Smoking Cessation

Front 1

What is the mechanism of action for nicotine?

Back 1

- binds to nicotinic acetylcholine receptors in the brain and leads to stimulation and depression of the central and peripheral nervous system

Front 2

How do low doses of nicotine affect cognitive function and alertness?

Back 2

produces heightened alertness and increased cognitive function

Front 3

What do high doses of nicotine do to the brain?

Back 3

stimulates the “reward” center in the limbic system of the brain mediated via dopamine and leads to

a) Cravings and feeling of positive reward after cigarette smoking
b) Enhanced mood and performance

Front 4

What are the three consequences on the brain/body of nicotine use?

Back 4

1.Physical dependence - when the body becomes dependent or accustomed to the presence of a substance and abrupt removal of the substance can produce withdrawal. Physical dependence does not equal addiction.
2. Tolerance - the need to increase the amount smoked to achieve the same effects.
3.Withdrawal - abrupt cessation can lead to withdrawal within 24 hours (Sx listed on page 2)

Front 5

What are the behavioral aspects of smoking?

Back 5

1.Psychological dependence or addiction - abnormal behaviors that can include compulsive use, little self-control regarding use, cravings, and continued use despite knowledge of harm.
2. Smoking becomes associated with:
i.Daily routines (e.g. morning coffee, alcoholic drink, end of a meal)
ii.Events and situations
iii.Management of stress, anger, and anxiety
3.In order to stop smoking, a smoker must learn new coping skills and break old patterns (self assessment for pt. example on page 2)

Front 6

What are the three current approaches to smoking cessation?

Back 6

1. General Approach (5 A's)
2. Behavioral Modification therapy
3. Pharmacological

Front 7

What are the 5 A's of smoking cessation included in the general approach?

Back 7

1.Ask about tobacco use: identify and document status for each patient at each visit
2. Advise: urge every tobacco user to quit
3. Assess: willingness to quit
4.Assist in quit attempts: by providing cessation therapies (behavioral + pharmacotherapy)
5. Arrange follow-up within the first week after the quit date to evaluate medications for efficacy and adverse effects

Front 8

For patients unwilling to quit, what interventions can be used to increase future quit attempts?

Back 8

- The 5 R’s
• Ask the patient to identify why quitting is relevant
• Have the patient identify risks associated with smoking
• Have the patient identify rewards of smoking cessation
• Ask the patient to identify roadblocks to cessation
• Repeat motivation each time the patient visits clinic
(this are part of Assist on the 5 A's)

Front 9

What are the five points to Behavioral Modification Theory?

Back 9

1. offer to everyone ready to quit
2. efficacy is augmented by pharmacologic therapies
3. necessary to change behaviors/habits
4. Counseling
5. social support inside and outside of treatment

Front 10

What does pharmacological therapy provide to patient?

Back 10

only prevents withdrawal and cravings while individuals learn to modify lifestyle behaviors

Front 11

What are the four important aspects of pharmacotherapy with smoking cessation?

Back 11

a. Should be used with everyone attempting to quit unless contraindicated
b. Should always be used with behavioral modification
c. Increases long-term smoking abstinence rates
d. Important to set a quit date

Front 12

What are the five drugs classified as Nicotine Replacement therapy?

Back 12

1. GUm
2. Lozenges
3. Pathc
4. Nasal Spray
5. Inhaler

Front 13

What are the adverse effects of NRT?

Back 13

1. nausea
2. light headedness

Front 14

Is NRT gum OTC/Rx, and what is a specific contraindications for use?

Back 14

1.OTC
2. TMJ is contraindication

Front 15

What are side effects of gum use?

Back 15

mouth soreness, dyspepsia, hiccups, jaw ache

Front 16

What are 3 helpful guidelines to follow for gum use?

Back 16

1. Limit to <24/day
2. maximal benefit is received from SCHEDULED use versus waiting for a craving
3.. PROPER CHEWING TECHNIQUE IS ESSENTIAL! Chew and Park!

