Patho/PCT II Exam 7 Smoking Cessation

Nicotiana tabacum, nicotine, addiction

What plant is tobacco processed from? This plant is the main natural source of ____, a highly toxic alkaloid that is a major component in tobacco smoke responsible for ____.

Tobacco use

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

E-cigarettes, nicotine, harmful, more likely

What is the most used tobacco product among youth? Most of them contain ____ which can hard adolescent brain development into the early and mid 20s. They also contain other ____ substances besides nicotine. Young people who use e-cigs are ____ ____ to smoke cigarettes in the future.

Flavoring, cancer, volatile, metals, particles

E-cigs contain nicotine, ____ such as diacetyl, ____-causing chemicals, ____ organic compounds, heavy ____, and ultrafine ____.

Decline, 75

Tobacco smoking is the leading cause of morbidity and mortality despite a ____ in tobacco use. About ____% of smokers want to quit with only limited success and significant relapse.

Positive, anxiolytic, decreased, anxiogenic

In humans, nicotine produces (positive/negative) reinforcing effects including mild euphoria and increased energy. Smoking produces ____ effect (reduced stress, reduced anxiety) and (increased/decreased) appetite. Smoking also causes ____ effects (withdrawal).

Dependence, relapsing, compulsion, control, negative

Drug addiction, also known as substance ____, is a chronically ____ disorder. It is characterized by ____ to seek and take drug, loss of ____ in limiting taking, and emergence of ____ emotional state when access to the drug is prevented.

Impulsive, compulsive

An example of (compulsive/impulsive) smoking addiction is someone who smokes socially at a bar. An example of (compulsive/impulsive) smoking addiction is someone who has been smoking since childhood and it is now a ritual.

Adaptation, vulnerability

There is chronic molecular and cellular ____ that occurs in drug addiction. There is positive neuroadaptation which leads to ____.

Tar, pH

Nicotine from burning tobacco is carried proximally on ____ droplets which are inhaled. Absorption of nicotine across biological membranes depends on ____.

Acidic, is

Nicotine in most cigarette smoke is (alkaline/acidic) and (is/is not) absorbed by lungs and delivered via pulmonary circulation.

Alkaline, more, without

Nicotine from pipe or cigar smoke is (alkaline/acidic) and much (less/more) readily absorbed through the oral mucous membrane (with/without) inhalation into the lung.

10-15, quickly, does

Nicotine reaches the brain quickly at about ____-____ seconds after inhaling. It clears from the brain (quickly/slowly). Nicotine (does/does not) cross the placenta barrier.

Liver, CYP2A6, UGT, FMO, cotinine, urine

80-90% of nicotine is metabolized by ____ enzymes (____, ____, ____). 70% of nicotine is converted to ____, which is excreted in the ____. 4% of nicotine is converted to nicotine-1-N-oxide which is further metabolized.

2, 19, psychoactive

The t1/2 of nicotine is about ____ hours after inhalation or parenteral admin. The t1/2 of cotinine is ____ hours. Cotinine also has some ___ effects in IV injection.

Cigarette

What route of nicotine administration (aka which product) has the highest plasma [nicotine] peak and also occurs the quickest (about 10 mins)?

Nasal spray

Which nicotine product has a quick peak like cigarettes (about 10 mins) but not as high of a peak?

Gum

What nicotine product mimics natural metabolism because it doesn't have a large peak and has a steady state decline?

Vapor inhaler

What nicotine product has a lower peak than cigarettes and takes longer to get to peak but does not have as rapid of a decline?

Carboxyhemoglobin

What is chemically modified hemoglobin that is used as a marker of cigarette exposure?

30-35, 1-2

The steady state blood nicotine level of cigarettes is ____-____ ng/mL. You receive ____-____ mg nicotine/cigarette.

Genome

People will have difference plasma nicotine peaks based on their ____.

Daily, weeks, four, distress

Nicotine withdrawal is experienced in those with ____ use of nicotine for at least several ____. Withdrawal is when cessation or reduction is followed by at least ____ s/sx. Sx cause ____ or impairment not due to other mental or physical disorders.

Insomnia, anxiety, decreased, increased

Symptoms of nicotine withdrawal:

Depression, ____ (sleep), irritability, frustration, or anger

____, difficulty concentrating, restlessness

(Increased/decreased) HR

(Increased/decreased) appetite or weight gain

5, muscle

Nicotine acetylcholine receptors (nAChRs) are transmembrane oligomers consisting of ____ subunits. NAChRs are found in the brain as well as the ____.

12, 9, 3

Neuronal nAChRs result from the combinatorial of ____ different nAChR subunits encoded by ____ genes for a-subunits (a2-10) and ____ B-subunits (B2-B4) that are expressed in the brain.

