Exam 3: Smoking Cessation Flashcards
(132 cards)
1
Q
5 A’s of Smoking Cessation
A
Ask - identify users Advise - encourage quitting Assess - willingness Assist - aid Arrange - f/u
2
Q
T/F: You should encourage strict dieting when quitting smoking
A
False - encourage healthful diet and meal planning, increase water intake or chew sugarless gum, non-food rewards
3
Q
On avg, quitters gain ___lbs
A
9-11lbs
- smoking can cause dullness in taste buds? nicotine appetite suppressant?
- Oral fixation replaced with snacking?
4
Q
How long do withdrawal symptoms last?
A
start first 1-2 days, peak within first week
Most pass within 2-4 weeks after quitting, cravings can last longer (months-years)
5
Q
How should patients deal with smoking after meals?
A
Need to disassociate behaviors
- immediately get up from table
- brush teeth
- take short walk
- call a supportive friend
6
Q
T/F: Smoking tobacco is the only harmful form of tobacco
A
False - all forms of tobacco are harmful
7
Q
How many cigarettes in a pack
A
20 cigs/pack
8
Q
How many packs in a carton?
A
10 packs/carton, 200 cigs/carton
9
Q
Machine measured Average nicotine yield per cig?
A
0.9mg
10
Q
Machine Measured Full-flavor (regular) nicotine yield per cig?
A
1.1mg
11
Q
Machine measured Light nicotine yield per cig?
A
0.8mg
12
Q
Machine measured Ultra-light nicotine yield per cig?
A
0.4mg
13
Q
Smoker’s nicotine yield per cig
A
1-2mg
14
Q
Total nicotine content per cig
A
avg 13.5mg (range 11.9-14.5mg)
15
Q
E-cig liquid components
A
Propylene glycol
Glycerin
Flavorings
Nicotine
16
Q
Potential health risks of e-cig
A
Propylene glycol may cause respiratory irritation (increased risk of asthma)
Glycerin may cause lipoid pneumonia on inhalation
Nicotine is highly addictive (refill carts with high conc of nic are poisoning risk)
Carcinogens
17
Q
T/F: E-cigs are safer alternative to smoking tobacco
A
False - e-cigs not proven to be safe
18
Q
T/F: Second hand exposure to e-cigs is harmless
A
False - long term safety is unknown
19
Q
T/F: E-cigs are recommended for treatment purposes
A
False - long-term safety and efficacy data are lacking
20
Q
Nicotine Absorption: In acidic media
A
Ionized, poorly absorbed across membranes
21
Q
Nicotine absorption: In Alkaline media
A
Nonionized, well absorbed across membranes
22
Q
At physiologic pH, ~31% of nicotine is _____
A
Physiologic pH = 7.4
Nonionized –> readily absorbed
23
Q
Buccal mucosa and nicotine absorption
A
pH = 7.0
Acidic - cigarettes
Alkaline - pipes, cigars, spit tobacco, oral nicotine products (even if not inhaling, nic is absorbed)
*beverages can alter pH, alter absorption
24
Q
Skin and nicotine absorption
A
Nicotine is readily absorbed through intact skin (helpful for transdermal products!)
25
GI Tract and nicotine absorption
Nic well absorbed in small intestine but low bioavailability due to first pass metabolism (why we don't use nic tabs)
26
Lung and nicotine absorption
Nicotine "distilled" from burning tobacco and carried in tar droplets
pH=7.4, readily absorbed
Large alveolar surface area, extensive capillary system in lungs
27
How long does it take for nicotine to reach the brain?
10-20 seconds
28
There is a quick spike in ___ plasma conc of nicotine compared to ____
Arterial plasma vs venous
29
T/F: Rapid high levels of plasma conc of nicotine reinforces behavioral act of administration
True
30
Nicotine effects on CNS
Pleasure
Arousal, enhance vigilance
Improved task performance (focus)
Anxiety relief
31
Nicotine effects on CV system
Increased HR, CO, BP
Coronary vasoCONSTRICTION
Cutaneous vasoCONSTRICTION
32
Other nicotine effects
Appetite suppression
increased metabolic rate
sk muscle relaxation
33
Dopamine effects
pleasure
| appetitie suppression
34
NE effects
arousal, appetite suppression
35
ACh effects
Arousal
| cognitive enhanacement
36
Glutamate effects
Learning, memory enhancement
37
Serotonin effects
Mood modulation, appetite suppression
38
Beta-Endorphin effects
Reduction of anxiety and tension
39
GABA effects
reduction of anxiety and tension
40
Dopamine reward pathway usually stimulated by behaviors we need for survival of our species like ...
