2 - Smoking Cessation Flashcards
(148 cards)
1
Q
Some key questions to ask?
A
- Do you smoke?
- Are you thinking about quitting?
- Are you ready to quit?
2
Q
List the components of cigarettes.
A
Tar
Carbon monoxide
Nicotine
3
Q
Describe Tar
A
contains > 4000 chemicals - increases risk of cancer, CV disease and pulmonary disease
4
Q
Describe Carbon monoxide
A
reduces oxygen-carrying capacity of blood
5
Q
Describe Nicotine
A
the addictive component (as strong as cocaine)
6
Q
What CV problems can result from smoking cigarettes?
A
- coronary heart disease
- cerebrovascular disease (stroke)
- peripheral vascular disease
7
Q
What types of cancer can result from smoking cigarettes?
A
- lung
- pharynx
- larynx
- esophagus
- pancreas
- kidney
- bladder
- cervix
8
Q
What type of respiratory problems can result from smoking cigarettes?
A
- chronic obstructive pulmonary disease (COPD)
- pneumonia
- emphysema
- bronchitis
9
Q
How can cigarette smoking affect pregnant women?
A
- low birth weight
- stillbirths
- miscarriage
- sudden infant death syndrome (SIDS)
10
Q
List some other impacts on health that smoking cigarettes have
A
- peptic ulcer disease
- osteoporosis
- cataracts
- macular degeneration
- infertility
- impotence
11
Q
Second-hand smoke results in ____ lung cancer deaths
A
300
12
Q
Second-hand smoke results in ____ deaths from coronary heart disease
A
700
13
Q
Exposure to smoke increases your risk of lung cancer by ___%
A
25
14
Q
Exposure to smoke increases your risk of heart disease by ___%
A
10
15
Q
Passive smoke (second-hand smoke) can adversely affect children's development of: ??
A
- speech
- language skills
- intelligence
- visual/spatial abilities
16
Q
Second-hand smoke will worsen which childhood illnesses?
A
- ear infections
- asthma
- bronchitis
- tonsilitis
- adenoid problems
- pneumonia
- allergies
17
Q
Nicotine has ____ effects at low doses
A
stimulant
18
Q
Describe the stimulant effects of nicotine at low doses
A
- increases alertness
- facilitates memory, attention
- reduces irritability, aggression
- suppresses appetite for sweets
- increases energy expenditure
- lowers likelihood of weight gain (because food doesn’t taste as good)
19
Q
Nicotine has _____ effects at higher doses
A
reward
*via limbic system’s “pleasure system”
20
Q
Immediate health benefits of quitting after 20 mins?
A
- BP and pulse rate return to normal
- Body temp increases to normal
21
Q
Immediate health benefits of quitting after 8 hours?
A
-Carbon monoxide levels in blood drop and oxygen levels return to normal
22
Q
Immediate health benefits of quitting after 48 hours?
A
- Sense of smell and taste improves
- The chances of having a heart attack start to go down
23
Q
Immediate health benefits of quitting after 72 hours?
A
-Lung capacity increases
24
Q
Long term health benefits of quitting after 2 weeks?
A
-Nicotine is gone from the body
25
Long term health benefits of quitting after 3 months?
-Circulation and overall energy increases
26
Long term health benefits of quitting after 6 months?
-Coughing, sinus congestion, tiredness and shortness of breath improve significantly
27
Long term health benefits of quitting after 1 year?
Risk of heart disease (CHD) goes down
28
Long term health benefits of quitting after 5 - 15 years?
-Risk of dying from lung cancer decreases by almost 1/2
29
Long term health benefits of quitting after 10-15 years?
-Risk of heart attack is equal to someone who has never smoked
30
When do physical nicotine withdrawl symptoms begin?
A few hours after quitting
31
When do physical nicotine withdrawl symptoms peak?
2-3 days
32
When do physical nicotine withdrawl symptoms usually resolve?
within about 2 weeks
33
So the immediate physical nicotine withdrawl symptoms are usually over in 2 weeks, up to how long can "Late" onset symptoms (milder symptoms) last?
