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100 Cards in this Set

  • Front
  • Back
what percent of people in the US are currently smokers
20.6% (46 million)
smoking leads to how many preventable deaths each year?
how many New Yorkers smoke?
consequences of smoking
Acute myeloid leukemia
Bladder and kidney
Oral cavity and pharyngeal
consequences of smoking
pulmonary disease:
Acute (e.g., pneumonia)
Chronic (e.g., COPD)
consequences of smoking
cardiovascular disease:
Abdominal aortic aneurysm
Coronary heart disease
Cerebrovascular disease
Peripheral arterial disease
consequences of smoking
reproductive effects:
Reduced fertility in women
Poor pregnancy outcomes (e.g., low birth weight, preterm delivery)
Infant mortality
consequences of smoking
cataract, osteoporosis, periodontitis, poor surgical outcomes
there are an estimated 4,800 compounds in tobacco smoke,
including 11 proven human carcinogens

(60 known carcinogens)
gases in tobacco smoke
Carbon monoxide
Hydrogen cyanide
particles in tobacco smoke
Nicotine is the addictive component of tobacco products,
but it does NOT cause the ill health effects of tobacco use
quitting health benefits
2 weeks to 3 months:
Circulation improves,
walking becomes easier
Lung function increases up to 30
quitting health benefits
1 to 5 months
Lung cilia regain normal function
Ability to clear lungs of mucus increases
Coughing, fatigue, shortness of breath decrease
quitting health benefits
1 year
Excess risk of CHD decreases to half that of a continuing smoker
quitting health benefits
5 years
Risk of stroke is reduced to that of people who have never smoked
quitting health benefits
10 years
Lung cancer death rate drops to half that of a continuing smoker
Risk of cancer of mouth, throat, esophagus, bladder, kidney, pancreas decrease
quitting health benefits
after 15 years
Risk of CHD is similar to that of people who have never smoked
surgeon general report on second hand smoke
Increased risk for sudden infant death syndrome (SIDS), acute respiratory infections, ear problems, and more severe asthma
surgeon general report on second hand smoke
Increased risk for coronary heart disease and lung cancer
how many deaths are attributed to second hand smoke annually?
tobacco use and cessation should be addressed as:
a CHRONIC disease not an acute condition
tobacco use behavior
Physical addiction


Psychological dependence
targets of tobacco cessation
Coping strategies
Modifying daily routines
Social interactions
targets of tobacco cessation
physical addiction
Alleviation of withdrawal symptoms
Use of Medications
Additional focus on behavioral changes
targets of tobacco cessation
Healthy alternatives
Weight control
2008 clinical practice guidelines
Reinforced 5A’s and 5R’s
Counseling and the use of medications are more effective than either intervention alone
7 First line agents (Addition of the nicotine lozenge and varenicline)
Specific considerations when counseling special populations
2008 clinical practice guidelines
special populations:
Pregnant patients
Light smokers
Smokeless tobacco users
2008 clinical practice guidelines
To utilize counseling cessation interventions rather than medications to assist in the quit process
5 A's
step 1 - ASK
Ask every patient if he or she uses tobacco
--Vital part of a complete medical history

Flag the patient records of tobacco users:
--For subsequent visits
--To monitor progress
step 2- ADVISE
Initiate the quitting process:
--Provide strong advice to quit
--Motivate the patient
--Educate the patient on the benefits of quitting
step 3- ASSESS
Assess a patient’s readiness to quit
--Not ready to quit
--Ready to quit
--Recent quitter or former user
step 3- ASSESS (cont)
based on their rediness to quit:
Not ready to quit--> Utilize the 5 R’s
Ready to quit-->Continue 5 A’s
Recent quitter or former user -->Continue 5 A’s
step 4- ASSIST
Assess tobacco use history
Discuss key issues or triggers
Facilitate quit process
--Discuss pharmacotherapy options
--Discuss cognitive and behavioral coping strategies (Handbook of Nonprescription Drugs- Table 50-4)
step 5- ARRANGE
Arrange for a follow up visit

In NY call 1-800- QUITNOW
5 R's

*personalize *
the difficult decision to quit
Faced with change, most people are not ready to act.
Change is a process, not a single step.
Typically, it takes multiple attempts.

how can I live without tobacco
effects of clinician interventions at 5+ months
no clinician:
effects of clinician intervention at 5 + months
self help material:
effects of clinician intervention at 5+ months
non physician clinician
effects of clinician intervention at 5 + months
physician clinician

