Smoking Cessation

How many cigarettes are in one pack?

20

What are the top three causes of smoking-related deaths?

● Cancer

● Cardiovascular/Metabolic Diseases

● Respiratory Diseases

What are examples of other health complications related to smoking?

● Type 2 diabetes

● Reduced fertility of sperm

● Decreased immune function

● Tooth loss and gum damage

● Rheumatoid arthritis and decreased bone health

● Cataracts and age-related macular degeneration

● Increased risk of birth defects and low birth weight

What are the Five A's from the 2008 Guidelines?

● Ask

● Advise

● Assess

● Assist

● Arrange

What is the brief intervention model for smoking cessation?

● Ask

● Advise

● Refer

Weight gain caused by smoking cessation is caused by....

● Reversal of appetite suppressive effect of nicotine

● Decreased metabolic rate due to less nicotine exposure

● Increased caloric intake

What are the smoking cessation recommendations to all adults who are NOT pregnant?

● Ask all adults about tobacco use and advise to stop using tobacco

● Provide behavioral interventions and pharmacotherapy

What are the smoking cessation recommendations to all adults who ARE pregnant?

● Ask all pregnant persons about tobacco use and advise to stop using tobacco

● Provide behavioral interventions (not pharmacotherapy)

What is done in the "Ask" step?

Ask about and document tobacco use status and exposure to secondhand smoke at every visit.

This includes degree of nicotine addiction, risk of relapse, and nonsmoker exposure to secondhand smoke.

What is done in the "Advise" step?

Advise to quit using strong, clear, personalized advice that emphasis benefits rather than harms.

Benefits include:

•Health

•Financial savings

•Behavioral control

•Setting an example for others

What is done in the "Assess" step?

Assess factors that influence likelihood of relapse.

Assess degree of motivation, readiness, and confidence in ability to quit.

What factors influence likelihood of relapse?

● Presence of comorbid psychiatric disorders (anxiety, depression)

● Other substance use (alcohol)

● Living with someone who smokes

What is done in the "Assist" step?

● Offer pharmacotherapy

● Offer behavioral support resources

● Encourage setting a quit date

● Provide a structured quit attempt

What are some example resources to offer patients who quit smoking?

● Telephone quit line

● Smokefree.gov

● Becomeanex.org

● Phone apps

● Support groups

What is done in "Arrange" step?

● Assess smoking status, adherence, and response to treatment

● Provide support and encouragement

● Address issues (barriers; side effects)

What are core concepts of motivational interviewing?

● Express empathy

● Develop discrepancy

● Roll with resistance

● Support self-efficacy

What are counseling points you could give a patient dealing with anxiety and irritability as they're quitting smoking?

● Exercise (even a 5-minute walk can help)

● Contact a friend for support

● Take a few slow, deep breaths

● Chew sugar-free gum

What are counseling points you could give a patient dealing with insomnia or sleep problems as they're quitting smoking?

● Avoid caffeine in late afternoon and evening

● Incorporate routine physical activity

● Go to sleep and wake up on a regular, consistent schedule

What are counseling points you could give a patient dealing with hunger and increased appetite as they're quitting smoking?

● Prioritize fruits and vegetables

● Avoid high-calorie foods and beverages

● Carry sugar-free gum or toothpicks

● Drink more water

What are counseling points you could give a patient dealing with restlessness as they're quitting smoking?

● Incorporate routine physical activity

● Focus on hobbies or try something new

● Consider household chores

What are counseling points you could give a patient dealing with situational triggers as they're quitting smoking?

● Avoid people who use tobacco, or ask them not to use tobacco around you

● Establish friendships with people who don't use tobacco

● Avoid smoke breaks and other social situations where you use tobacco

● Avoid other situations where you usually use tobacco

What are counseling points you could give a patient dealing with things that are triggers as they're quitting smoking?

● Get rid of cigarettes, matches, lighters, ashtrays, and any other objects that are cues or triggers for smoking or using other tobacco products

● Avoid alcohol (at least for the first month) as it may trigger a desire to smoke

● Develop new ways to manage stress (hobbies, exercise)

What are counseling points you could give a patient dealing with places that are triggers as they're quitting smoking?