6 months in rare cases
34
What are some nicotine withdrawl symptoms?
- constipation
- diarrhea
- fatigue
- headache
35
How can nicotine withdrawl symptoms be managed?
with nicotine replacement therapy (NRT) and behavioural treatment
36
How long does dizziness last?
1-2 days
37
How long does restlessness/anxiety last?
a few days or weeks
38
How long does cough/dry throat and mouth last?
a few days or weeks
39
How long does fatigue and increased appetite last?
2-4 weeks
40
How long does insomnia last?
1 week
41
How long does irritability, frustration, anger and headaches last?
1-2 weeks
42
How long does constipation, gas and bloating last?
1-2 weeks
43
The Fagerstrom Questionnaire measures what?
degree of 'physical' dependence
44
Fagerstrom Questionnaire scale:
| <5 = ?
low nicotine dependence
45
Fagerstrom Questionnaire scale:
| 5 = ?
moderate nicotine dependence
46
Fagerstrom Questionnaire scale:
| 6-7 = ?
high nicotine dependence
47
Fagerstrom Questionnaire scale:
| 8-10 = ?
very high nicotine dependence
48
What are the 5 A's?
```
Ask about tobacco use
Advise to quit
Assess willingness to make a quit attempt
Assist in quit attempt
Arrange for follow-up
```
49
What is the formula for pack years?
(#cigs/day) x (# years smoked) / 20 = ____ pack years
50
Barriers to quitting?
- lack of reason to change
- emotional stress
- social habits
- discouragement bc of failure before
- fear of withdrawl symptoms and cravings
- attachments to smoking rituals
- influence of others smoking
- sense of loss in giving up cigs
51
Roughly how much savings after 5 yrs of quitting?
$$18,250
52
For patients to quit smoking successfully, they must: ?? (3)
- overcome pharmacological nicotine dependence
- cope with nicotine withdrawal
- extinguish strong behavioural associates with smoking
53
Non-pharms for smoking cessation?
- Set a target quit date
- Get professional help
- Enlist social support from friends and family
- Use problem-solving methods of counselling to quit and remain smoke free
54
How long will cravings last?
only a few minutes (use coping methods to get through)
55
What are some coping methods?
- manage cravings and triggers
- stress relief
- environmental control
- social support
- motivational thinking and rewards
- handling withdrawl symptoms
56
How should you handle relapses?
- remind patients that slip ups are normal
- avoid "all or nothing" thinking
- think of it as a learning opportunity (ask why it happened and think of what you can do in the future to prevent it from happening)
- Remind patient that it's not a lack of willpower but a lack of an effective strategy for that situation
57
List the Methods of Smoking Cessation
1) Cold Turkey - not effective at all if highly addicted
2) Self-Treatment Nicotine Replacement Therapy
- gum/lozenge/mouth spray
- transdermal patch
- inhaler
3) Prescription Therapy (oral/tablets)
- Bupropion
- Varenicline
- Nortriptyline/Clonidine (3rd line) - off label uses
4) Nonpharmacologic Aids
- behavioral interventions
- patient counselling
- nutritional advice
* *Alternative methods (not very effective alone)
- hypnotism
- acupuncture
- laser
- herbal products
- electronic cigs
58
Who do you need to refer to a doctor?
Pregnancy women and adolescents (under 18)
59
Why is nicotine replacement therapy (NRT) a cleaner form of getting nicotine?
There is no tar and no carbon monoxide, so you don't get any gross chemicals, just pure nicotine.
60
After smoking a cigarette, it only takes ____ seconds for nicotine to get into the brain..
7
61
Why do NRT's have slower onset and absorption?
They are not absorbed through the lung.
62
What can Mb pharmacists prescribe?
- Varenicline (Champix)
- As well as other NRT's
*We cannot prescribe Bupropion
63
What are the 2 brands of Nicotine Polarcrilex Gum?
