14 - Smoking Cessation

Question 1

What enzymes does smoking induce?

Answer 1

1A1, 1A2, 2E1

Question 2

What are the 5 A’s?

Answer 2

• Ask
• Advise
• Assess
• Assist
• Arrange

Question 3

What are the 5 evidence based steps required to successfully quit?

Answer 3

• Setting a target quit date
• Getting professional help
• Enlisting social support
• Using medication to quit smoking
• Using problem-solving methods of counselling to quit and remain smoke-free

Question 4

What is first line?

Answer 4

NRTs (patch, gum, lozenge) - 1st line for many patients because it is so accessible

Question 5

How long do you use NRTs for?

Answer 5

8-12 weeks (can go up to 24 weeks though)

Question 6

What is varenicline?

Answer 6

alpha4beta2 nicotinic receptor partial agonist

Question 7

How does bupropion work?

Answer 7

aminoketone that blocks reuptake of D, NE and S

Question 8

What therapy has the highest quit rates?

Answer 8

varenicline

Question 9

What kind of boxed warnings did varenicline have?

Answer 9

• boxed warnings for patients with thoughts of harm to self or others
• caution for those with past or current psych illness and those with CV concerns

Question 10

Can you combine bupropion with NRT patch?

Answer 10

yes

Question 11

What are two other options for smoking cessation?

Answer 11

• clonidine

- nortriptyline

Question 12

points about clonidine?

Answer 12

good for those with HTN, must be tapered to prevent rebound HTN

Question 13

points about nortriptyline?

Answer 13

used when 1st line therapies are either unaffordable or have not worked

Question 14

What is the NHP that can be used for smoking cessation?

Answer 14

cytisine

Question 15

Describe cytisine

Answer 15

NHP, partial nicotine agonist that demonstrated efficacy over placebo

Question 16

Limitations of cytisine

Answer 16

• multiple daily doses (9mg/day in 6 doses then gradually tapered until 1.5mg is achieved)
• set quit date on day 5 after starting therapy

Question 17

Describe smoking cessation in pregnancy

Answer 17

• non-pharms first
• then low-dose short acting NRT (ex. gum)
• bupropion may be used (use in pregnancy has not been associated w higher risk of congenital malformations)

Bottom Line: NRTs prob not safe in pregnancy but are safer than smoking

Question 18

Can you use varenicline in pregnancy?

Answer 18

prob shouldn’t - data about varenicline in pregnancy is limited

Question 19

If pregnant ppl use the patch, remove at ______

Answer 19

night

Question 20

How does smoking affect breastfeeding?

Answer 20

smoking reduces production and quality of milk, but amount of nicotine exposure to baby is minimal and overall benefits of breastfeeding outweigh risks of continued smoking

Question 21

Can you use pharmacological therapies in breastfeeding?

Answer 21

NRT and bupropion may be used if benefits outweigh the risk

Question 22

Can you use varenicline in breastfeeding?

Answer 22

no published safety data for varenicline and breastfeeding mothers

Question 23

Key points for breastfeeding mothers who smoke

Answer 23

• non-pharms first
• try NRT and buproprion if needed
• try not to use NRT/smoke right before or during breastfeeding
• change clothes, frequent handwashing
• don’t smoke around the baby or in the house

Question 24

Avoid bupropion in severe _____ dysfunction

Answer 24

hepatic

Question 25

Bupropion and Champix - start ____ weeks before quit date

Answer 25

1-2

Question 26

Varenicline has a high incidence of ____ and _____

Answer 26

nausea and insomnia * tell patients to take with food and a full glass of water for nausea * take 2nd daily dose at suppertime if insomnia is bad

Question 27

How long do you use varenicline for?

Answer 27

- for 12 weeks usually, but can be repeated for another 12 weeks if necessary - can also combine with NRT

Question 28

Some counselling points about NRTs?

Answer 28

- avoid coffee or acidic substances while in mouth and 15 mins before - inhaler is absorbed buccally, not through the lungs (don't use for more than 6 months) - Quick mist spray has to be primed - Gum = bite bite park (Max 20 pieces/day for no more than 12 months

Question 29

Normally the patch is started at 21mg/day. When would you start at 14mg/day?

Answer 29

if person has CV disease, weights < 45 kg or smokes < 1/2 pack/day

Question 30

Can you use habitrol when exercising?

Answer 30

no, should avoid it

Question 31

Which patch peaks faster than the other?

Answer 31

Nicoderm peaks faster than Habitrol

Question 32

When do you start the patch?

Answer 32

on the quit date

Question 33

What are the 5 R's of motivational interviewing?

Answer 33

- Relevance - Risks - Rewards - Roadblocks - Repetition