Differ, localization

The various nAChR subunit combos (are the same/differ) in their pharmacological and kinetic properties and also in their cellular and subcellular ____ in the brain.

Extracellular, transmembrane, cytoplasmic

Each nAChR subunit contains 450-500 AA that form a large amino-terminal (intracellular/extracellular) domain with an immunoglobulin-like B-sandwich, a ____ domain, and a variable ____ domain.

ACh-nicotine, transmembrane

The extracellular domain of nAChR carries the ____-____ binding sites at the boundary between subunits. The number of binding sites per pentamer ranges. Sites for allosteric modulators are located in the ____ domain.

Binding, affinity

There are different NAChR subtypes that can differ in how many ____ sites for ACh there are and the ____ of binding.

More

nAChR that have higher binding affinity are going to be (less/more) sensitive to responding to nicotine.

Close, desensitize, inactivate

Once activated, NAChRs can:

1. ____ (resting) then open again

2. ____ (inactive state, remains closed for minutes to hours)

3. ____ (remains closed until degraded inside the cell)

a-BTX, competitive, paralysis, cholinergic

____-____ is a neurotoxin in the venom of the Taiwanese many-banded krait. It is a ____ antagonist of nAChRs that produces ____ of striated muscles by blocking ____ receptors. Toxic effects include HA, delusions, unconsciousness, convulsions.

Epibatidine, toxic, potent

____ is from a Ecuadoran frog. It is a (toxic/nontoxic) and ____ agonist at both the a4B2 and a3B4 subtypes of the nicotinic receptor for nicotine binding sites with little activity at many other receptor types.

Catecholamines, reward, DA, VTA

Nicotine is a sympathomimetic chemical that promotes the release of ____ acting centrally and peripherally (elevated HR, BP, CO). It causes an alteration of brain ____ system. At a cellular level, nicotine self-admin causes hyperactivity of ____ neurons in the ____.

Resets, increases

Self-administered nicotine ____ DA reward circuits and (increases/decreases) their sensitivity to subsequent exposures to nicotine (sensitization).

DA, DA, desensitization, upregulation, increased

Neuroadaptation in long-term smokers:

1. Nicotine increases the firing of midbrain ____ neurons and ____ release in the nucleus accumbens.

2. Chronic nicotine causes persistent ____ of nAChRs in the midbrain neurons.

3. Chronic nicotine induces (upregulation/downregulation) of nAChR, resulting in (increased/decreased) reward responses to nicotine. Nicotine induces receptor expression.

Low, withdrawal, habit, tapering

Rationale for NRT is that stable (low/high) levels of nicotine prevent ____ sx. It initially break the smoking ____, followed by nicotine ____.

Fewer, gateway

E-cigs contains (fewer/greater) harmful chemicals compared to tobacco but ongoing concern with their own chemical contaminants and that they can be a ____ for youth into tobacco use.

Weak, NE-DA, nAChRs

Bupropion (Zyban) is a non-NRT tx that is a very (strong/weak) inhibitor of reuptake of ____-____ (NDRI) as well as some antagonism at ____. Mostly focuses on reward system not nAChR.

Insomnia and dry mouth, craving, some

What are the two SE of bupropion? It is effective in suppressing tobacco ____ and helps (some/most) smokers quit smoking.

High, partial, a4B2

Varenicline (Chantix) is a (low/high) affinity (partial/full) agonist for the ____ nAChR subtype.

DA, withdrawal, binding, reward

Unlike nicotine's full agonist activity, Chantix has reduced effect on ____ release. It relieves nicotine ____ sx by partially preventing nicotine ____ to nAChRs to block the ____ pathway. It reduces the feelings of craving and withdrawal.

Longer, kidneys, nausea

Chantix t1/2 is 24 hours, making it (shorter/longer) than the t1/2 of nicotine. It is excreted by ____. The main SE s mild ____ but can also experience HA, difficulty sleeping, and nightmares.

Chantix, Zyban

(Zyban/Chantix) primarily acts on the nAChRs while (Zyban/Chantix) acts downstream.

Ask, assess, advise, assist (offer and connect to tx), arrange follow up

What are the 5 A's of smoking cessation?

Smoking status, dependence, quit

In the 5 A's, ask means ask about patient's ____ ____. Assess means assessing the extent of nicotine ____ and willingness to ____.

Dependence, number of cigs/day and how soon after waking first cig is

The Fagerstrom test and heaviness smoking index assess the extent of nicotine ____. What are the two biggest indicators in this test?

Higher

In Fagerstrom test and heaviness smoking index interpretation, higher numbers are associated with a (lower/higher) dependence on nicotine.

Number of cig per day and time to first cig after waking

What are the two factors of the heaviness of smoking index?

Heaviness of smoking index, relapse

(Fagerstrom test/heaviness of smoking index) has equivalent or stronger validity in predicting ____ back to smoking after a quit attempt.