Nicorette and Thrive
64
Describe Nicotine Polarcrilex Gum
-one of the fastest delivery forms for nicotine other than smoking (time to peak is 20-30 min) via buccal mucosa, short duration of action
65
Nicotine Polarcrilex Gum:
| Half life ?
2 hours
66
Nicotine Polarcrilex Gum:
| What strengths are available?
2mg or 4mg
67
Nicotine Polarcrilex Gum:
| Can it be used in combination with other NRTs or bupropion?
Yes, but with caution.
*I don't think we are counselling on combination therapy in this lab.
68
When do you recommend 2mg gum?
-If they smoke their first cigarette after more than 30 minutes after waking up
OR
-Fagerstrom score less than or equal to 6
OR
-Smoke less than 25 cigarettes/day
69
When do you recommend 4mg gum?
-If they smoke their first cigarette in less than 30 minutes after waking up
OR
-Fagerstrom score greater than or equal to 7
OR
-Smoke 25 or more cigarettes/day
70
What are the directions for using the Nicotine Polarcrilex Gum?
- Chew one piece at a time, no more than 1 per hour
- 10-12 pieces/day initially up to a max of 20/day
- Chew and park between teeth and cheeks
- Repeat chew every minute or so
- Each piece lasts approximately 30 minutes
- Use for 12 weeks (1 piece/hour PRN)
- Taper off by one less piece per day each week!
*To reduce urges, best to use on a fixed schedule for the first month
71
Describe the Nicotine Gum: Tapering Dosing Scheduele
2nd month: one piece every 2-4 hours
3rd month: one piece every 4-8 hours
* Discontinue when using only 1 or 2 pieces of gum/day
* Products should not be used beyond 12 weeks
* If patient is still having difficulty (4th-6th month), Pt can chew one piece if urge to smoke returns
72
When should they consult a physician?
If still using the product after 6 months
73
What happens when nicotine gum is chewed too fast, too frequently, or using an incorrect chewing method?
- Nicotine is released too quickly
- Nicotine is then swallowed instead of absorbed through the buccal mucosa
- Reduces efficacy/results in unpleasant taste
- Leads to symptoms similar to over-smoking (nausea, hiccups, cough, light-headedness)
74
Describe the Bite-Bite-Park Technique for Nicotine Gum
**Always instruct patients to read product insert for proper technique
- Bite the gum gently (once or twice) to start the release of nicotine until a tingle is felt in the mouth
- Park the nicotine gum between the cheek and the gums
- After the tingle subsides (about 1 minute), bite again until the tingle returns, park the gum once again, repeat the process
- After approximately 30 minutes, the tingle stops and you can discard the gum
75
What are the 3 main indications for Nicorette gum?
1) Stop to Quit (most common)
- patients choose a quit date and initiate gum on that day to minimize withdrawal
2) Temporary Abstinence
- gum can be used in cases in which a smoker temporarily refrains from smoking (i.e. during long smoke-free flights)
3) Reduce to Quit (RTQ Method)
- the newest indication for users who are not ready or unable to quit abruptly
76
List some important drug/food interactions associated with NRT
- Avoid food/drink 15 minutes before and during use
- Acidic beverages (coffee, alcohol, soda, citrus fruit juice) may interfere with bioavailability or absorption of nicotine (decreases absorption)
77
Can you smoke while taking nicorette gum?
- Smoking with the gum (or any other NRT) is no longer contraindicated - especially with the RTQ method
- If patient decides to smoke while using an NRT, must monitor nicotine side effects and caution patient on nicotine toxicity
- Obviously smoking while taking NRTs is not ideal, but it can be done.
78
Why are NRTs not as addictive as cigarettes?
- slower onset
| - slower benefit
79
What are some common side effects of NRT gum?
- jaw pain, dental problems (CI'd in TMJ - temporomandibular joint disorders
- gum sticking to denture
- throat irritation, cough, hiccups
- unpleasant taste or taste alteration
- some dependence risk
- CNS: headache, dizziness, insomnia, irritability
- CV: chest pain, HTN, tachycardia
- GI: indigestion, nausea, flatulence (CI'd in gastric ulcers)
80
When is NRT gum CI'd?
