Smoking Cessation

tobacco use

is the leading preventable cause of disease, disability, and death in the US

46 million

How many adults in the US used a tobacco product?

harms of smoking

-brain disease

-heart disease

-lung disease

-GI disease

-weak bones

-yellow teeth

reasons that nicotine is harmful

-Activates nicotine receptors in CNS → NT release

-NE, dopamine, acetylcholine

-Activates SNS• ↑ BP, HR, stroke volume, cardiac output

-Exacerbates complications of other diseases

-Cardiac, respiratory, etc.

-Endocrine and metabolic effects

11 seconds

How long does it take nicotine to cross the BBB after inhalation?

dopamine

Stimulating receptors release ________ when nicotine is inhaled which results in pleasure and euphoria.

cigarettes

most common type of tobacco product

vapes (e cigs)

are 2nd most common type of tobacco product

45-64 yrs old

What age group typically uses cigarettes?

18-24 yrs old

What age group typically uses E cigs?

tobacco related health disparities

-living in a rural area

-low income

-education level

-uninsured or medicaid insurance

-sexual orientation

-disability status

-psychological distress

-price increases

-media campaigns

-implementation of smoke free policies

-access to cessation support

What are some strategies that have been implemented to decrease smoking?

smoking cessation benefits

-increase longevity

-decrease risk of lung cancer, COPD, and heart disease

-decrease risk of low brith weight babies

weight gain

What do a lot of pts worry about when they start thinking about trying to stop smoking?

20 mins

How long after quitting does you blood pressure decrease?

8 hrs

How long after quitting does the amount of carbon monoxide in your blood drop back to normal while O2 increases to normal?

48 hrs

How long after quitting does it take for your nerve endings to regenerate, and you can smell and taste things better?

1 to 9 months

How long after quitting does is take for coughing, sinus congestion, fatigue, and SOB decrease?

1 yr

How long after quitting does the added risk of heart disease decline to half of that of a smoker?

5 yrs

How long after quitting does your stroke risk somewhat reduce to that of someone of that of a non-smoker?

10 yrs

How long does it take after quitting to have your risk of all smoking related cancers to decrease up to 50%?

15 yrs

How long does it take after quitting for your risk of heart disease and smoking related death to be similar to those of someone who never smoked?

identify and offer tx to everyone who uses tobacco

What is the pharmacists role in smoking cessastion?

USPSTF

recommends that clinicians ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and FDA-approved pharmacotherapy for cessation to non-pregnant adults who use tobacco

clinical

There is more success with long term cessation with __________ help.

1) Ask

2) Advise

3) Assess

4) Assist

5) Arrange

What are the 5 As?

Ask

-everyone at every visit

-clinic setting (during vitals and rooming)

-pharmacy (when filling new rxs)

Advise

clear, strong, personalized message

Assess

-readiness to quit (transtheoretical model of change)

-Fagerstrom Test

Assist

-help the pt with a quit plan

-provide practical counseling

-recommend pharmacotherapy

-provide social and other support

Arrange

follow-up visit within 1 week then routinely

Transtheoretical model

precontemplation, contemplation, preparation, action, maintenance, relapse

pre-contemplation

no intention of changing behavior

contemplation

aware a problem exists but with no commitment to action

preparation

intent on taking action to address the problem

action

active modification of behavior

maintenance

sustained change; new behavior replaces old

relapse

fall back into old patterns of behavoir

smoking hx components

-Current and past tobacco use

• Pack-year history

-Previous quit attempts

• Why unsuccessful

• Medications used

-Identify "triggers"

-Identify support system

Nicotine Dependence

-identify confidence level

-Fagerstrom test

10

How many cigs in a 1/2 pack?

20

How many cigs in a pack?

