Smoking Cessation

Question 1

What makes cigarette smoking so addictive?

Answer 1

Rapid delivery of nicotine to the mesolimbic reward pathway

Short half life of nicotine (60-90 min) forces repeated administration

Question 2

What drug enzyme does smoking impact (causes many drug interactions with)?

Answer 2

Inducer of CYP1A2

Good for keep in mind for patients who quit smoking

Question 3

Is reduction in smoking provide health benefits?

Answer 3

No, but it is associated with subsequent successful quitting

Question 4

What are the “5 A’s Approach” to smoking cessation?

Answer 4

Ask
Advise
Assess
Assist
Arrange

Question 5

What non-pharms can be recommended for smoking cesssation?

Answer 5

Behavioural therapy for 8-24 weeks has been shown to be effective at follow-up at 6 months

Long-term remission >1 year following single course of therapy was only in small number of patients

Question 6

What non-pharm choices have no clear evidence for long-term efficacy?

Answer 6

Hypnosis
Acupuncture
Acupressure
Laser therapy

Question 7

What are 5 evidence-based steps required to successfully quit?

Answer 7

1) Set a target quit date
2) Getting professional help
3) Social support
4) Medications to quit smoking
5) Problem solving methods of counselling

Question 8

Is abruptly stopping on quit day or gradual reduction associated with better quit rate?

Answer 8

Both have comparable quit rates

Question 9

There is a dose-response relationship between _________ and quit success.

Answer 9

Counselling

Question 10

When should pharmacotherapy be added to patient’s smoking cessation plan?

Answer 10

If patients smoke more than 10 cigarettes per day

Question 11

When is a contraindication to pharmacotherapy?

Answer 11

Adolescents (no benefit over behavioural approaches)

Question 12

What is first line for smoking cessation?

Answer 12

Good to note that varenicline and bupropion is not actually considered second-line.
However, Health Canada has advised prescribers to consider giving:
Nicotine replacement therapy (NRT) prior to prescribing bupropion and varenicline.

Question 13

What does American Thoracic Society suggest as first-line smoking cessation therapy?

Answer 13

Varenicline (higher quit rates than bupropion and single forms of NRT)

Especially if patient is uninterested, unwilling, or not ready to set a quit date to achieve smoking cessation

Question 14

What can you combine with the nicotine patches to act as boluses to help control cravings?

Answer 14

As-needed gum, inhaler, lozenges, mouth spray

Question 15

What two forms of nicotine add-on therapy is not available in Canada?

Answer 15

Nicotine nasal spray
Sublingual tablets

Question 16

What is the standard duration of therapy for NRT?

Answer 16

8-12 weeks

Question 17

Even though that is the standard duration, it is often insufficient in facilitating abstinence. How long can you extend the use of NRT to?

Answer 17

24 weeks

Question 18

What is the max number of weeks you can extend NRT use to?

Answer 18

24 weeks
No additional benefit past that

Question 19

NRT is relatively safe. When do we need to be cautious?

Answer 19

Extreme exercise can increase nicotine absorption

OK to keep on for mild to moderate exercise.
Remove patch if vigorous exercise.
Apply after exercise and limit to upper body to reduce risk of excess absorption.

Question 20

Which smoking cessation drugs are only available by prescription?

Answer 20

Bupropion and varenicline

Question 21

What drug class is varenicline?

Answer 21

Alpha4 beta2-nicotinic receptor partial agonist

Question 22

What is on the boxed warning of varenicline product monograph?

Answer 22

Caution and monitor for mood changes and thoughts of harm to self or others (reports of neuropsychiatric side effects)

For patients with a history of past and current psychiatric illness, use varenicline with caution

Subsequent studies show that risk is much lower than anticipated but still monitor

Question 23

What is another concern with varenicline use?

Answer 23

Potential cardiovascular risk

Exercise caution before initiating varenicline in patients with cardiovascular concerns

Question 24

What drug class is bupropion?

Answer 24

Dopamine, norepinephrine and serotonin reuptake blocker

Question 25

Bupropion combined with ________ is more effective than bupropion alone, but only if started at the same time (not as add-on therapy).

Answer 25

NRT

Question 26

What are some side effects we need to watch out for with bupropion?

Answer 26

Agitation type reactions Mood or behavioural changes Thoughts of self harm

Question 27

What are actual second line pharmacotherapies? Have evidence for efficacy but not officially indicated

Answer 27

Clonidine Nortriptyline

Question 28

When would nortriptyline come into play?