- TMJ (temporomandibular joint disorders)
- gastric ulcers
- hypersensitivity to drug or any ingredient in formulation (DUH DRENA)
- Patients in the immediate post-myocardial infarction period, patients with life-threatening arrhythmias and pt with severe or worsening angina pectoris
- pregnant women
- breastfeeding mothers as nicotine is excreted in breast milk
- non-smokers (LOL)
- children under 18
81
What are some warnings and precautions with NRT gum?
-oral or pharyngeal inflammation, active peptic ulcer, hyperthyroidism, pheochromocytoma, insulin-dependent diabetes, severe renal insufficiency, uncontrolled hypertension
82
What are the 2 brands available for NRT lozenges?
Thrive
| Nicorette
83
When do the lozenges reach peak?
20-60 minutes
84
Lozenges:
| One main indication to quit?
stop to quit
85
Lozenges:
| Special instructions?
Do not eat or drink 15 minutes before (or during) lozenge use
86
Lozenges:
| Same side effects
ok
87
Lozenges:
| Describe the dosing regimen
For 6 weeks: One lozenge every 1-2 hours
For 3 weeks: One lozenge every 2-4 hours
For 3 weeks: One lozenge every 4-8 hours
88
Lozenges:
| When do you discontinue?
when using 1 or 2 lozenges per day
89
Lozenges:
| Do you chew the lozenges?
no
90
What strengths are available for Thrive lozenges?
1 or 2 mg (they last about 30 minutes)
91
When would you suggest 1 mg Thrive lozenge?
If a person smokes less than 20 cigarettes per day (or less than a pack per day)
92
When would you suggest 2 mg Thrive lozenge?
If a person smokes 20 or more cigarettes per day (or a pack or more per day)
93
Lozenges:
| What are the directions for use?
- suck on lozenge until strong taste, then "park" lozenge between cheek and gum
- when the taste diminishes, repeat
94
Lozenges:
| Max per day of 1 mg Thrive lozenges?
25 lozenges
95
Lozenges:
| Max per day of 2 mg Thrive lozenges?
15 lozenges
96
What strengths are available for Nicorette lozenges?
2 and 4 mg strengths available (lasts about 10 mins)
97
When would you recommend 2 mg Nicorette lozenge?
If first cigarette is > 30 minutes after waking
98
When would you recommend 4 mg Nicorette lozenge?
If first cigarette is < 30 minutes after waking
99
Special directions for Nicorette lozenges?
- Once lozenge is in mouth, move intermittently from one side to other side of mouth.
- Try to avoid swallowing while lozenge is in mouth.
100
Max dose per day for nicorette lozenges?
15 lozenges for both strengths
101
What is the conversion between Thrive and Nicorette lozenges?
Thrive 1mg = Nicorette 2 mg
| Thrive 2 mg = Nicorette 4 mg
102
Directions to use the NRT: Mouth Spray
**Max concentration reached after 13 mins
- First time: point nozzle away and press top of dispenser several times until fine mist. May need to repeat if spray has not been used for 2 or more days.
- Point nozzle towards open mouth, holding as close as possible
- Press top of dispenser for release of one spray into mouth (avoid lips)
- Do not inhale while spraying, avoid swelling for a few seconds after spraying
* *contains ethanol
- not for alcoholics
- not for pregnant women
103
Dose of Nicorette Quick Mist
1 or 2 sprays when you normally smoke a cigarette or having a craving to smoke. Use 1 spray first and if craving does not disappear within a few minutes, use second spray.
If 2 sprays needed, future doses may be delivered as 2 consecutive sprays.
Most smokers: 1-2 sprays every 30 minutes to 1 hour
104
Max dose of Nicorette QuickMist?
2 sprays at a time, 4 sprays per hour, 64 sprays per day
105
Dosing schedule of Nicorette: Quick Mist?
