Exam #2: Treating Nicotine Dependence

Question 1

What are the big three tobacco products?

Answer 1

1) Cigarettes
2) Smokeless
3) Cigars/ pipes

Question 2

What are the physiologic effects of nicotine?

Answer 2

Epinephrine is released leading to:

1) Increased HR, BP, RR
2) Suppressed insulin output
3) Sudden glucose release

DA dump leads to feelings of pleasure

Question 3

What pathologies do the physiologic effects of nicotine lead to?

Answer 3

• Heart disease
• Lung disease
• DM

Question 4

Why does tobacco meet the definition of addiction?

Answer 4

Tobacco induces:

1) Tolerance
2) Withdrawal
3) Continued use in spite of harm

Question 5

What is the definition of a cigarette? What is the nicotine dose of a cigarette?

Answer 5

Any roll of tobacco wrapped in paper or substance not containing tobacco
- 21mg of inhaled nicotine per pack

Question 6

Why is menthol put in cigarettes?

Answer 6

Mild anesthesia

Question 7

What is snus?

Answer 7

• Parked in upper lip and gum
• Marked to women
• No spitting

Question 8

What is snuff?

Answer 8

Snorted

Question 9

How many packs of cigarettes is tin of Kodiak equal to?

Answer 9

4 packs

Question 10

What causes cancer in smokeless tobacco?

Answer 10

TSNA (Tobacco Specific Nitrosamines)

Question 11

How is smokeless tobacco manipulated to increased absorption?

Answer 11

Free basing decreases acid levels and increases salivation

Question 12

What is the definition of a cigar? What is the nicotine dose of a cigar?

Answer 12

Any roll of tobacco wrapped in TOBACCO
- 100-444mg of nicotine

Doesn’t have to be smoked to be absorbed

Question 13

What are the 5 A’s?

Answer 13

• Ask= Id users
• Advise= urge to quit
• Assess= determine willingness to quit
• Assist= aid the patient
• Arrange= schedule follow-up

Question 14

What are the 5 R’s?

Answer 14

• Relevance= why is it personal
• Risks= id. consequences
• Rewards= id. benefits
• Roadblocks= what are barriers
• Repetition= re-eval w/ each visit

Question 15

What is NRT?

Answer 15

Nicotine Replacement Products

*No TSNAs

Question 16

What is the “patch” as an NRT? Why do these need to be bridged with an alternative source of nicotine?

Answer 16

Long-acting nicotine

- 21mg dose but ONLY 17mg absorbed, which is LESS than a normal pack of cigs

Question 17

How long do people need to be on the patch?

Answer 17

6 months

Question 18

Should patients wear the patch at night?

Answer 18

Yes, but they can take it off with “bad dreams”

Question 19

What are gum and lozenges used for?

Answer 19

Breakthrough cravings i.e. bridge the patch

Question 20

When do patients get have a peak absorption from gum or lozenge? What is the implication?

Answer 20

15-20 min.

Need to take BEFORE they would have normally smoked

Question 21

What is bupropion? What is the mechanism of action?

Answer 21

• Wellbutrin, an antidepressant that increases DA reward, mimicking nicotine
• Nicotine receptor blocker

Question 22

What patients should NOT use wellbutrin?

Answer 22

Seizure hx 
Brain tumor 
CVA 
Brain surgery 
Alcoholics 
Anorexia/ Bulimia 
Hx of abuse 
LOC >30 min 
Skull Fx 
Inter-cranial bleed

Question 23

What is Varenicline? What is the mechanism of action?

Answer 23

Chantix

• Binds nicotine receptor and activates it; also blocks nicotine

Question 24

What should Chantix be taken with?

Answer 24

Water and a banana

Question 25

What patients is Chantix contraindicated with?

Answer 25

• Pilots
• Heavy equipment user
• Seizure hx.

Question 26

What is the best treatment for spit tobacco users?

Answer 26

Chantix

Question 27

What other NRTs can spit tobacco users besides Chantix?

Answer 27

Gum, Patch, Lozenge

NOT nasal spray or oral inhaler*

Question 28

How do you determine the dose effectiveness of NRTs?

Answer 28

Too much= nausea

Too little= cravings

Question 29

Why not use nasal spray or oral inhaler?

Answer 29

Very expensive

300-500 dollars a months

Question 30

What does nicotine do the caffeine?

Answer 30

Increases clearance b/c of CYP1A2 induction

Question 31

What is the relationship between opiates and smoking?

Answer 31

Need more pain medication than non-smokers

Question 32

What do you need to be weary of in spit tobacco users? Why?

Answer 32

Spit tobacco= high level Vitamin K

Dose of coumadin can be v. high–>MUST CHECK PT/INR to ensure no risk of bleeding when quitting

Question 33

How many cigs is 45 minutes of hookah use equivalent to?

Answer 33

60

Question 34

During 45 minutes of hookah use, what is the carcinogen dose?

Answer 34

50x higher

Charcoal used to burn tobacco increased the carcinogen dose.

Question 35

What are the drawbacks to e-cigs?

Answer 35

• No regulation
• Cannot control nicotine/ titrate
• Contains propylene glycol–>carcinogen
• Vegetable glycerin–>pneumonia (suppository)
• Contain NSTAs

Question 36

What is the danger of e-juice or smoke juice used in e-cigs?

Answer 36

• Contain v. concentrated nicotine doses that exceed lethal nicotine dose for children
• Approach adult nicotine dose

Question 37

What is the effect of SHS exposure in utero?

Answer 37

Increases the risk of SIDS

Question 38

What are teen smokers at higher risk for?

Answer 38

• Depression

- Suicide

Question 39

What is third hand smoke?

Answer 39

• Nicotine deposits and gets re-aerosolized

- Contains TSNAs