Front 17

What is the duration of use for gum?

Back 17

12 weeks. (short acting MOA)

Front 18

Are lozenges OTC/RX?

Back 18

OTC

Front 19

What are directions and duration of tx for lozenges?

Back 19

1.DO NOT CHEW
2. avoid food or drink 15 minutes before/during
3. duration of tx=12 weeks

Front 20

what are adverse effects of lozenges?

Back 20

heartburn, hiccups, coughing

Front 21

Is nicotine patch OTC/RX and what is it's duration of action?

Back 21

1. OTC
2. long acting- releases a constant amount nicotine slowly through the skin

Front 22

What are directions for patch?

Back 22

a) Worn for 24 hours, removed and replaced each morning
b) Apply a patch as soon as you wake up
c) Remove old patch and apply new patch each morning to a hairless location between the neck and waist (rotate site to prevent irritation)
(not specific on objectives, but was bolded)

Front 23

What are Side effects and Tx duration for the patch?

Back 23

insomnia, vivid dreams, 50% of subjects develop local skin irritation
a)Local irritation - rotate patch site, may also use 1% hydrocortisone cream
b)Insomnia - remove the patch prior to bedtime
TX duration- 10 weeks

Front 24

Drug class of Nicotrol NS

Back 24

Nicotine Replacement Therapy

Front 25

Dosage form of Nicotrol NS

Back 25

Rx- Nasal spray
Instill one (0.5mg) spray to each nostril (1mg total). Initially, use 1-2 doses/hour.
Increase as needed for symptomatic relief. (Max 40 doses/day, 5 doses/hour)

Front 26

Mechanism of action of Nicotrol NS

Back 26

Delivers aqueous nicotine solution to nasal mucosa

Front 27

duration of action (long vs short)

Back 27

Short?

Most rapid nicotine delivery system - peaks within 10 minutes

Front 28

place in therapy for Nicotrol NS (contraindications)

Back 28

Contraindications: reactive airway disease (asthma)

Front 29

Special considerations Nicotrol NS

Back 29

Produces higher peak nicotine levels than other forms of NRT leading to the highest dependence potential. 20% of patients use longer than recommended due to dependence.

Due to higher peak levels, this form may be most effective for those who are most addicted

Cost= $200.00 per bottle

Front 30

Adverse effects of Nicotrol NS

Back 30

Moderate to severe nasal irritation

Front 31

Drug class for Nicotrol

Back 31

Nicotine replacement therapy

Front 32

Dosage form for Nicotrol

Back 32

Inhaler
-1 inhalation= 1 dose
-Used as needed to control cravings during the day

Front 33

Is Nicotrol OTC or Rx?

Back 33

Rx

Front 34

Mech of action for Nicotrol

Back 34

Delivers nicotine vapor (not smoke) into mouth and throat

Nicotine absorbed in oral mucosa with minimal delivery to lung

Front 35

Special considerations for Nicotrol

Back 35

a) High administration burden (puffs/hour)
b) Requires deep and vigorous inhalations
c) Potential benefit in those needing the fix of hand to mouth movement
d) expense- $200.00 for 1 box of 168 cartridges (recommended 6-16 cartridges/day)

Front 36

Adverse effects of Nicotrol

Back 36

local mouth irritation, coughing, rhinitis

Front 37

Drug class for Bupropion sustained-release (SR) (Zyban®, Wellbutrin SR®)

Back 37

Antidepressant, Dopamine-reuptake inhibitor

Front 38

dosage form for Bupropion sustained-release (SR) (Zyban®, Wellbutrin SR®)

Back 38

0.5 mg and 1 mg tablets
i. Begin therapy 1-2 weeks before quit date and stop smoking during 2nd week of treatment
ii. Can consider a maintenance therapy of 150 mg BID x 6 months
iii. Those who are not making improvements towards cessation by week 7 of therapy should have treatment discontinued as cessation is not likely
iv. Can be used in combination with NRT
v. Do not crush sustained release products

Front 39

Is Bupropion OTC or Rx?