- Use when a cigarette would have been smoked or if having a craving
- During weeks 1-6, use prn up to 1-2 sprays every 20 mins
- By weeks 7-9: decrease by 50% average number of sprays per day
- By weeks 10-12: use 2-4 sprays per day
- Discontinue after week 12
106
When do nicotine levels of NRT transdermal patches peak?
2-6 hours
107
Nicoderm patches are _____-controlled
system
* Nicotine release regulated by a rate-controlling membrane
* Releases nicotine at a constant rate - predictable
* Adhesive contains nicotine
108
Habitrol patches are _____-controlled
skin
* Nicotine release regulated by the rate at which the nicotine can cross the individual's skin
* Rate of release dependent on individual's skin permeability
* Adhesive does not contain nicotine
*Nicotine levels will change if person's temp increases from exercise or showering, etc.
109
Dosing schedule for Nicoderm patches?
21mg for 6 weeks
14mg for 2 weeks
7mg for 2 weeks
OR
14mg for 6 weeks
7mg for 2 weeks
*for those who smoke less than 10 cigarettes daily, those weighing less than 45 kg (100lbs), or those with cardiac/heart disease.
110
Dosing schedule for Habitrol patches?
21mg for 4 weeks
14mg for 2 weeks
7mg for 2 weeks
OR
14mg for 6 weeks
7mg for 2 weeks
*for those who smoke less than 10 cigarettes daily, those weighing less than 45 kg (100lbs), or those with cardiac/heart disease.
111
Patch application
- Patch stays on for 24 hours
- Patch site should be: clean, non-hairy, dry
- Apply pressure to patch for 10 seconds on application
- Apply every morning for 24 hour patch
- Rotate sites frequently
112
Common SE of the patch
- local skin irritation
| - sleep disturbances (remove at night if this occurs)
113
CI of the patch
- Patients with skin disorders
- Immediate post-MI patients
- Patients with life-threatening arrhythmias, and patients with severe angina pectoris
- Pregnant women
- Breast feeding mothers (nicotine is excreted in breast milk)
- Non smokers or occasional smokers and those under 18
114
Dosing with the nicotine inhaler ?
- Each 10 mg cartridge delivers 4 mg nicotine (2 mg systemically absorbed)
- One cartridge = one cigarette
- 15 minutes to peak effect
- One cartridge lasts 20 mins with frequent and continuous puffing
- Can puff for 5-10 minutes at a time as you would a cigarette
- Wash mouthpiece daily with soap and water
- Cartridge food for 24 hours once punctured
115
Dosing schedule for Nicotine Inhaler
- First 6-12 weeks: use 1 cartridge as needed (whenever you get a craving)
- Max # of cartridges is 6-12 per day
- Dosing is gradually reduced to a few cartridges a day
- Stop using inhaler when the daily use is reduced to 1-2 per day
116
Common SE with nicotine inhaler?
cough
throat irritation
pharyngitis
117
With nicotine inhaler: Avoid ??
drinking acidic beverages such as coffee, tea, soft drinks when using the inhaler
118
Nicotine inhaler has same CI as nicotine patches: What are they?
- Immediate post-MI patients
- Patients with life-threatening arrhythmias, and patients with severe angina pectoris
- Pregnant women
- Breast feeding mothers (nicotine is excreted in breast milk)
- Non smokers or occasional smokers and those under 18
119
Safety precautions with NRTs?
- store away from children and pets
| - ensure proper disposal
120
What combo therapies are options?
Combo of:
- patch and gum or lozenge or inhaler
- buproprion and an NRT
121
Describe the MOA of bupropion in Smoking Cessation
- Though to be independent of antidepressant activity.
- Increases mesolimbic reward system Dopamine (DA) and Norepinephrine (NE) levels and blocks brain nicotinic receptors involved in tobacco addiction.