Answer 28

When first line options are unaffordable or have not worked

Question 29

When would clonidine come into play?

Answer 29

Good for if patient has coexisting hypertension where appropriate. Caution with postural hypotension

Question 30

What is a natural health product that is advertised for smoking cessation. Is it effective?

Answer 30

Cytisine (Cravv) Non-inferior to NRT

Question 31

What drug class is cytisine?

Answer 31

Partial nicotine agonist

Question 32

Do you need a prescription for cytisine?

Answer 32

No

Question 33

How is cytisine dosed?

Answer 33

Initial: 9 mg/day (divided in 6 doses) Taper until 1.5mg (approximately day 21-25)

Question 34

When should the quit attempt be made?

Answer 34

Fifth day after starting the medication

Question 35

When do we initiate combo therapy for smoking cessation?

Answer 35

Monotherapy is preferred but if unsuccessful, can try initiating combo therapy.

Question 36

What are electronic delivery systems?

Answer 36

E-cigarettes - battery powered mechanism that heats and vaporizes a liquid mixture that contains nicotine and mimics cigarette behaviour

Question 37

What is Health Canada's stance on EDS?

Answer 37

Does not recommend due to lack of safety in regard to exposure to vaporized propylene glycol

Question 38

What is a possibly bothersome side effect of smoking cessation for patients?

Answer 38

Post-smoking cessation weight gain

Question 39

Does smoking cessation with pharmacotherapy affect the change in body weight?

Answer 39

No, they are both associated with changes in body weight. However, smoking cessation with pharmacotherapy is associated with less weight gain.

Question 40

Of the three different pharmacotherapies, which associated with the least weight gain?

Answer 40

Bupropion due to its anorexiant properties

Question 41

When does post cessation weight gain occur the most?

Answer 41

First 3 months of quitting 4-5kg at 12 months

Question 42

What are some tips we can suggest to help patients minimize food cravings that can cause weight gain?

Answer 42

Eat low calorie snacks such as carrots, celery sticks, and/or using sugar free candy and gum. Encourage physical activity as well.

Question 43

What drug interactions are associated with smoking cessation?

Answer 43

Smoking induces CYP1A2 enzyme. Smoking cessation can lead to higher doses of drugs such as caffeine, clozapine, diazepam, estrogen, fluvoxamine, methadone, nifedipine , olanzapine, rasagiline, theophylline, trifluoperazine, warfarin

Question 44

What are adverse effects associated with smoking and pregnancy?

Answer 44

Intrauterine growth retardation, increased risk of sudden infant death syndrome, reduction in amount of breast milk

Question 45

Pregnancy is the one of the best times to promote smoking cessation. Quitting at anytime during pregnancy is associated with improved birth outcomes. True/False?

Answer 45

True

Question 46

Are there any risks with stopping cold-turkey while pregnant?

Answer 46

No

Question 47

Is pharmacotherapy like varenicline and bupropion safe for pregnancy?

Answer 47

No

Question 48

What would be a more acceptable pharmacotherapy option if patient needs in pregnancy?

Answer 48

NRT, but still lack of concrete evidence and efficacy in pregnancy. Start with lowest dose if needed (gum) Behavioural therapy preferred

Question 49

If we must use NRT therapy in pregnancy, what is the recommended dosing and formulation?

Answer 49

Gum for 8-12 weeks with the goal of quitting. Reserve the transdermal patch for heavily dependent people who smoke and do not respond to gum. If using patch, remove after 16 hrs (bedtime) to reduce fetal nicotine exposure.

Question 50

How long should you stop smoking prior to conception if possible?

Answer 50

At least 3 months for male to allow for sufficient time to replace abnormal sperm (major cause of infertility)

Question 51

When does bupropion come into play during pregnancy?

Answer 51

Only if patient has diagnosis of depression However, there is a higher risk of congenital malformation

Question 52

Which therapies are safe in breastfeeding?

Answer 52

NRT and bupropion Varenicline (no safety data)

Question 53

Continued breastfeeding is associated with delayed relapse in quit smoking. What non-pharms can we recommend to limit baby from smoke exposure during breastfeeding?

Answer 53

Smoke outdoors Don't smoke before or during breastfeeding Chang clothing and hand wash

Question 54

If patients often have slips while on medications, what can we recommend?

Answer 54

Continue on medication for at least 4 weeks