Fagerstrom Test

A questionnaire that tests for degree of nicotine dependence that ranges from 10-0. 6+ indicates a significant dependency that may benefit from pharmacological therapy

1-2

low dependence

3-4

low to moderate dependence

5-7

moderate dependence

8+

high dependence

preparation

discuss meds and nonpharm therapy, behavioral management, support systems, and patient concerns

medication vs nonpharmacologic

-cold turkey

-tapering

-aversion therapy

-single vs dual therapy strategies

-start before or on the quit date

behavioral management

-individual counseling sessions

-group counseling sessions

support system

-family, friends

-coworkers

-smoking cessation groups

combining counseling + pharmacotherapy

What is more effective in smoking cessation than any other strategy alone?

nicotine withdrawal symptoms

-HA

-tremors

-difficulty concentrating

-insomnia

-increased coughing

-irritability, frustration, or anger

-decrease HR

-increase appetite

-fatigue

-depression

-constipation or upset stomach

-anxiety or nervousness

-cig cravings

-restlessness

Chantix (Varencicline)

nicotine partial agonist

Zyban (Bupropion)

neurotransmitter regulator

nicotine replacement therapy (NRT)

-gum

-patch

-lozenge

-nasal spray

-inhaler

gum

Nicorette

lozenge

Commit

patches

Nicoderm, Nicotrol

nasal spray

Nicotrol NS

on the quit date

When should you start taking nicotine replacement therapy?

precaution with NRT

-underlying CV disease

-recent myocardial infarction

-life threatening arrhythmias

-severe or worsening angina

-temporomandibular joint disease

-pregnancy or lactation

timing of the first cig

What is nicotine gum dosing based on?

AEs of Nicorette

-hiccups

-N

-mouth irritation

15 min

You should avoid eating/drinking _________ before or during use of Nicorette.

more

Nicotine Lozenge (Commit) has ______ nicotine than equivalent gum dose.

yes

Should you avoid eating/drinking 15 mins before or during use of Commit?

4 mg q1-2 hrs for 6 weeks

What is the starting dose of gum/lozenge dose for someone who has their first cig ≤ 30 mins after waking up?

2 mg q1-2h for 6 weeks

What is the starting dose of gum/lozenge for someone who has their first cig > 30 mins after waking up?

≥ 9 pieces in the first 6 weeks

What is the typical starting dose of nicotine gum/lozenges?

nicoderm CQ, Nicotrol

What nicotine cessation agent has the highest adherence rates?

number of cigs smoked per day

What is the dose of nicotine patches (Nicoderm CQ/Nicotrol) based on?

AEs of Nicotine Patches

-vivid dreams

-skin irritation

Nicoderm CQ, Nicotrol

-apply to upper body

-1 patch per 24 hrs

-can remove at bedtime

-rotate application sites

21 mg/day for 6 weeks

If a pt smokes > 10 cigs a day what is their starting dose of Nicotine patches?

14 mg/day for 6 weeks

If a pt smokes ≤ 10 cigs a day what is their starting dose of Nicotine patches?

Nicotrol NS

-RX only

-aqueous solution of nicotine

-0.5 mg nicotine spray

-absorbed across nasal mucosa

avoid in asthma and COPD

What is the warning with Nicotrol NS?

AEs of Nicotrol NS

-nasal irriation

-watery eyes

-sneezing

Bupropion SR (Zyban) MOA

-blocks reuptake of dopamine + NE

• Reduced cravings & withdrawal symptoms

• Requires titration, but not taper

• Often used x12 weeks

before the quit date (1-2 weeks)

When is Bupropion SR started?

suicidal thinking

What is the BBW for Bupropion SR (Zyban)?

CI with Bupropion SR

-seizures

-anorexia/bulimia

-usage with MAO inhibitors

-linezolid

-IV methylene blue

AEs of Bupropion SR

-dry mouth

-insomnia

-tremors

-weight loss

Varencicline (Chantix) MOA

-partial nicotinic receptor agonist

• Requires titration, but not taper

• Often used x12 weeks

before the quit date (1 week)

When is Varenicline (Chantix) started?

neurophsychiatric events, seizures

What is the warning with Varenicline (Chantix)?

AEs of Varenicline (Chantix)

-N/V

-constipation

-insomnia

-vivid dreams

-HA

take after eating with a full glass of water

What is a good counseling tip with Varenicline (Chantix)?

combination therapy

using 2 pharmacologic agents may be more beneficial

long acting product

NRT patch or bupropion SR

short acting product

NRT gum or NRT lozenge