Precontemplation

In the transtheoretical model, what is it when pt is not thinking about quitting in the next 6 months?

Contemplation

In the transtheoretical model, what is it when pt is not thinking about quitting in the next 30 days but is in the next 6 months?

Preparation

In the transtheoretical model, what is it when pt is thinking about quitting in the next 30 days?

Action

In the transtheoretical model, what is it when pt has set a quit date and is starting to be quit?

Maintenance

In the transtheoretical model, what is it when pt is in the 6 months after quitting and maintaining the quit attempt?

Every, consequences, benefits

In the 5 A's, advise means to urge (some/every) nicotine user to quit. This can be done by telling patients the ____ of not quitting and health ____ of quitting.

Vaping, is not

Advise dual users (smoking + vaping) to switch to ____ only but avoid black market products and harmful ingredients. Outside of this scenario, vaping (is/is not) recommended as smoking cessation.

5 R's or DARES

If patient declines tx, follow (5 R's or DARES/STARR).

Relevance, risks, rewards, roadblocks, repetition

What are the 5 R's of motivational interviewing if pt declines tx?

Comorbidities, consequences, benefits

Relevance in the 5 R's is where you relate smoking to ____. Risks is the ____ of not quitting. Rewards is the health ____ of quitting.

Dependence, withdrawal, alcohol, smokers, gain, fear

Roadblocks to smoking cessation:

High nicotine ____

____ sx

Stress

Psychiatric disorder

____ or substance abuse

Exposure to other ____

Weight (loss/gain)

Lack of support

____ of failure

Develop discrepancy, avoid argumentation, roll with resistance, express empathy, support self-efficacy

What does DARES stand for in motivational interviewing if pt declines tx?

Behavior, goals, change

When developing discrepancy, highlight the difference between ____ and ____, reinforce patient's ____ talk, and strengthen commitment to change.

Empathy, permission

To roll with resistance, use reflection, express ____, and ask ____ to provide info.

STARR

If patient accepts tx, follow (5 R's or DARES/STARR).

Set a quit date, tell family and friends, anticipate barriers, remove tobacco products, rx pct

What does STARR stand for when pt accepts tx?

Support system

Telling family and friends when deciding to quit smoking is to build a ____ ____. There are phone numbers and websites that can provide support.

Alcohol, smokers, non-tobacco, routines, gain, cravings

Behavioral strategies to anticipate barriers include:

Manage stress

Limit ____ intake

Limit contact with other ____

Use ____-____ substitutes that also don't have lots of sugar/calories

Anticipate smoking ____

Eat healthy and exercise to minimize weight ____

Have a plan to combat ____

Commitment, distractive, self-talk

Cognitive strategies to anticipate barriers include:

Review ____ to quit

____ thinking

Positive ____-____

Mental rehearsal

1 week, 1 month

Contact pt within ____ ____ of quit date. Contact again within ____ ____ of quit date. Further follow up as needed.

Lapse, barriers, adherence

During follow up, assess for ____ (slip) or relapse, congratulate successes, address management of ____ to quitting, and assess med ____ and tolerability.

NRT combo or varenicline

What are the two first line PCT options?

Patch, cravings

Combo NRT is nicotine ____ to get consistent levels + gum, nasal spray, or lozenge for rapid action to combat ____.

Pregnancy, MI, arrhythmias, angina

In all NRT, the risk outweighs the benefit in ____ and breastfeeding. There are warnings for recent (< 2 weeks) ____. Also warnings for serious ____ and serious or worsening ____.

Is not, cigs

While there is a warning on NRT for recent MI, studies have reported there (is/is not) an increase in adverse CV events compared to placebo. Although NRT is not harmless, it is much less harmful than ____.

Eczema, psoriasis, TMJ, airway, nasal

The nicotine patch should not be used in pt with severe ____ or ____. Gum should not be used in patients with ____ disease and caution with dentures/braces. Nasal spray has warnings in severe reactive ____ disease or chronic ___ disorders (rhinitis, polyps, sinusitis).

Daily, hairless, rotate

Nicotine transdermal patch directions are to place a new patch (daily/weekly). Place in a relatively ____ location between the neck and waist. ____ sites to reduce local skin irritation.

10, 14, 6, 7, 2

If a patient is a light smoker (

10, 21, 6, 14, 2, 7, 2

If a patient is a heavy smoker (>____ cigs/day), start them on nicotine patch ____mg/24hr for ____ weeks. Titrate down to ____mg/day for ____ weeks. Titrate down to ____mg/24hr for ____ weeks.

Skin, insomnia, dreams, cannot, slow, daily

Nicotine patch AE include local ____ rxns, ____ (can take off when go to bed), vivid ____, and HA. (Can/cannot) titrate dose to control cravings/withdrawal. Proves (fast/slow) release of nicotine and has better adherence due to once ____ dosing.

