Non-Rx Smoking Cessaion

Question 1

Consequences of Smoking

Answer 1

-Cancer (not just lung cancer)…
-Cardiovascular Disease
-Pulmonary Disease (asthma, COPD)
-Reproductive Effects
-Ophthalmic

Question 2

Benefits of quit Smoking

Answer 2

-Health
-Appearance: Smell, wrinkles, teeth
-Money
-Family/loved ones

Question 3

Quitting benefits in a time frame

Answer 3

minutes: decreases BP
hours: CO goes down
months: improved circulation, lung function, better mucus clearing, decreased respiratory symptoms (walk longer w/o shortness of breath)
1 year: heart disease goes down
5 years: stroke risk goes down
10y: lung cancer and other cancer risk goes down
15y: risk of heart disease normalizes

Question 4

Pathophysiology of Nicotine Dependence

Answer 4

-Tobacco is the vehicle to deliver nicotine
-Nicotine acts on nicotine acetylcholinergic receptors (nAChRs) ->AP cause Dopamine release

Question 5

What causes Withdrawal symptoms?

Answer 5

-nicotine receptors are upregulated but no nicotine to bind (stopped smoking)

-Anxious, irritable, insomnia
-cravings, impatience, restlessness
-frustration, hostility, inability to concentrate

starts within 24 hours, can last days, weeks, or longer

Question 6

When is the phase with the most severe symptoms?

Answer 6

Day 1-3
-set day of quitting
-prepare the patient for symptoms (person of support)

Question 7

Relapse vs. Slip up

Answer 7

-Relapse: back to smoking habits

-Slip up: attempting to quit, but having 1 cigarette

Question 8

How does smoking affect caffeine consumption?

Answer 8

-smoking upregulates enzymes that make people tolerate more caffeine
-> So when people stop smoking, the enzymes go down and people are more sensitive to caffeine

-> Withdrawal symptoms after drinking coffee + in top of the symptoms from quitting smoking

Question 9

Assessments of Smoking Abstinence

Answer 9

-MO levels -> fall within hours after the last cigarette (done in clinical trials)
-How confident is the patient? (rate from 0-10)
-Fagerstorm test
-Why I smoke: 18 questions -> allows behavioral intervention
-

Question 10

What is the Fagerstorm test?

Answer 10

-Assess physical dependence on nicotine

-How soon do you smoke? How many cigarettes?

Question 11

Why I smoke

Answer 11

-18 questions -> allows behavioral intervention
-Stimulation
-Handling
-Pleasure
-Relaxation/ Tension Reduction
-Craving
-Habit

Question 12

Ultimate Assessment

Answer 12

Ready to quit?
Stage 1: Not ready within the next month
Stage 2: Ready within the next month
Stage 3: Recent quit with last 6 months
Stage 4: Former smoker, quit > 6 months ago

Question 13

What are the 5As?

Answer 13

-Ask about tobacco use ´: recent quitter? former smoker?
-Advise to quit: Normalize, permission to share, encourage

-Assess readiness: Not thinking? -> Start thinking
5Rs: (Relevance, Risks, Rewards, Roadblocks, Repetition)

-Assist
-Arrange

Question 14

When should patients start using nicotine replacement products?

Answer 14

The day they quit

Question 15

Nonpharmacologic
How to create a plan

Answer 15

-QUIT DATE: 2 days to 2 weeks
-Top reasons for quitting
-Top triggers à Top coping strategies
-Smoke-free-vision
-Support system

Question 16

Nonpharmacologic
Coping Triggers

Answer 16

-Stimulating: walks, healthy food, jogging
-Handling: pencil, stress ball
-Pleasure: build them a reward system (healthy snacks, movies)
-Relaxation: stress relief
-Cravings: let them know it is there, medication
-Habits: avoid situations, inform others to change

Question 17

Nonpharmacologic

Answer 17

-Counseling
-QUITline
-Motivational Interviewing
-> READS
Rolling with resistance
Express empathy
Avoid arguing
Develop discrepancy
Support self-efficacy

Question 18

5 Rs

Answer 18

Relevance: Why quit?
Risks: NEGATIVE Consequence
Reward: Benefits of cessation
Roadblocks: Blockers
Repetition: continue to address

Question 19

Treatment Principles

Answer 19

-Medication
-Counseling
-Medication + Counseling
-Combination of Medication: short-term (Gum, Lozenges) + Long-term (Patch)

Question 20

First line of medication

Answer 20

1st line:
-Nicotine-Replacement Therapy
-Bupropion
-Varenicline (Chantix)

2nd line:
-Nortriptyline
-Clonidine

Question 21

Exclusion of Self-Treatment
EXAM!

Answer 21

-Heart disease (recent heart attack, last 2 weeks, uncontrolled! BP)
-for Gum and Lozenges (GI ulcers)
-Pregnancy
-under 18
-> not absolute contraindication (pt might be in hospital and use NRT, so supervised?)

Question 22

Nicotine Gum

Answer 22

> 30 minutes – 2 mg
< 30 minutes after waking - 4 mg
if patients wear dentures -> Lozenges might be preferable

-Short-acting
-Max: 24 pieces a day
-Side: jaw muscle soreness (too much or fast chewing)

Question 23

Nicotine Gum Chewing

Answer 23

Chew slowly, PARK between cheek and gum when a tingling sensation (nicotine release) appears -> Resume chewing when tingling sensation fades and park in a
different area of the mouth

Question 24

Nicotine Lozenge

Answer 24

> 30 minutes – choose 2 mg
< 30 minutes – choose 4 mg

-short-acting
-Max: 20 per day
-dissolve slowly over 20-30 minutes
-NO chewing, don’t Swallow, rotate in the mouth

Question 25

Gum and Lozenges Similarities

Answer 25

-Short-acting
-Onset: 5-10 minutes onset; cigarettes work within 10 sec
-Dosing
-Side effects are similar
-oral substitute and may cause delayed weight gain (nicotine suppresses appetite -> stop cigarette -> more appetite)
-no food or beverage before or during use
-can and should be used combined with a nicotine patch
-use at least 9 pieces a day for the first 6 weeks -> to be ahead of cravings

Question 26

Nicotine Transdermal Patch

Answer 26

-Long-acting: (delivered over 24 hours)
-discrete
-Dosing: 7, 14, 21 mg

-Same exclusions to self-treatment as other NRT
-Unique side effect: local skin reactions (not for patients with skin conditions)

Question 27

Nicotine Transdermal Patch

Answer 27

-7 mg, 14 mg, 21 mg
more than 10 cigarettes – start at 21 mg
less than 10 min cigarettes – start at 14 mg

Question 28

What are the side effects of Nicotine Patches?

Answer 28

-Itching, burning, and redness from the adhesive
-treated with OTC hydrocortisone cream

Question 29

How long to use the patch?

Answer 29

-Don’t use the same patch within a week
-rotate application sites
-done leave on for more than 24 hours

Question 30

Patient case Algorithm

Answer 30

Step 1: Is he ready? Why quitting? How much, how often do you smoke? Coffee? Quit-date? Cut back method?

Step 2: Excluded from Self-treatment: Heart disease, pregnancy, under 18, skin conditions

Step 3: Find the right product

Step 4: Counsel on dosing, side effects, and how to use