IGP 4 smoking Cessation

Health risk of smoking: cardiovascular

Tobacco use increases risk of stroke (~2×) and MI (~4×)

Most deadly pulmonary consequence of smoking

COPD—leading cause; cessation slows progression and reduces mortality

Cancer impact of smoking

Associated with 15+ cancers; causes ~30% of all cancer deaths

Early health benefit 2-3 weeks after quitting

Improved circulation and up to 50% improvement in lung function

Health benefit 1-9 months after quitting

Cilia recovery, improved mucus clearance, ↓ fatigue and SOB

Annual success rate of smoking cessation without treatment

~7.5%

Most common time for relapse

Within first 3 months after quitting

Primary causes of relapse

Stress, withdrawal symptoms, weight gain, triggers

Examples of smoking triggers

Meals, coffee, alcohol, waking up, driving, boredom, social situations

First step in the 5 A's model

Ask about tobacco use and document history

5 A's: Assess step purpose

Determine readiness to quit

5 R's: Relevance

Link quitting to the patient's personal health, family, and goals

5 R's: Rewards examples

Cost savings, improved breathing, better taste/smell

5 R's: Risks examples

Stroke, MI, COPD progression, cancer, effects on family members

5 R's: Roadblocks examples

Fear of weight gain, withdrawal, stress, enjoyment of tobacco

Key CBT components

Withdrawal education, trigger identification, coping strategies, stress management

Duration of CBT

Weekly or biweekly sessions, continue 6 months with follow-up

Nicotine PK: fastest absorption site

Lungs—nicotine reaches brain within 10-20 seconds

Nicotine PK: absorption considerations for gum/lozenge

Acidic beverages reduce absorption; avoid for 15 minutes before/after

Nicotine PD stimulant effects

↑ heart rate, ↑ BP, ↑ concentration, ↓ appetite

Major neurotransmitter driving nicotine addiction

Dopamine (reward pathway)

Nicotine withdrawal onset and duration

Begins 1-2 days after cessation, lasts 2-4 weeks

Cravings characteristics

Psychological + trigger-driven; may persist for months

Smoking interaction: CYP1A2 induction effect

Decreases levels of caffeine, theophylline, clozapine, olanzapine

Smoking + combined hormonal contraceptives risk

Increased risk of MI, stroke, and thromboembolism in women >35 smoking >15 cig/day

NRT rationale

Reduces withdrawal, desensitizes receptors, allows focus on behavioral components

Most discreet and inexpensive NRT form

Nicotine patch

NRT product to avoid in patients with dentures

Nicotine gum

Purpose of combining patch + gum/lozenge

Provides basal nicotine level plus PRN craving relief

Nicotine patch advantage

Steady-state delivery; simple once-daily dosing

Signs of high nicotine dependence (HSI)

Smoking within 5 minutes of waking and high daily cigarette count

ENDS role in cessation

Not FDA-approved; short-term less harmful than cigarettes but long-term safety unknown

E-cigarette toxicant linked to "popcorn lung"

Acetoin

Mechanism of bupropion

Weak dopamine and norepinephrine reuptake inhibitor → ↓ cravings and withdrawal

Bupropion contraindications

Seizure disorder, eating disorders, alcohol withdrawal, use of MAOIs

Common adverse effect of bupropion

Insomnia—avoid bedtime dosing

Mechanism of varenicline

Partial nicotinic receptor agonist; blocks nicotine binding while mildly stimulating dopamine

Most common adverse effect of varenicline

Nausea

Varenicline warning

Monitor for mood or behavior changes, especially in those with psychiatric history

Preferred therapy in pregnancy

Avoid varenicline; NRT or bupropion acceptable with shortest possible duration

Best cessation option in obesity

Bupropion (may promote weight loss)

Best pharmacotherapy post-acute coronary syndrome

NRT—safe and recommended

Cessation strategy for smokeless tobacco users

Prefer lozenge or varenicline; patch less effective

Best option for patient who wants hand-to-mouth simulation

Nicotine inhaler

Monitoring within first month of therapy

Adverse effects, abstinence/relapse, adjusting therapy, reinforcement of behavioral strategies