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100 Cards in this Set
- Front
- Back
what percent of people in the US are currently smokers
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20.6% (46 million)
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smoking leads to how many preventable deaths each year?
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440,000
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how many New Yorkers smoke?
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18.9%
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consequences of smoking
cancer: |
Acute myeloid leukemia
Bladder and kidney Cervical Esophageal Gastric Laryngeal Lung Oral cavity and pharyngeal Pancreatic |
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consequences of smoking
pulmonary disease: |
Acute (e.g., pneumonia)
Chronic (e.g., COPD) |
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consequences of smoking
cardiovascular disease: |
Abdominal aortic aneurysm
Coronary heart disease Cerebrovascular disease Peripheral arterial disease |
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consequences of smoking
reproductive effects: |
Reduced fertility in women
Poor pregnancy outcomes (e.g., low birth weight, preterm delivery) Infant mortality |
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consequences of smoking
other: |
cataract, osteoporosis, periodontitis, poor surgical outcomes
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there are an estimated 4,800 compounds in tobacco smoke,
including 11 proven human carcinogens |
true
(60 known carcinogens) |
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gases in tobacco smoke
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Carbon monoxide
Hydrogen cyanide Ammonia Benzene Formaldehyde |
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particles in tobacco smoke
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Nicotine
Nitrosamines Lead Cadmium Polonium-210 |
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Nicotine is the addictive component of tobacco products,
but it does NOT cause the ill health effects of tobacco use |
true
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quitting health benefits
2 weeks to 3 months: |
Circulation improves,
walking becomes easier Lung function increases up to 30 |
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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 |
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quitting health benefits
1 year |
Excess risk of CHD decreases to half that of a continuing smoker
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quitting health benefits
5 years |
Risk of stroke is reduced to that of people who have never smoked
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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 |
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quitting health benefits
after 15 years |
Risk of CHD is similar to that of people who have never smoked
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surgeon general report on second hand smoke
children: |
Increased risk for sudden infant death syndrome (SIDS), acute respiratory infections, ear problems, and more severe asthma
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surgeon general report on second hand smoke
adults: |
Increased risk for coronary heart disease and lung cancer
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how many deaths are attributed to second hand smoke annually?
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50,000
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tobacco use and cessation should be addressed as:
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a CHRONIC disease not an acute condition
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tobacco use behavior
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Physical addiction
Habit Psychological dependence |
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targets of tobacco cessation
environment/habit |
Coping strategies
Modifying daily routines Social interactions |
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targets of tobacco cessation
physical addiction |
Alleviation of withdrawal symptoms
Use of Medications Additional focus on behavioral changes |
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targets of tobacco cessation
psychological |
Healthy alternatives
Stress Weight control Pleasure/relaxation |
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2008 clinical practice guidelines
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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 |
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2008 clinical practice guidelines
special populations: |
Pregnant patients
Light smokers Adolescents Smokeless tobacco users |
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2008 clinical practice guidelines
recommendations |
To utilize counseling cessation interventions rather than medications to assist in the quit process
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5 A's
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Ask
Advise Assess Assist Arrange |
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step 1 - ASK
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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 |
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step 2- ADVISE
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Initiate the quitting process:
--Provide strong advice to quit --Motivate the patient --Educate the patient on the benefits of quitting |
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step 3- ASSESS
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Assess a patient’s readiness to quit
--Not ready to quit --Ready to quit --Recent quitter or former user |
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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 |
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step 4- ASSIST
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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) |
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step 5- ARRANGE
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Arrange for a follow up visit
In NY call 1-800- QUITNOW |
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5 R's
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Relevance
Risks Rewards Roadblocks Repetition *personalize * |
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the difficult decision to quit
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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 |
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effects of clinician interventions at 5+ months
no clinician: |
10.2
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effects of clinician intervention at 5 + months
self help material: |
10.9
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effects of clinician intervention at 5+ months
non physician clinician |
15.8
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effects of clinician intervention at 5 + months
physician clinician |
19.8
** with help from clinician, the success rate almost doubles ** |
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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.
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true
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tobacco cessation treatments
NRT's |
Gum
Patch Lozenge Nasal spray Inhaler |
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tobacco cessation treatments
non NRT's (medications) |
Bupropion SR (Zyban®)
Varenicline (Chantix®) |
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how does nicotine work?
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Core neurotransmitter
Nicotene attaches onto the receptors Pleasurable neurotransmitter Makes you want to keep doing it |
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pharmacotherapy
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“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.”
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NRT rationale
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Reduces withdrawal symptoms
Allows patient to focus on behavioral and psychological aspects **improves success rate ** |
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NRT precautions
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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* |
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NRT drug interactions
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none known
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Nicotene Gum
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Nicorette Gum- OTC
2mg, 4mg Original, orange, mint, cinnamon and fruit |
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nicotene gum
dosing (what mg) |
> 25 = 4mg
< 25 = 2mg |
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chewing technique for nicotene gum
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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 |
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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 ** |
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how long should you wait to eat or drink while using this NRT?