Back 39

Rx

Front 40

Mech of action for Bupropion

Back 40

Inhibits the neuronal reuptake and potentiates the effects of norepinephrine and dopamine (decreases withdrawal symptoms)

Front 41

Special considerations for Bupropion (contraindications)

Back 41

i. Patients with a history of seizures/epilepsy or eating disorders
ii. Use of monoamine-oxidase inhibitors (MOAi) within 14 days (i.e. phenelzine, rasagiline, selegiline, tranylcypromine, isocarboxazid, procarbazine, linezolid)

Front 42

Adverse effects of Bupropion

Back 42

insomnia, dry mouth, tremor, rash, headache

i.Insomnia - take evening dose earlier in the afternoon (but at least 8 hours after first dose)

Front 43

Duration of action (long or short) for Buproprion

Back 43

long

Front 44

Drug class for Varenicline (Chantix®)

Back 44

Partial Nicotine Agonist

Front 45

Dosage form for Varenicline (Chantix®)

Back 45

Tablet

i. Start 1 week before quit date
ii. Take with food or water
iii. If patient successfully quits in 12 weeks, an additional 12 weeks may be offered to maintain success. If patient has not quit in 12 weeks, stop therapy and re-evaluate.

Front 46

Is Varenicline (Chantix®) OTC or Rx?

Back 46

Rx

Front 47

Mechanism of action for Varenicline (Chantix®)

Back 47

selective nicotinic agonist that binds specifically at the α4β2 nicotinic receptor which mediates the rewarding properties of nicotine by causing a release of dopamine. Causes 30-60% of the dopamine release associated with nicotine which will attenuate craving and withdrawal. It has a higher affinity than nicotine for the receptor therefore is a competitive antagonist for nicotine.

Front 48

Duration of action (long or short) for Varenicline (Chantix®)

Back 48

Long

Front 49

Special considerations for Varenicline (Chantix®)

Back 49

-psychiatric illness (bipolar, schizophrenia, depression)
-Do NOT use in combination with NRT or bupropion
-Cost: $130.00 for 30 day supply

Front 50

Adverse effects of Varenicline (Chantix®)

Back 50

FDA Warning: depressed mood, agitation, behavioral changes, suicidal ideations and suicide have been reported. Psychiatric illness or history of should be disclosed prior to initiation. Mood and behavior should be monitored closely.

nausea, insomnia, abnormal dreams
i. Take with food if nausea occurs
ii. Move dose further from bedtime if sleep disturbances occur
iii. SE may warrant a temporary dose reduction

Front 51

When might combination NRT tx be beneficial?

Back 51

in highly nicotine dependent patients or those with a history of severe withdrawal symptoms

Front 52

The patch is associated with good compliance, but what are some draw backs?

Back 52

slow onset of action
no dose flexibility for cravings

Front 53

When creating a combination NRT therapy, what should you consider regarding duration of action?

Back 53

combination of long and short acting NRT agents

Front 54

Bupropion SR + nicotine patch facts

Back 54

i. Proven effective in clinical trials
ii. Combination is FDA-approved

Front 55

Smoking is an inducer of what enzymes?

Back 55

Cytochrome P450 enzymes

Front 56

What effect does tobacco smoke have on some drugs

Back 56

induces metabolism

Front 57

During smoking, these drugs are metabolized more quickly, so what do you need to do to tx while smoking?

Back 57

increase dose while smoking

Front 58

Upon cessation, what should you be aware of related to other medications the pt may be on?

Back 58

Inducer is removed, so concentrations of other meds may be increased and can lead to toxicity

Front 59

What meds should you be concerned about toxicity with after smoking cessation?

Back 59

Olanzapine
haloperidol
clozapine
alprazolam (xanax)
caffeine
theophylline
Etc.

Front 60

Does NRT have the same effects on P450s as smoking?

Back 60

NO