122
Describe bupropion in Smoking Cessation
- 150 mg SR tablets (Rx)
- Dosing: 1 tablet daily for 3 days, then increase to 1 tab BID for the remaining 12 weeks (not to exceed 300mg/day), no tapering required
- Slower onset: may take 1-2 weeks
- Set quit date for 1 week after starting Tx
123
Benefits of bupropion in Smoking Cessation
- reduces withdrawl symptoms and cravings
- less weight gain
- cheapest alternative overall
124
SE's of buproprion
insomnia
agitation
Gi upset
dry mouth
125
CI's of buproprion
- personal or family history of seizures or eating disorders, patients on MAOi agents (within 14 days)
- excessive alcohol users
126
Can bupropion be used in pregnancy?
yes
127
_____ is a non-nicotine agent
Champix - Varenicline
128
Describe Champix - Varenicline
- newest smoking cessation therapy
- binds specifically to alpha4/beta2 receptors preventing binding of nicotine to these same receptors (mesolimbic system)
- decreases the sense of satisfaction and reward that would normally come from nicotine (smoking)
129
Describe the dosing of Champix - Varenicline
-slow onset of action/long acting
```
Dosing regimen:
Days 1-3: 0.5mg OD (3 tabs)
Days 4-7: 0.5mg BID (8 tabs)
Days 8-14: 1mg BID (14 tabs)
*Then continue til the end of treatment.
```
Set quit date 1-2 weeks after start of Tx
Total of 12 weeks generally
130
Common SE's of Champix - Varenicline
nausea
insomnia
fatigue
131
Champix - Varenicline should not be combined with ____
NRTs
132
Describe Nortriptyline in smoking cessation
- antidepressant
- 3rd line agent - off label use for SC
75-100 mg OD
start 10-28 days before quitting and use for 12 weeks
133
SE of Nortriptyline
sedation
dry mouth
blurred vission
134
CI's for Nortriptyline
ECG abnormalities
| suicide/seizure risk
135
Describe Clonidine in smoking cessation
- 3rd line agent - off label use for smoking cessation
- used for various addictions (narcotics, alcohol)
- 0.15-0.45 mg/day PO for 12 weeks
- may be useful in cardiac/HTN patients
136
SE's of clonidine
dry mouth
sedation
dizziness
137
List some herbal or alternate therapies
1) Resolve - actually was withdrawn from market
- contained cestemenol-350
- potential health risks of liver, kidney or RBC damage
2) Hypnotherapy
and
3) Acupuncture
*may be useful for some patients as add-ons
**Evidence for herbal/alternate therapies is lacking
138
Are eCigarettes helpful in quitting smoking?
- We do not know
- Hand to mouth motion may be beneficial
- They are advertised as a healthier option to quitting smoking (less tar and chemicals) but are not approved by Health Canada as a smoking cessation tool.
139
Describe the Immunization idea that is underway for smoking cessation
- Goal is to stop all cigarette and nicotine cravings and therefore smoking cessation would be easy.
- Biological effect is to be produced by causing an immunologic response to nicotine. It is then quarantined by nicotine-specific antibodies causing a reduction in available nicotine to have a response in the CNS and reduce response in the dopamine and reward pathway
140
While quitting smoking, you have increased levels of _____
caffeine
141
Special populations in smoking cessation ?
- pregnancy
- high risk CVD
- under 18
142
Pregnant patients who want to quit smoking are an automatic ______
Referral dude
143
What is smoking in pregnancy associated with?
- low birth weight
- spontaneous pregnancy loss
- preterm delivery
144
Can bupropion be used in CV patients?
No - raises BP
145
Can clonidine be used in CV patients?
yes - lowers BP
*caution regarding rebound hypertension upon discontinuation
146
Can varenicline be used in CV patients?
No - health canada warning
147
How do we treat adolescents (under 18) for SC (smoking cessation)?
- start with non-pharms always
| - then refer to a physician for an NRT
148
Does nicotine in the NRT products have the same addictive potential as nicotine in the cigarettes?
- Nicotine's addictive potential determined by rate and route of administration
- Cigarettes are highly addictive because of rapid delivery of nicotine (10 seconds) to the mesolimbic reward pathways in brain
- Rapid, intense, repeated brain exposure = addiction
-In general, NRT does not have the same addictive potential - much less (still caution with gum more so than the patch)
