Smoking Cessations

PEBC

smoking

• releases dopamine = “feel good” effect —> addiction and physical dependence

• increases risk of:

  • cancer

  • Heart attack

  • diabetes

  • stroke

nicotine

beneficial effects:

• improves anxiety, depression, schizophrenia

• decreases appetite

• improves ADHD, Tourette’s, pain

• triggers alertness and memory

harmful effects:

• addictive

• teratogenic —> affects blood flow to baby and development

• increases BP (5-10 mmHg)

• Increases HR (10-20 bpm)

5 A’s

systematic approach to treat tobacco use and dependence

1. Ask = What is your patients smoking status?

   • do you use any tobacco products?

2. Advise = highlight the importance of smoking cessation in a manner that is personally relevant

   • ex. smoking status can affect your asthma

3. Assess = is your patient willing to quit? is your patient ready for change?

   • are you thinking about quitting smoking?

4. Assist = create a quit plan with patient, recommend appropriate pharmacological therapy and offer educational resources

   • set realistic quit date

   • anticipate barriers

   • enlist social support

5. Arrange = book follow up with patient

cycle of change

before recommended any behavioural changes, clinicians should assess patients’ readiness, willingness and barriers to change

1. pre-contemplation = not considering

2. contemplation = considering but undecided

   • not against it —> “im thinking of quitting”

3. preparation = Agrees and starts planning

   • setting a quit date

4. ACTION = adopts change

   • actually start

5. Maintenance = sustains change

   • 6 months in and have not smoked

6. a) lasting change = changes become permanent

   b) relapse = returns to concerning behaviours (can happen multiple times)

assist

create a quit plan with patient, recommend appropriate pharmacological therapy and offer educational resources

1. set realistic quit date

2. Anticipate barriers:

   • identify situations that trigger smoking habits

   • Educate patients regarding withdrawal symptoms: irritability, lack of focus, hunger, headaches, flu-like symptoms —> effects peak 2-3 days after quitting and decrease over weeks-months

3. Enlist social support

5 D’s to reduce cravings:

• Delay

• Distract

• Deep breathing

• Drink water

• Discuss

treatment

1st line:

• NRT = patches, gum, lozenges, inhaler, spray

• Varenicline

• Bupropion

2nd line:

• Cytisine = NHP

• Nortriptyline

others (limited benefit)

• Clonidine

• SSRI

• electronic cigarettes

selecting NRT patch

Relative contraindications:

• pregnancy and breastfeeding

• smoking while using this medication (nicotine toxicity)

• age <18 y

NRT patch

• provides consistent nicotine delivery

• strengths = 7, 14, 21mg

• s/e:

  • skin reactions = erythema, pruritus, edema, blisters, rash, burning sensation

  • insomnia and vivid dreams = can remove at night

  • headache, dizziness, paresthesia

  • palpitations, chest pain, blood pressure changes, tachycardia

  • abdominal pain, dyspepsia, nausea, diarrhea, constipation, dry mouth, nausea and vomiting

• Administration:

  • 1 patch/day (24 hr) or 16 hr application (remove at bedtime)

  • apply to dry hairless area of upper arm, chest or hip

  • rotate application sites

• Time to peak = 2-6 hrs

• remove patch before prolonged, strenuous exercise —> re-apply after exercise

NRT gum

• rapid relief of cravings

• buccal absorption

• strengths = 2, 4mg

• s/e:

  • jaw soreness

  • hiccups

  • nausea

  • heartburn

  • headache

• administration:

  • flexible dosing

  • bite and park technique = place 1 piece of gum in the mouth. Bite down once or twice then park it between the teeth and gums for about 1 min. Repeat when the desire to smoke arises or once the tingling sensation stops (up to once per min for up to 30 min) then discard piece

  • acidic foods and fluids impair buccal absorption —> AVOID for 15 mins before use

• time to peak = 20-30 mins

• max dose = 20 pieces/day

NRT lozenge

• rapid relief of cravings

• buccal absorption

• strengths = 1, 2, 3, 4 mg

• s/e:

  • Hiccups

  • Nausea

  • Headache

• Administration:

  • flexible dosing

  • suck until strong taste and park

  • acidic foods and fluids impair buccal absorption = avoid for 15 mins before use

  • GI upset if swallowed

• time to peak = 20-60 mins

• max = 15-25 mg/d (depends on strength)

NRT inhaler

NRT spray

varenicline (champix)

• strength = 0.5, 1mg

• s/e:

  • vivid/ abnormal dreams

  • nausea, vomiting

  • insomnia

  • constipation and flatulence

  • HA

• Administration:

  • start 1-2 weeks prior to quit date (quit smoking 1–2 wk after starting)

  • 0.5 mg x 3 days, then 0.5 mg BID x 4 days, then 1 mg BID x 3 months

• renal impairment (max dose) = 0.5 mg BID

• cardiovascular risk - inconclusive evidence

• CAUTION - pts w Hx of or experiencing psychiatric disease, Hx of suicidal ideation

• lack of data in pregnancy —> AVOID

bupropion (zyban)

• strength = 150 mg

• s/e:

  • dry mouth

  • insomnia

  • weight loss

  • agitation

  • seizures

• administration:

  • start 1-2 weeks prior to quit date

  • 150 mg daily x 3 days, then BID x 3 months

  • 8 hr interval for BID dosing

  • CrCl <60 = 150mg/d

• C/I:

  • bullimia, Anorexia

  • Seizures

  • taking MAO INHIBITORS!! Within 14 days

• precautions:

  • May use in pregnancy if benefits > risks = no good studies on this

  • substance use disorder or withdrawal

  • hepatic or renal failure

  • taking anti-depressants, antipsychotics, corticosteroids, stimulants, theophylline, quinolone antibiotics

  • Strong CYP2D6 inhibitor = increase concentrations of Atomoxtine, Duloxetine, Fluoxetine, Fluvoxamine, metoclopramide and tamsulosin

  • decreases efficacy of tamoxifen and codeine by decreasing their metabolites

combination therapy

cytisine

• plant based alkaloid = acts as partial agonist on nicotinic receptor

• NHP = less strict regulatory requirements regarding efficacy and safety

• evidence: similar in efficacy and may be more effective than NRT BUT POOR QUALITY data

• s/e:

  • sleep disturbances

  • dyspepsia

  • nausea

• complex dosing

nortriptyline

• 2nd line

• not officially indicated for smoking cessation but some evidence of efficacy

• TCA

• use for ~12 weeks

• s/e:

  • sedation

  • dry mouth

  • blurred vision

  • dizziness

  • tremor

  • urinary retention

  • orthostatic hypotension

special populations

interactions

• cigarette smoking (tobacco smoke) induces CYP1A2

• results in increased drug metabolism, decreased serum concentration and decreased efficacy

• drug affected:

  • clozapine

  • fluvoxamine

  • caffeine

  • olanzapine

  • propranolol

  • theophylline

  • warfarin —> monitor

• patients drinking > 4 cups coffee/day should HALF their daily intake when they quit smoking (otherwise they will have a lot of caffeine in their body)

ecigarettes

• not recommended

• unregulated

• limited studies available

• use is uncertain

• may reinforce smoking behaviours