15, buccal, chew, heartburn, 20

When using nicotine lozenges, don't use within ____ mins of eating or drinking cause acid will prevent ____ absorption of nicotine. Do not ____ or swallow; will get ____. Do not exceed ____ lozenges/day.

Insomnia, heartburn, flatulence, dosing, titrate, dental, weight gain

Nicotine lozenge AE include nausea, ____ (sleep), HA, hiccups, cough, ____, and ____. A disadvantage is the frequent ____ required. They are easy to use and ____ to control cravings, can be used in smokers with ____ considerations, and they may delay ____ ____.

15, park, 24

When using nicotine gum, don't use within ____ mins of eating or drinking. Chew slowly until tingling or peppery taste and then ____. Do not exceed ____ pieces/day.

Soreness, stomach, jaw, dental, chewing, weight gain

Nicotine gum AE include mouth ____, hiccups, upset ___ (ulcers, reflex), and ____ muscle ache. Frequent dosing is required, it may stick to ____ work, and proper ____ technique is required to limit SE. It is easy to use and titrate and may delay ____ ____.

1-2, 2-4, 4-8

Nicotine lozenge/gum dosing regimen:

Weeks 1-6 - 1 lozenge/gum q____-____ hrs

Weeks 7-9 - 1 lozenge/gum q____-____ hrs

Weeks 10-12 - 1 lozenge/gum q____-____ hrs

30, 4, 30, 2

If patient has high nicotine dependence (smoking <____ min of waking), they get ____mg lozenge and gum. If patient has low nicotine dependence (smoking >/= ____ min of waking), they get ____mg lozenge and gum.

5, back, mouth, 3, 5, 40

Nicotine nasal spray should not be used within ____ mins of driving (can cause tearing up). To use, prime, tilt head ____, and spray while ____ breathing. Do not inhale. Do not blow nose within ____ mins. Do not exceed ____doses/hour or ____ doses/day.

1-2, 2, 1, 1

Nicotine nasal spray for weeks 1-6 (or 8) is ____-____ doses/hr initially and titrate PRN. Weeks 9-12 (or 14) attempt to reduces doses/day. 1 dose is ____ sprays (____ spray per nostril at 0.5 mg/spray), so you get ____mg of nicotine per dose.

Peppery, sneezing, watery, addiction, rapid, insomnia

Nicotine nasal spray AE (usually lessen after 1 week) include hot ____ feeling in back of throat or nose, ____/nasal mucosa irritation, coughing, ____ eyes, and runny nose. There is an ____ potential due to rapid nicotine delivery and frequent dosing is needed. It is easy to use an titrate, has ____ nicotine delivery, and less ____ compared to other formulations (cause fast on fast off).

Varenicline

What is the gold standard PCT option for smoking cessation?

Skin, angioedema, sleepwalking, renal, cannot, alcohol, seizure

Varenicline warnings include serious ____ rxns, ___ (swelling), accidental injury from falling while ____, and severe (renal/hepatic) impairment. It (can/cannot) be used in pregnancy. It increases the effects of ____ and the ____ risk.

CV, is, neuropsychiatric

A caution statement for ____ events remains on varenicline package label, but it (is/is not) considered for use in stable CVD and with caution in patients with ACS. It has been thought to cause ____ events, however that BBW was removed.

After, heavy machinery

Take Chantix with a full glass of water (before/after) meals. Stop and notify provider if any neuropsychiatric events occur. Use caution when operating ____ ____.

7, 0.5, 0.5, twice, 1, twice

Start varenicline ____ days before quit date. On days 1-3 of varenicline, take ____mg daily. On days 4-7, take ____mg ____ daily. Thereafter take ____mg ____ daily.

0.5 mg daily, 0.5 mg BID, 0.5 mg daily

If on varenicline and CrCl <30 mL/min, what is the initial dose? What is the max dose? What is the max dose for hemodialysis?

Nausea, AE, BID, withdrawal, reward, efficacious

What is the most common SE of varenicline? Patients also experience insomnia, abnormal dreams, vomiting, flatulence, and constipation. One disadvantage is that ____ can be serious. But it is easy to use and has ____ dosing. Its dual action relieves nicotine ____ and blocks ____ from smoking. It is the most ____ PCT available.

NRT single agent or bupropion SR

What are the second line options for smoking cessation PCT?

Seizure, anorexia, sedatives, alcohol, cirrhosis

Bupropion SR is CI in ____ disorder. This can be things like concomitant use of Wellbutrin, ____ or bulimia, abrupt d/c of ____ or ____, CNS tumor or trauma, and hepatic ____.

MAO, should not, glaucoma

Bupropion SR is CI if ____ inhibitor were used in last 14 days. It (should/should not) be used in pregnancy. It can worsen angle-closure ____.