● Avoid places where you usually buy tobacco products

● Avoid locations where you usually use tobacco

● Take a different route to work or school

What is the nicotine patch dosing for a patient who smokes 10 or more cigarettes a day?

21 mg daily x 6 weeks

14 mg daily x 2 weeks

7 mg daily x 2 weeks

What is the nicotine patch dosing for a patient who smokes less than 10 cigarettes a day?

14 mg daily x 6 weeks

7 mg daily x 2 weeks

Nicotine Patch Counseling Points

● Apply a new patch each morning to dry skin.

● Rotate application site to avoid skin irritation.

● Keep using even if a slip occurs.

● Remove patch at bedtime if insomnia or vivid dreams occur.

● Remove patch prior to MRI because it may contain aluminum.

● Do not cut the patch.

What are common side effects of the nicotine patch?

● Vivid dreams

● Skin irritation

● Trouble sleeping

Nicotine Patch Pros

● Discrete use

● Once daily dosing

● Easiest nicotine product to use

● Provides a steady nicotine level

● Use in combination with other NRT

Nicotine Patch Cons

● User cannot alter dose if cravings or withdrawal symptoms occur during the day

● Not recommended for patients with dermatologic conditions (eczema; psoriasis)

What is the nicotine gum or lozenge strength for a patient who smokes a cigarette in 30 minutes or less of waking?

4 mg

What is the nicotine gum or lozenge strength for a patient who smokes a cigarette more than 30 minutes after waking?

2 mg

Administration Counseling for Nicotine Gum

● Chew briefly until mouth tingles, then park gum inside cheek until tingle fades

● Repeat chew-and-park each time tingle fades

● Discard gum after 30 minutes of use

What is the maximum amount of nicotine gum that may be used in a day?

24

What are common side effects of nicotine gum?

● Nausea

● Hiccups

● Heartburn

● Jaw soreness

● Mouth irritation

Nicotine Gum Pros

● Oral nicotine substitute

● User controls nicotine dose

● Oral substitute for cigarettes

● May delay weight gain

● May be added to patch to cover acute cravings

Nicotine Gum Cons

● Not chewed in same way as regular gum

● Can damage dental work and be difficult to use with dentures

● No food or drink 15 minutes prior to use and during use

● Frequent dosing needed

● Avoid use in temporomandibular joint (TMJ) disease

Administration Counseling for Nicotine Lozenges

● Place between gum and cheek

● Allow to melt slowly

● Do not chew

What is the maximum amount of nicotine lozenges that may be used in a day?

20

What are common side effects of nicotine lozenges?

● Nausea

● Hiccups

● Heartburn

● Mouth irritation

Nicotine Lozenge Pros

● Oral nicotine substitute

● User controls nicotine dose

● Oral substitute for cigarettes

● Easier to use than gum for those with dental work or dentures

● May delay weight gain

● May be added to patch to cover acute cravings

Nicotine Lozenge Cons

● No food or drink 15 minutes prior to use and during use

● Frequent dosing needed

Which available nicotine product needs to be tapered off when discontinuing therapy?

Nicotine nasal spray

What are common side effects of the nicotine nasal spray?

● Nasal irritation

● Throat irritation

● Rhinitis

● Sneezing

● Coughing

● Tearing

Nicotine Nasal Spray Pros

● User controls nicotine dose

● Most rapid delivery of nicotine among all NRT products

● May be added to patch to cover acute cravings

Nicotine Nasal Spray Cons

● May be more expensive

● Nasal administration may cause irritation

● Frequent dosing needed

● Has the most side effects of all NRT products

● Not recommended with chronic nasal disorders or severe airway disease (severe COPD or asthma)

Which smoking cessation agents may increase blood pressure?