eating, drinking, sex
41
What is the effect of upregulation of nicotine receptors
Tolerance, need more to have same effect
42
Smokers have an ____ of nicotine receptors
upregulation
43
Withdrawal symptoms
```
Irritability/frustration/anger
anxiety
difficulty concentrating
restlessness/impatience
depressed mood/depression
insomnia
impaired task performance
increased appetitie
weight gain
cravings
```
44
Tobacco smoke and caffeine
PAH induces CYP1A2, metabolizes caffeine more (caffeine levels increase when you quit, may experience insomnia, recommend to decrease caffeine 50% and no caffeine after 1pm)
45
Tobacco smoke and hormonal contraceptives
smokes who use combined hormonal contraceptives have increased risk of stroke, MI, thromboembolism
* esp if ≥35yo and smoke at least 15 cigs/day
* does not decrease effect of contraceptives
46
T/F: You can restore original pulmonary function when you quit smoking
False -- some irreversible damage but can still regain good amount, beneficial at any age
47
Tobacco dependence: Physiological >> solution
Addiction to nicotine >> medications for cessation
48
Tobacco dependence: behavioral >> treatment
Habit of using tobacco >> behavior change program
49
What is QuitKey
an assisted taper based on pt's smoking level
| includes telephone counseling support
50
What is a good telephone counseling quitline
1-800-QUIT-NOW
51
Nonpharmacologic method examples
```
Cold turkey
Assisted tapers
Formal cessation programs (counseling, self help, group, telephone, web-based)
Acupuncture
Hypnotherapy
Massage therapy
```
52
Brief counseling
Ask
Advise
Refer
53
Smoking cessation pharmacotherapy not recommended for...
pregnant smokers (not enough evidence)
smokeless tobacco user (no FDA indication)
Smokers <10 cigs
Adolescents (need rx if <18)
54
NRT products approx. ___ quit rates
doubles
55
Components of nicotine gum
Resin complex (nicotine, polacrilin)
Sugar-free chewing gum base
Buffering agents to enhance buccal absorption (increase pH)
56
Nicotine gum dosing
2mg, 4mg
57
Nicorette
Nicotine polacrilex gum
58
Directions for use of nicotine gum
Chew slowly, stop chewing when tingle or peppery taste, park between cheek and gum, chew again when tingle/taste stops
~30min/piece
59
Nicotine gum ADE
```
Mouth and throat irritation
hiccups
Gi complaints (dyspepsia, nausea)
Jaw muscle ache
May stick to dental work
```
60
Nicotine lozenges dosing
2mg, 4mg
61
Components of nicotine lozenges
Nicotine polacrilex formulation - delivers ~25% more nicotine than equivalent gum dose
Sugar-free
Buffering agents to enhance buccal absorption of nic
62
Nicotine lozenges direction of use
Place in mouth and allow to dissolve slowly (may feel warm/tingly)
Do not chew or swallow
Rotate
takes 20-30min
63
Nicotine lozenges ADE
Mouth and throat irritation
Hiccups
GI complaints (dyspepsia, nausea)
64
Choosing dosing for gum/lonzenges
Time to first cigarette (TTFC)
2mg - if cig >30min after waking
4mg - if cig ≤30min within waking
65
Gum/lozenges dosing schedule
1-6 weeks 1 piece q1-2h
7-9weeks 1 piece q2-4h
10-12 weeks 1 piece q4-8h
*to increase changes of quitting use at least 9 pieces/day during first 6 weeks
66
Max pieces of gum/day
24 pieces
67
Max pieces of lozenges/day
20 lozenges
68
Effectiveness of nicotine gum/lozenges may be reduced by foods/beverages ...
coffee, wine, juices, soft drinks
69
Do not eat/drink ____ before or while using gum/lozenges
15 min before
70
Chewing lozenges or incorrect gum chewing technique can cause excessive/rapid release of nicotine which may cause side effects of ...
