Smoking Cessation

Question 1

How does nicotine dependence work?

Answer 1

There’s a physiological and psychological addiction

Pharm effect = acts as agonist at nicotine Ach receptor in peripheral & CNS –> through BB to cortex and hippocampus –> release of NA, DA, 5HT, Ach –> anxiety relief, reduced hunger, improved task performance, tachycardia, vasocon, skeletal muscle relax, pleasure, inc metabolic rate

Question 2

What is the role of the pharmacist in smoking cessation

Answer 2

Raise awareness of:

Health risks = lung cancer, heart disease, erectile dysfunction

RIsks for non-smoking fam members and contacts = coughing, headaches, childhood illness

Maternal risks = reduce O2 to baby, affects fetal heartbeat/breathing, inc risk of ectopic preg

Benefits of quitting = improved taste, smell, exercise tolerance

Quitting strategies

Question 3

Prior to stopping smoking, what does the pharmacist need to determine

Answer 3

Assess level of nicotine dependence, strategies for dealing with cravings

Assess barriers to quitting, assess stage of change, patient motivations

support

sell benefits of quitting

Question 4

What questions are asked to assess nicotine dependence?

Answer 4

How many minutes after waking to first cigarette?

Number of cigarettes per day?

Craving or w/drawal symptoms in previous attempts?

Question 5

What are the stages of change?

Answer 5

Pre-contemplation

contemplation

preparation

action

maintenance

Question 6

Discuss the pre-contemplation stage of change

Answer 6

smoked not thinking about quitting in next 6 months

Question 7

Discuss the contemplation stage of change

Answer 7

smoker begins to think seriously about quitting in next 6 months

Question 8

Discuss the preparation stage of change

Answer 8

Quit attempt is planned within next 30 days

Question 9

Discuss the action stage of change

Answer 9

quit attempt is made lasting for at least 24 hrs

Question 10

Discuss the maintenance stage of change

Answer 10

Person becomes a non-smoker for at least six months

Question 11

What drugs interact with smoking?

Answer 11

Smoking induces CYP1A2 and CYP2B6 (NRT) does not influence theres

CYP1A2 activity = inc clearance of drugs (abrupt smoking, new SS CYP1A2 activity will be reached in 1 weeks)

Stop smoking = reduction in enzyme activity –> reduces clearance and inc risk of ADRs

Question 12

Discuss NRT use in smoking cessation

Answer 12

First line for all motivated smokers, all equally effective –> abrupt smoking cessation is better

Question 13

What S4 drugs are available to treat smoking cessation?

Answer 13

1) Varenicline = equal to NRT but superior efficacy to NRT monotherapy

2) Bupropion

Question 14

What considerations are made for pharmacotherapy in smoking cessation?

Answer 14

Previous exp with pharmacotherapy

Cost and convenience

adherence issues

script meds versus OTC

potential for ADR

possible drug interactions

Question 15

Discuss NRT patches for smoking cessation

Answer 15

ADRs = headache, dizzy, vomiting, vivid dreams, skin irritation

Apply to non-hairy, clean and dry area of body, rotate each day

Good for high dependence smokers

Question 16

Discuss NRT gum for smoking cessation

Answer 16

ADRs = headache, dizzy, N/V, irritation of throat/mouth, dyspepsia

Chew slowly until taste becomes strong/tingly, park in cheek for 30 mins

Question 17

Discuss NRT inhaler for smoking cessation

Answer 17

used based on cravings

ADRs = cough, mouth/throat irritation, headache, dizzy, N/V

shallow puffs every 2 seconds or 4 deep puff per min

Question 18

Discuss NRT oral film/strips for smoking cessation

Answer 18

ADRs = hiccups (and the others)

DO not chew or swallow, allow to dissolve

Quick acting

Question 19

Discuss NRT lozenge for smoking cessation

Answer 19

Good for heavy dependence

ADRs = same as others

allow to dissolve, dont chew, last around 20-30 mins

Question 20

Discuss NRT oral spray/mist for smoking cessation

Answer 20

ADRs = like others, burning lips, indigestion

Used prn, side of cheek or under tongue

Question 21

Discuss the reasoning behind NRT dual therapy

Answer 21

Two NRT products are more effective

Patches = steady release
Oral forms = fast relief from cravings

Question 22

When is dual NRT therapy recommended?

Answer 22

1st line for those who smoke and are nicotine dependent

Unable to quit using NRT monotherapy

experience cravings using NRT monotherapy

Question 23

Discuss the mechanism of Varenicline

Answer 23

Nicotine receptor partial agonists

In absence of nicotine = reduces withdrawal and cravings

In presence of nicotine = blocks nicotine’s ability to bind with receptors (no pleasure)

There are changes in mood, behaviour, and suicidal thoughts

Question 24

How and why is Varenicline’s dose titrated?

Answer 24

The dose is titrated due reduce the occurrence of nausea during the initial phases of treatment

Day 1-3 = 0.5 mg once daily
Day 4-7 = 0.5 mg twice daily
Day 8 onwards (11-23 wks) = 1 mg twice daily

Question 25

What are some counselling points for varenicline?

Answer 25

Start taking at least a week before you stop smoking
swallow tablet whole, dont chew or crush
May feel nauseous when taking this, can take with food to help this

Monitor for unusual mood changes, behaviour disturbances, depression, or suicidal thoughts

Finishing this treatment, can cause temporary increases in cigarette craving, irritability, and insomnia –> use fast acting product on hand

follow up with Dr 2-3 wks after starting

Question 26

Briefly discuss some properties of bupropion

Answer 26

Antagonist at nicotinic cholinergic receptor, reduced urge to smoke, improve symptoms of withdrawal

As effective as NRT but less effective than varenicline

Drug interactions with antidepressants due to inhibition of CYP2D6 and metabolised by CYP2B6

Question 27

When should bupropion not be used?

Answer 27

Hx of seizures, anorexia/bulimia

CNS tumours
alcohol/benzodiazepines w/drawal, use with MAOi

Question 28

What are some counselling points for bupropion use

Answer 28

Start taking at least a week before you stop smoking
Take in morning to minimise sleep disturbances
swallow tablets whole, do not crush or chew

Only drink small amounts of alcohol or avoid all together, inc risk of fits and other ADRs
Use alongside NRT to improve effectiveness

Use with caution in patients taking other drugs that lower seizure threshold (antipsychotics, antidepressants)

follow up with Dr 2-3 wks after starting

Question 29

Which non-prescription drugs that aid smoking cessation are listed on the PBS?

Answer 29

Nicotine patches = aid to quitting for those in support/counselling programs, not available at same time as other subsidised patches

Oral forms of NRTs subsidised = gum and lozenges for use as sole PBs subsidised therapy (combination therapy not on PBS)

Under PBS = max 12 weeks of PBS-subsidised NRT available per 12 month period