** with help from clinician, the success rate almost doubles **
Compared to smokers who receive assistance from no clinicians, smokers who receive assistance from two or more clinicians are 2.4–2.5 times as likely to quit successfully for 5 or more months.
tobacco cessation treatments
Nasal spray
tobacco cessation treatments
non NRT's (medications)
Bupropion SR (Zyban®)

Varenicline (Chantix®)
how does nicotine work?
Core neurotransmitter
Nicotene attaches onto the receptors
Pleasurable neurotransmitter
Makes you want to keep doing it
“Clinicians should encourage all patients attempting to quit to use effective medications for tobacco dependence treatment, except where contraindicated or for specific populations* for which there is insufficient evidence of effectiveness.”
NRT rationale
Reduces withdrawal symptoms
Allows patient to focus on behavioral and psychological aspects

**improves success rate **
NRT precautions
Patients with underlying cardiovascular disease
Recent myocardial infarction (within past 2 weeks)
Serious arrhythmias
Serious or worsening angina

*may be used if monitored by MD*
NRT drug interactions
none known
Nicotene Gum
Nicorette Gum- OTC
2mg, 4mg
Original, orange, mint,
cinnamon and fruit
nicotene gum
dosing (what mg)
> 25 = 4mg
< 25 = 2mg
chewing technique for nicotene gum
1.chew slowly
2. stop chewing when you notice a peppery taste or tingle
3. park between cheek and gum
4. chew again when no taste or tingle
nicotene gum
dosing (how long and how many)
week 1 to 6= 1 q1 - 2h

week 7 to 9= 1 q2 - 4h

week10 to 12= 1 q4 - 8h

** max of 24 pieces in a day **
how long should you wait to eat or drink while using this NRT?
15 minutes before and during use
advantages of nicotene gum
Satisfies oral cravings
Delays weight gain
Flexible titration
disadvantages of nicotene gum
“Park and chew” may not be socially acceptable
Use may be difficult
Proper chewing technique necessary to minimize adverse effects (nausea, hiccups)
nicotene lozenge
Commit Lozenge- OTC
2mg, 4mg

“Time to first
cigarette” dosing
Nicotine Lozenge: Dosing
Dosage is based on the “time to first cigarette” (TTFC) as an indicator of nicotine addiction
use commit lozenge 2mg if:
you have your first cigarette after 30 minutes of waking up
use commit 4mg lozenge if:
if you smoke the first cigarette within 30 minutes of waking up
nicotene lozenge dosing (how many days and how much) is the same as for nicotene gum
advantages of nicotene lozenges
Satisfies oral cravings
Easy to use
Flexible titration
disadvantages of nicotene lozenges
Gastrointestinal side effects (nausea, hiccups, and heartburn)
NRT patches
Nicoderm CQ- OTC
7mg, 14mg, 21mg (24 hour)

** 1 pack/day = 21mg **
step down method
NRT patches
dosing for light smokers
<10 cigarettes per day
step 2 (14mg for 6 weeks)
step 3 (7mg for 2 weeks)
NRT patches
dosing for heavy smokers
>10 cigarettes per day
step 1 (21mg for 6 weeks)
step 2 (14mg for 2 weeks)
step 3 (7mg for 2 weeks)
** typical duration is 12 weeks **
directions for use of NRT patches
Choose an area of skin on the upper body or upper outer part of the arm
Make sure skin is clean, dry, hairless, and not irritated
Apply patch to different area each day
Do not use same area again for at least 1 week
advantages of NRT patches
Consistent nicotine levels
Easy to use
Good compliance
disadvantages of NRT patches
Unable to titrate the dose
Local skin reactions

Doesn't help with "oral" cravings
how much nicotine in a cigarette
nicotine nasal spray
Nicotrol NS- Prescription
0.5mg nicotine per spray

One dose = 1 mg nicotine (2 sprays,
one 0.5 mg spray in each nostril)

Recommended use-
1-2 doses/hour

Maximum- 5 doses/hour

Duration= 3 months
nicotine nasal spray
dosing and administration
One dose = 1 mg nicotine
(2 sprays, one 0.5 mg spray in each nostril)

For best results, patients should use at least 8 doses daily for the first 6–8 weeks

Gradual tapering over an additional 2–4 weeks
nicotine nasal spray
Convenient titration
Effective relief of cravings
nicotine nasal spray
Nasal/throat irritation
Dependence concerns
nicotine inhaler
Nicotrol Inhaler- Prescription
10mg cartridge delivers 4mg of nicotine