lightheadedness/dizziness
N/V
Hiccups
Irritation of throat and mouth
71
Advantages of gum/lozenges
Might serve as oral sub for tobacco
Might delay weight gain
Can be titrated to manage withdrawal symptoms
Can be used in combination with other agents to manage situational urges
Relatively inexpensive
72
Disadvantages of gum/lozenges
Need frequent dosing (adherence)
GI adverse effects may be bothersome
Specific to gum - might be problematic for pts w sig dental work, proper chewing technique required, chewing might not be acceptable/desirable for some pts
73
Nicotine transdermal patch examples
Generic
| NicoDerm CQ
74
Advantages of transdermal patch
```
once-daily dosing (adherence)
Less obvious NRT product option
Can be used in combo with other agents, delivers consistent nicotine levels over 24 hrs
Relatively inexpensive (OTC, usually covered by insurance)
```
75
Disadvantages of transdermal patch
When used as monotherapy, cannot be titrated to acutely manage withdrawal (short acting use like gum/lozenges is better)
Not recommended for pts with dermatologic conditions
76
Nicotine transdermal dosing: Light smoker ≤10cigs/day
```
Step 2 (14mg x 6weeks)
Step 3 (7mg x2weeks)
```
77
Nicotine transdermal dosing: Heavy smoker >10cigs/day
```
step 1 (24mg x6 weeks for brand, x4 weeks for generic)
Step 2 (14mg x2 weeks)
Step 3 (7mg x2 weeks)
```
78
Pt counseling for transdermal patches
Choose area of skin on upper body or upper outer part of arm
Make sure skin is clean, dry, hairless, and not irritated
Apply to different area each day (do not repeat area for at least 1 week)
Wash hands (nicotine on hands can irritate eyes/nose
Do not leave for over 24 hrs (can cause irritation)
Remove sticky residue with alc or acetone
Fold patch onto itself when throwing out
79
T/F: You can cut nicotine patches in half to save money
False - unpredictable nicotine delivery
80
Please remove nicotine patch before ___
MRI procedures
81
If applied correctly, you can ___ with nicotine patch
bathe, swim, shower, and exercise
82
ADE Nicotine patches
```
Irritation at patch application site (itching, burning, tingling)
Sleep disturbances (remove before bedtime if so -- abnormal/vivid dreams, insomnia)
Skin may be red when you remove (if longer than 4 days or swell/rash then might be allergic)
```
83
Nicotine inhaler absorbed by ___
Mostly buccal mucosa, little absorbed in lungs
84
Advantages of nicotine inhaler
Might serve as oral sub for tobacco
Can be titrated to manage withdrawal symptoms
Mimics hand to mouth
Can be used in combo with other agents
85
Disadvantages of nicotine inhaler
Need for freq dosing (adherence)
Cartridges may be less effective in cold
cost of treatment
86
Nicotine inhaler ADE
Mild irritation of mouth/throat
cough
hiccups
GI complaints (dyspepsia, nausea)
*severity generally rated as mild, frequency declines with continued use
87
Counseling pts for nicotine inhaler
Use inhaler at room temp (>60F)
Use inhaler longer and more often at first to control cravings (freq continuous puffing over 20 min)
Effectiveness of nicotine inhaler may be reduced by some foods/bevs (absorbed via buccal)
Do not eat/drink 15min before or during use
88
Nicotine Nasal Spray examples
Nicotrol NS
89
Nicotine Inhaler exampels
Nicotrol
90
Nicotine nasal spray doses/bottle
100 doses/bottle (1 dose = 2 sprays (1 per nostril = 200 sprays/bottle)
91
Advantages of nasal spray
Can be titrated to rapidly manage withdrawal symptoms
| Can be used in combo with other agents
92
Disadvantages of nasal spray
Need for freq dosing (adherence)
Nasal admin might not be acceptable/desirable for some pts (nasal irritation often problematic)
Not recommended for pts with chronic nasal disorders or severe reactive airway disease
Cost of treatment
93
T/F: You can blow your nose right after using nasal spray
False - wait 2-3 min before blowing nose
94
T/F: Sniff/inhale as you spray nicotine nasal spray
False - do not
95
Pt Counseling for nasal spray
1st week - hot peppery feeling in back of throat or nose, sneezing, coughing, watery eyes, runny nose
ADE lessen over few days (regular use during first week helps tolerance of irritant effects)
If ADE persist after a week, contact PCP for alternative
96
Bupropion SR brand
Wellbutrin for antidepressant
| Zyban for smoking cessation
97
Non-nicotine cessation aid example
Bupropion SR
| Varenicline
98
Bupropion SR: MOA
Atypical antidepressant through to affect levels of various brain NT like dopamine and NE
99
Clinical effects of bupropion SR
Decrease craving for cigs and decrease symptoms of nicotine withdrawal
100
Bupropion absorption
Bioavailability 5-20%
101
Bupropion SR metabolism
extensive hepatic metabolism (CYP2B6)
102
Bupropion SR elimination
urine (87%) and feces (10%)
103
Half-life of bupropion
21 hrs
| Metabolites (20-37hrs)
104
Advantages of bupropion SR
```
Oral dosing is simple, associated with fewer adherence problems
Might delay weight gain
Might benefit pts with depression?
