Smoking Cessation

What harms does cigarette smoking cause?

increased risk of coronary heart disease (CHD) and stroke by 2-4x

decline in overall health

increase work absenteeism

increase health care utilization + cost

What enzymes does smoking introduce?

hepatic cytochrome p450 (CYP) enzymes primarily CYP1A2

Smoking/Nicotine DI

Clonazpine and Olanzapine (antipsychotics): increase serum levels

Fluvoxamine (SSRI): increase plasma levels

Alcohol: increase alcohol levels, cognitive impairment, intoxication, sedation

What effects happen on women when they smoke?

women >35 yrs who smoke and take systemic estrogen have increased risk of CV events/venous thromboembolism

Non pharm treatment for smoking cessation

Cognitive Behavioral Therapy (CBT) techniques

-structure efforts to change smoking behavior

-goal setting

-self monitoring

-rewards

-skills training

goal oriented, patient centered counseling style

eliciting from pts their own motivations for change instead of imposing a plan

What are the 5 Ds of smoking cessation?

Delay

Distract

Drink water

Deep breathing

Discuss

What are the 5 Rs of smoking cessation?

Relevance

Risks

Rewards

Roadblocks

Repetition

NRT patch (NicoDerm CQ, Habitrol, generics) MOA

Nicotine binds stero-selectively to nicotinic-cholinergic receptors at the autonomic ganglia in the brain resulting in a stimulating effect (via cortex) and a reward effect (via limbic system)

NRT Patch dosing

>10 cigs

21mg/day x 6weeks

then 14 mg/day x 2weeks

then 7 mg/day x 2 weeks

<10 cigs/day

14mg/day x 6 weeks

then 7 mg/day applied x 2weeks

NRT patch side effects

Headache

sleep disturbances

Local skin rxns (erythema, pruritus, burning)

Nicotine effects (nausea, agitation, tremor, Increase BP, HR, palpitations)

When should you refer to PCP when using the NRT patch?

Eczema, rash or other skin conditions

adhesive tape allergy

if skin redness caused by patch does not resolve after 4 days

symptoms of nicotine overdose

allergic rxn

NRT patch advantages and disadvatages

Advantages: easy to use and discrete, steady nicotine level, can use with short acting NRT

Disadvantages: cannot alter dose for cravings

NRT gum (Nicorette, generics) MOA

quick acting formulation

NRT Gum dosing

1st cig <30 min of waking: 4mg

1st cig >30 min of waking: 2 mg

weeks 1-6: chew 1 piece every 1-2 hrs

weeks 7-9: chew 1 piece every 2-4 hrs

weeks 10-12: chew 1 piece every 4-8 hrs

MAX: 24 pieces/day

NRT gum side effects

mouth and throat irritation

jaw muscle soreness or ache

hiccups

GI complaints (HB, nausea)

Lightheadedness

unpleasant taste

Nicotine effects

Avoid using NRT gum when….

Dental work has been done

dentures

temporomandibular joint disease/jaw problems

When to refer to HCP when using NRT gum

mouth, teeth, or jaw problems occur

sodium restricted diet

NRT GUM advantages and disadvantages

advantages: user controls nicotine dose

helps with oral fixation

can use with NRT patch

Disadvantages: no food or drink 15 mins before or during use

difficult to use with dentures or can damage dental work

NRT Lozenge (Nicorette, generics) dosing

1st cig <30 min of waking: 4 mg

1st cig >30 min of waking: 2mg

weeks 1-6: 1 lozenge every 1-2 hrs

weeks 7-9: 1 lozenge every 2-4 hrs

weeks 10-12: 1 lozenge every 4-8 hrs

MAX: 5 lozenges every 6 hours, 20 lozenges/day

NRT Lozenge administration

Dissolve lozenge between cheek and gum and occasionally move lozenge from one side of the mouth to the other until completely dissolved

NRT Lozenge SE

Mouth and throat irritation

GI complaints (HB, nausea)

Hiccups

Lightheadedness

Nicotine effects

AVOID IN SOY ALLERGY

When to refer to HCP when using NRT Lozenge

if mouth problems, persistent indigestion or severe sore throat

Na restricted diet

NRT Lozenge advantages and disadvatages

Advantages: user control nicotine dose

helps with oral fixation

ease of use for those with dentures or dental work

can use with NRT patch

Disadvantages: no food or drink 15 mins before or during use

NRT Nasal spray (Nicotrol NS) dosing

MOA: rapid relase

Dose:0.5 mg nicotine per spray

1 dose= 2 sprays (one in each nostril)= 1 mg of nicotine

Initial: 1-2 doses/hour (while awake) for 6-8 weeks

MAX: 5 doses per hour (10 sprays)

40 mg/day (80 sprays)

NRT nasal spray administration

blow nose prior to use, tilt head back slightly and insert tip of bottle into nostril, breathe through mouth and spray once in each nostril

NRT nasal spray side effects

mouth or throat irritation

eye irritation/tearing

rhinitis

sneezing

coughing

headache

dyspepsia

nicotine effects

AVOID IN: chronic nasal disorders

NRT Nasal spray advantages and disadvantages

Advantages: user controls nicotine dose

most rapid delivery of nicotine

can use with NRT patch

Disadvantages: most adverse effects of all our NRT products

prime device prior to 1st use and if not used for >24 hrs

Varencline (Chantix, generic) MOA

Partial neuronal a4B2 nicotinic receptor agonist. Prevents nicotine stimulation of mesolimbic dopamine system associated with nicotine use disorder. Relieves nicotine withdrawal and blocks reward of smoking

Varenicline dosing

days 1-3: 0.5 mg tablet daily

days 4-7: 0.5 mg tab BID

days 8 or later (maintence): 1 mg BID (continue for 11 weeks tot 12 weeks)

renal impairment (CrCl <30 ml/min): 0.5 mg daily

max 0.5 mg BID

Varenicline (Chantix, generic) SE

sleep disturbances

headache

irritability

constipation/flatulence

neuropsychiatric symptoms

increased seizure risk

CNS depression

When should you avoid Varenicline

H/o seizure or excessive alcohol use

Serious hypersensitivity reactions or skin reaction to varenicline

CAUTION IN: operating machinery/driving

Varenicline advantages and disadvantages

Advantages: oral pill option, dual mechanism, highly effective mono therapy option

Disadvantages: monitoring for mood changes and CNS depression

increased seizure risk

Buproprion SR (Wellbutrin SR, generic) MOA

unclear, mediated by noradrenergic and/or dopaminergic effects

start at least 1-2 weeks before quit date

Bupropion dosing

Days 1-3: 150mg once daily

4 or later: 150mg BID (continue for at least 11 weeks, tot of 12 weeks)

Max: 300mg/day

renal impairment (CrCl 15-60 mL/min)

Max: 150 mg daily

Buproprion SR side effects

CNS activation (agitation, insomnia)

dry mouth

vivid dreams

headaches

increased seizure risk

When should you avoid taking Buproprion SR

hypersensitivity to bupropion

those at high risk for seizures

use of MAOIs in past 14 days

What are the advantages and disadvantages of taking Buproprion?

Advantage: oral pill option

may experience less weight gain with tobacco cessation

Disadvantages: increased seizure risk

When to refer patients for smoking cessation

<18 yrs

pregnancy or chest feeding

smokeless tobacco users

CV disease:

-myocardial infarction

-arrythmia

-servere angina

-uncontrolled HTN

PUD
stomach, esophageal and duodenal ulcers

diabetes

uncontrolled psychiatric illness

What is the 1st line OTC treatment?

Combination NRT

What is the first line Rx treatment for smoking cessation?

Varenicline (Chantix)