● NRT

● Bupropion

NRT Warnings and Precautions

Avoid in the following:

● Immediately after MI (within 2 weeks)

● In patients with serious arrhythmias

● In patients with severe/worsening angina (chest pain)

● Patients with peptic ulcer disease (PUD) because it can delay healing

Varenicline Dosing

Days 1-3: 0.5 mg/day

Days 4-7: 0.5 mg BID

Day 8: 1 mg BID thereafter

Minimum Duration of Varenicline

3 months

Administration Counseling for Varenicline

Take with food and a tall glass of water to minimize nausea

What are common side effects of the Varenicline?

● Insomnia

● Irritability

● Headache

● Vivid dreams

● Nausea/vomiting

Varenicline Warnings and Precautions

● Renal dose adjustment needed

● CNS depression

● Neuropsychiatric effects

● Somnambulism

● Seizures (not as severe of an issue compared to bupropion)

Varenicline Pros

● Quit date can be flexible, from 1 week to 3 months after starting drug

● Dual action: 1) Relieves nicotine withdrawal and 2) Blocks reward of smoking

● Predictable side effects

● Oral agent

● Most effective smoking cessation agent

Varenicline Cons

● May be expensive

● Because of previous FDA boxed warning, many patients fear psychiatric adverse events, even though they are no more common than with other smoking cessation medications

● Side effects may be intolerable

Bupropion Dosing

150 mg x3 days then 150 mg twice daily thereafter for 7-12 weeks

What are common side effects of the bupropion?

● Insomnia

● Agitation

● Dry mouth

● Headache

● Dizziness

● Diaphoresis

● Weight loss

Bupropion contraindications

● History of seizures

● History of anorexia/bulimia

● Undergoing abrupt discontinuation of alcohol, benzodiazepines, barbiturates

● Concurrent use of MAOI or within the past 14 days

● Concurrent use of linezolid or IV methylene blue

Bupropion Warnings and Precautions

● Suicidality

● Neuropsychiatric (changes in mood/behavior)

● CNS stimulation (restlessness, anxiety, insomnia, anorexia)

● Hypertension

● Seizures!

● Weight loss

● Other effects: tachycardia, diaphoresis, constipation, nausea, xerostomia, dizziness

Bupropion Pros

● May lessen post-cessation weight gain while drug is being taken

● Oral agent

Bupropion Cons

● Increased seizure risk

● Wide variety of side effects

Which medication is the most effective smoking cessation aid?

Varenicline

Which is more effective for smoking cessation: NRT monotherapy or NRT combination?

NRT combination

Which is more effective for smoking cessation: bupropion monotherapy or bupropion with NRT as combination therapy?

Bupropion with NRT as combination therapy

Are e-cigarettes considered a safe option for smoking cessation?

No.

The safety data is not well-established regarding long-term use. While it's likely healthier than smoking traditional cigarettes, we should encourage all patients to avoid nicotine products.

True or False: In general, different types of tobacco products pose different levels of risk to people's health.

True.

While e-cigarette aerosol generally contains lower levels of harmful chemicals than cigarette smoke, no tobacco products are safe.

True or False: E-cigarettes are FDA-approved as a smoking cessation aid.

False.

While certain e-cigarettes may help adults stop smoking or significantly reduce their use of more harmful cigarettes, no e-cigarette product has been FDA-approved as a smoking cessation device. More research is needed to determine the safety and effectiveness of e-cigarettes as a smoking cessation aid, especially long-term.

People who don't currently use tobacco products should not start.

Additionally ,the FDA does not "approve" tobacco products for sale in the US. To legally sell or distribute a new tobacco product in the US, manufacturers must receive authorization from the FDA. A marketing authorization does not indicate that the tobacco product is either safe or "approved."

There is no such thing as a safe tobacco product, so the FDA's safe and effective standard for evaluating medical products does not apply to tobacco products.

True or False: In general, transitioning completely from using cigarettes to an e-cigarette would reduce the risk of exposure to harmful chemicals.

True.

Switching completely to e-cigarettes can reduce health risks among adults who smoke. But continued use of both products ("dual use") does not meaningfully reduce one's risk.

For an adult who smokes to benefit from e-cigarette use, they have to transition completely from cigarettes to e-cigarettes.