Can be used in combo with NRT agents
Relatively inexpensive (generic)
```
105
Disadvantages of bupropion SR
Seizure risk is increased
Several CI and precautions
Monitor for neuropsychiatric symptoms
106
When should pts begin bupropion SR therapy?
1-2 weeks PRIOR to quit date
107
Initial treatment of bupropion SR
150mg po qAM for 3 days
108
Maintenance dosing for bupropion SR
150mg po bid for 7-12 weeks
Doses at least 8 hrs apart
Tapering not necessary when discontinuing therapy
109
Bupropion SR ADE
Insomnia (avoid bedtime dosing)
Dry mouth
Nausea
Less common but reported effects: anxiety/difficulty concentrating, constipation, tremor, skin rash
110
Bupropion SR CI
Pts with seizure disorder (lower seizure threshold)
Pts with bulimia or anorexia nervosa (electrolyte abnormality can lead to seizure)
Pt undergoing abrupt d/c of alc, benzos, barbiturates, and antiepileptic drugs
MAOi (within 14 days of initiating or d/c therapy)
111
Bupropion SR BBW
Neuropsychiatric symptoms and suicide risk, later removed in Dec 2016
112
Varenicline brand
Chantix
113
Varenicline MOA
Partial nicotinic receptor agonist
Competitively inhibits binding of nic
Decreases symptoms of nicotine withdrawal
Blocks dopaminergic stimulation responsible for reinforcement and reward associated with smoking
114
Varenicline absorption
virtually complete (~90%) after oral admin, not affected by food
115
Varenicline metabolism
Minimal metabolism
116
Varenicline elimination
Primarily renal thru glomerular filtration and active tubular secretion
92% excreted unchanged in urine
117
Varenicline half life
24 hrs
118
Advantages for varenicline
Oral dosing is simple (less adherence problems)
Offers diff MOA for pts who failed other agents
Most effective agent for cessation when used as monotherapy
119
Disadvantages for varenicline
Cost of treatment
| Monitor pts for potential neuropsychiatric symptoms
120
Which cessation agent is most effective as monotherapy?
Varenicline
121
Varenicline Day 1-3 dosing
0.5mg qd
122
Varenicline Day 4-7 dosing
0.5mg BID
123
Varenicline Day 8-last day (up to 12 weeks)
1mg BID
124
3 approaches to varenicline
Fixed quit, flexible quit, gradual quit
125
Fixed quit approach for varenicline
Set quit date for 1 week after starting varenicline
| Continue treatment for 12 weeks
126
Flexible quit approach for varenicline
start taking varenicline and pick quit date between 8-35 days from treatment initiation
Continue for 12 weeks
127
Gradual quit approach for varenicline
Start taking varenicline and reduce smoking by 50% within first 4 weeks, an additional 50% in next 4 weeks, and continue until complete abstinence by 12 weeks
128
Varenicline ADE
Nausea, insomnia, abnormal dreams, headache
Less common: GI (flatulence, constipation), taste alteration
129
Varenicline BBW
Neuropsychiatric symptoms and suicide risk, later removed
130
Pt Counseling for varenicline
Doses should be taken after eating with a full glass of water
Nausea and insomnia are usually temporary (if persistent, contact PCP)
May experience vivid, unusual, strange dreams during treatment
Use caution driving, drinking alc, and operating machinery until effects of quitting smoking with varenicline are known
131
Combo NRT
Long-acting (patch) + short-acting (Gum, inhaler. lozenge, nasal spray)
Bupropion SR + nicotine patch (1.5x likelihood of sustained quit)
132
Compare cessation options
Combo NRT and varenicline are more effective than bupropion SR or NRT monotherapy