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15 minutes before and during use
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advantages of nicotene gum
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Satisfies oral cravings
Delays weight gain Flexible titration |
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disadvantages of nicotene gum
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“Park and chew” may not be socially acceptable
Use may be difficult Proper chewing technique necessary to minimize adverse effects (nausea, hiccups) |
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nicotene lozenge
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Commit Lozenge- OTC
2mg, 4mg “Time to first cigarette” dosing |
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Nicotine Lozenge: Dosing
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Dosage is based on the “time to first cigarette” (TTFC) as an indicator of nicotine addiction
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use commit lozenge 2mg if:
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you have your first cigarette after 30 minutes of waking up
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use commit 4mg lozenge if:
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if you smoke the first cigarette within 30 minutes of waking up
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nicotene lozenge dosing (how many days and how much) is the same as for nicotene gum
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true
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advantages of nicotene lozenges
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Satisfies oral cravings
Easy to use Flexible titration |
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disadvantages of nicotene lozenges
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Gastrointestinal side effects (nausea, hiccups, and heartburn)
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NRT patches
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Nicoderm CQ- OTC
7mg, 14mg, 21mg (24 hour) ** 1 pack/day = 21mg ** step down method |
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NRT patches
dosing for light smokers |
<10 cigarettes per day
step 2 (14mg for 6 weeks) step 3 (7mg for 2 weeks) |
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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 ** |
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directions for use of NRT patches
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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 |
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advantages of NRT patches
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Consistent nicotine levels
Easy to use Good compliance |
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disadvantages of NRT patches
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Unable to titrate the dose
Local skin reactions Doesn't help with "oral" cravings |
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how much nicotine in a cigarette
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1mg
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nicotine nasal spray
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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 |
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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 Termination: Gradual tapering over an additional 2–4 weeks |
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nicotine nasal spray
advantages |
Convenient titration
Effective relief of cravings |
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nicotine nasal spray
disadvantages |
Nasal/throat irritation
Dependence concerns |
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nicotine inhaler
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Nicotrol Inhaler- Prescription
10mg cartridge delivers 4mg of nicotine Start with 6 cartridges to a maximum of 16 cartridges/day Duration= 3 months |
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nicotine inhaler: dosing
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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 |
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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 |
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nicotine inhaler
other facts: |
The inhaler may not be as effective in very cold (<59F) 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) |
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nicotine inhaler
advantages |
Easy titration
Mimics hand-to-mouth routine |
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disadvantages of nicotine inhaler
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Throat or mouth irritation
Cartridges should not be stored in very warm or cold conditions. High frequency of use |
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Bupropion SR
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Atypical antidepressant thought to affect levels of various brain neurotransmitters
Dopamine (Inhibits reuptake of dopamine) Norepinephrine Clinical effects - craving for cigarettes - symptoms of nicotine withdrawal |
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Bupropion SR
dosing: |
Initial treatment
150 mg po q AM x 3 days Then… 150 mg po bid Duration, 7–12 weeks ** should start 1 to 2 weeks before quitting ** |
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Bupropion SR
advantages |
Easy oral option (Twice daily can address compliance)
Benefit in depressed patients |
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Bupropion SR
disadvantages |
Common side effect (insomnia)
Seizure risk Precaution/Contraindications --History of seizures --Anorexia or bulimia nervosa --Medications that lower seizure threshold |
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Bupropion in the news
|
July 2009, Bupropion received a black-box warning for neuropsychiatric events.
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Varenicline
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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 |
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Varenicline
dosing: |
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 ** |
|
Varenicline
advantages |
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 |
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Varenicline
disadvantages |
May induce nausea in up to one third of patients.
Post-marketing surveillance data indicate potential for neuropsychiatric symptoms. |
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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. |
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Combination Pharmacotherapy
|
Combination NRT
Long-acting formulation (patch) Produces relatively constant levels of nicotine PLUS Short-acting formulation (gum/lozenge, inhaler, nasal spray) Allows for acute dose titration as needed for nicotine withdrawal symptoms Bupropion SR + Nicotine Patch |
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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 |
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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 |
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Step 1 and 2 - gather information
subjective and objective information |
CC
PMH Current medications Allergies SH FH pqrssta - N/A |
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Step 3 - Identify MRP
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Indication without treatment
Treatment without indication Drug Interaction Adverse drug reaction Overdose Underdose Wrong treatment Failure to receive treatment Inappropriate monitoring |
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Step 4 - exclusions for self care
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All patients should be provided with smoking cessation counseling.
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Step 5 - Identify Alternative Solutions/Treatment Options Available
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Before deciding which treatment approach is appropriate for our patient, we need to utilize the 5 _A’s______.
|
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Step 6 -Recommend a Treatment option and Rationale
|
targets of smoking cessation
1.Physical addiction 2. Habit 3. Pscychological ?? Slides posted |
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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 |