with

Underlying CV disease OR Uncontrolled HTN (caution with all NRT)

Ulcers (oral agents can exacerbate)

Asthma (don’t use inhaled nicotine)

Diabetes (oral agents can exacerbate due to sugar )

Sodium-restricted diet (oral agents can impact)

NRT is not appropriate for people with

Recent MI or heart attack (2 weeks)

Arrhythmias

Worsening or unstable angina

True or False: gum and lozenges are better than patches for emotional smokers

true; Emotional smokers tend to do better with lozenges and gum - so if stress or anxiety or 'issues' make them crave cigarettes or is the root of why the smoke, consider using these options over the patch and often times have more 'cravings' that need immediate NRT support

Potential adverse effects of gum and lozenges NRT

incorrect technique= lightheadedness, N/V, throat or mouth irritation

NRT gum/lozenge dosing

2 mg vs 4 mg is based on how dependent patient is on nicotine (time to first cigarette)

NRT gum technique

Avoid eating or drinking 15minutes before or while using gum/lozenge

1. Chew for a few seconds to activate = tingle

2. Park it & wait

3. Rotate and repeat

When should NRT gum not be recommended?

patients with dentures, TMJ disorders, dental work

NRT lozenge technique

Avoid eating or drinking 15minutes before or while using gum/lozenge

1. Do not chew

2. Allow to dissolve and rotate around gums

*Typically lasts for 30 minutes (mini-lozenge: 10 minutes)

T/F: you can cut a nicotine patch and wear it during an MRI

false

True or False: smokers that use nicotine as the stimulant (to stay awake, to focus when the study, to keep them motivated) they tend to do better with the patch instead of lozenges or gum

true

Nicotine patch strengths available?

7mg, 14mg, 21mg

NRT patch dosing

Heavy Smoker (>10 cigarettes/day)= 21 mg starting dose

Light smoker (<10 cigarettes/day)= 14 mg starting dose

*12 Week long duration of dosing schedule

*wear for 24 hours a day. Patients may bathe, swim, shower, or exercise as normal

Pack year calculation

# packs smoked per day X # of years smoking

Application of NRT patch product counseling points?

1. Wash hands before and after use

2. Press firmly for 10 seconds

3. Apply to different area daily

4. Remove each patch daily

5. Fold in half when done

6. Plastic baggy good

Combination therapy

"seatbelt": daily maintenance (patch)

"airbag": PRN for craving breakthroughs (gum or lozenge)

Adverse effects and precautions: Nicotine patches

1. Topical burning, itching, redness: may be helped by applying TCS prior to application

2. Vivid dreams

3. DO NOT USE IN patients with dermatological conditions

Nicotine nasal spray

Rapid absorption across nasal mucosa= Highest dependence potential

Start with 1-2 doses (1 dose= 2 sprays) per hour and increase prn

Nicotine inhaler

-Absorbed across buccal mucosa

-1 cartridge every 1-2 hours: Maximum of 16 cartridges/day

-Do not eat or drink 15 minutes before or while using inhaler= unrealistic for q 1H administration

*mainly for patients with the behavioral depending on sucking on something

Bupropion SR

- lowers craving for cigarettes

-lowers symptoms of nicotine withdrawal

-Delays weight gain

* Contraindicated in patients with seizure disorder

MOA of bupropion SR?

Inhibits reuptake of dopamine and norepinephrine

Potential adverse effects of Bupropion SR

1. Insomnia

2. Dry mouth

3. Headaches

4. Itchy

5. Pharyngitis

6. Tachycardia

8. Seizures

9. Neuropsychiatric effects

10. Suicide risk

Explain up-titration dosing for bupropion?

Days 1-3: 150 mg daily

Days 3+: 150 mg BID

Regimen lasts 7-12 wks

*begin therapy PRIOR to quit date

T/F: Bupropion is contraindicated in persons susceptible to seizures.

True

Bupropion SR black box warning

Increased risk of suicidal thinking and behavior in young adults 18 to 24 years of age

Varenicline (Chantix)

Selective a4B2 nicotinic acetylcholine receptor partial agonist= competitively inhibits binding of nicotine

Clinical effects:

- lowers symptoms of nicotine withdrawal

- decreases dopamine stimulation responsible for reinforcement and reward with smoking

Varenicline up-titration dosing schedule

Start 1 week before quit date

Days 1-3: 0.5mg daily

Days 4-7: 0.5 mg PO BID

Day 8 to end of treatment: 1 mg PO BID

*can be renally adjusted to 0.5 mg once daily

Typical treatment duration for Chantix?

12 weeks

Max 24 weeks, but not usually

Common adverse effects of varenicline? (nine)

1. Irritability

2. Insomnia

3. Abnormal dreams= NIGHTMARES

4. Nausea: minimized by taking with water/ food

5. Headache

6. Suicidal ideation

7. Depression

8. Flatulence

9. Constipation

T/F: Women 35 years and older using oral contraceptives AND smoking at least 15 cigarettes per day are at significant elevated risks for increased cardiovascular complications.

True

Consult about alternative methods• IUD, progestin only, and others.

True or False: using smoking cessation pharmacotherapy in pregnancy must be assessed using risk and benefits

True: risk of smoking are greater than risk of the medications however the safest intervention is behavioral therapy

Smoking induces which CYP enzyme?

CYP1A2 which thus decreases effects of medications

Approaches to Dependence, Treatment, and Relapse

1. Fagerstrom test for nicotine dependence= see how dependent patient is by how often they smoke

2.

Addressing dependence

Successful tobacco treatment requires multipart considerations between underlying physiological and behavioral issues

Define the "precontemplation" phase of quitting

Not really even thinking about quitting

Greater than 6 mths

Tobacco cessation: Stages of change

Smoking Cessation's 5 A's

At how many pack years should someone be recommended for lung cancer screening?

30 pack years