Start with 6 cartridges to a maximum of 16 cartridges/day

Duration= 3 months
nicotine inhaler: dosing
Start with at least 6 cartridges/day during the first 3-6 weeks of treatment

Gradually reduce daily dosage over the following 6–12 weeks
nicotine inhaler
directions for use
Inhale into back of throat or puff in short breaths

Nicotine in cartridges is depleted after about 20 minutes of active puffing
Cartridge does not have to be used all at once
Open cartridge retains potent for 24 hours

Inhaling lightly, not doing a deep inhalation

Release the nicotene into the mouth
nicotine inhaler
other facts:
The inhaler may not be as effective in very cold (<59F) temperatures—delivery of nicotine vapor may be compromised

Use the inhaler longer and more often at first to help control cravings (best results are achieved with frequent continuous puffing over 20 minutes)
nicotine inhaler
Easy titration
Mimics hand-to-mouth routine
disadvantages of nicotine inhaler
Throat or mouth irritation
Cartridges should not be stored in very warm or cold conditions.
High frequency of use
Bupropion SR
Atypical antidepressant thought to affect levels of various brain neurotransmitters
Dopamine (Inhibits reuptake of dopamine)
Clinical effects
- craving for cigarettes
- symptoms of nicotine withdrawal
Bupropion SR
Initial treatment
150 mg po q AM x 3 days
150 mg po bid
Duration, 7–12 weeks

** should start 1 to 2 weeks before quitting **
Bupropion SR
Easy oral option (Twice daily can address compliance)
Benefit in depressed patients
Bupropion SR
Common side effect (insomnia)
Seizure risk
--History of seizures
--Anorexia or bulimia nervosa
--Medications that lower seizure threshold
Bupropion in the news
July 2009, Bupropion received a black-box warning for neuropsychiatric events.
Binds at the alpha4 beta2 neuronal nicotinic acetylcholine receptors
Stimulates low-level agonist activity
Competitively inhibits binding of nicotine
Clinical effects
-decrease craving for cigarettes
-decrease symptoms of nicotine withdrawal
day 1 to 3 = 0.5mg daily
day 4 to 7 = 0.5mg bid
day 8 to end = 1mg bid
* for up to 12 weeks *

** begin therapy 1 week prior to quitting **
Easy to use oral formulation.
Twice daily dosing might reduce compliance problems.
Offers a new mechanism of action for persons who have failed other agents
May induce nausea in up to one third of patients.
Post-marketing surveillance data indicate potential for neuropsychiatric symptoms.
varenicline in the news
In 2008, Pfizer added a warning label advising patients and caregivers:
Patients should stop taking varenicline and contact their healthcare provider immediately if agitation, depressed mood, or changes in behavior that are not typical for them are observed, or if the patient develops suicidal ideation or suicidal thoughts.

July 2009, Varenicline received a black-box warning for neuropsychiatric events.
Combination Pharmacotherapy
Combination NRT
Long-acting formulation (patch)
Produces relatively constant levels of nicotine
Short-acting formulation (gum/lozenge, inhaler, nasal spray)
Allows for acute dose titration as needed for nicotine withdrawal symptoms
Bupropion SR + Nicotine Patch
evaluating patients
ASK every patient about their tobacco use
ADVISE patients on the risks of tobacco use and the benefits of quitting
ASSESS patient’s level of readiness
--Not ready to quit
--Ready to quit
--Recent quitter
ASSIST patient in facilitating in the quit process
ARRANGE for follow up
what can YOU do
Quitting is a process that occurs over time, not a discrete, one-time event.
ASK every patient about their tobacco use

Provide support to help the patient’s
quit attempt stay on track

Arrange for follow up
Step 1 and 2 - gather information

subjective and objective information
Current medications

pqrssta - N/A
Step 3 - Identify MRP
Indication without treatment
Treatment without indication
Drug Interaction
Adverse drug reaction
Wrong treatment
Failure to receive treatment
Inappropriate monitoring
Step 4 - exclusions for self care
All patients should be provided with smoking cessation counseling.
Step 5 - Identify Alternative Solutions/Treatment Options Available
Before deciding which treatment approach is appropriate for our patient, we need to utilize the 5 _A’s______.
Step 6 -Recommend a Treatment option and Rationale
targets of smoking cessation
1.Physical addiction
2. Habit
3. Pscychological

?? Slides posted
Step 7- 11- Patient Education and Monitoring/Follow up
Educate patient on the dosing and administration for the pharmacotherapy option chosen

Discuss ways to reduce cravings and stay on track for a successful quit process
Cognitive and behavioral coping strategies

Arrange for follow up