Smoking cessation notes

Question 1

When will I feel better? (pt will ask this)
Answer:withdrawal within 24 hours
Peak 1 week (worst within a week)
Subside 2-4 weeks

Question 2

First month things usually get better and the behavioral issues can last longer…physical dependence is usually over within first month and the thing about behavioral is you continually have to monitor that so it may be that they are doing well and they see people they haven’t seen in a long time and people that got them smoking in the first place in high school

Question 3

Smoking…burning of tobacco induces 1A2 and there are times when a pt quits smoking that you have to dose adjust certain medications and these are potentially medications that you have gotten with therapeutics but some may be familiar like theophyilline,clozapine,olanzapine, etc…a pt will start to feel side effects from some of these medications most of them are mental health medications

Question 4

People who smoke also drink a lot of Caffeine and they don’t have the same effect as the coffee as somebody who doesn’t smoke and that’s because they break down the caffeine faster so 1A2 is also responsible for breaking down caffeine. When pt quits smoking caffeine will start having more an effect on them and so they need to start drinking less coffee.

Question 5

What CYP enzyme is induced by smoking cigarettes? _________

Answer 5

1A2

Question 6

Olivia asks for counseling on her levofloxacin prescription. She states she can’t understand how or why she got pneumonia.

Which of the 5 A’s would you start with?

Answer 6

Ask

How many cigarettes? Make sure cigarettes are for her

Then advise pt to quit that it’s the cause of pneumonia, see if she is willing to quit, assess willingness to quit and if she is then your going to assist her with the quit and then arrange for a followup where you can see how she is doing and then you start again if she had a relapse and if she is doing well and was able to quit…your just checking in on her again to make sure she is doing well

Question 7

Methods for Quitting

Cold-turkey or tapering down are difficult for the pt and its NOT shown to be effective

Pharmacologic
FDA-Approved medications

Question 8

What have you tried to quit in the past?

To see if pt failed on this and they did it properly then this is probably not going to be a choice

What cigarette is going to be hardest to give up (give them suggestion…pt should go to dunkin donuts to have coffee

Set a quit date. (Make sure pt doesn’t have ash trays or cigarettes hiding in secret spots…if thankgiving in 2 days and their family smokes then this is not the best time to quit

Question 9

Cigarettes give instant hit of nicotine so they will get into the arterial system very quickly and we are trying to mimic that and you can see and we are not really there.

Question 10

The best one in graph is the nasal spray but we are still trying to get faster options with over the counter products but its not as instant as cigarettes

Question 11

Exclusion to self-care

Patient comes in and pt is pregnant. There is insufficient for self care…a provider may decide that pt might need nicotine replacement therapy but they are recommended to try without medication first before if they are unsuccessful they may give them nicotine replacement therapy but it is not approved for self care

Smokeless tobacco users is an
EXCLUSION TO SELF CARE…because its not studied in that population

Pts under the age of 18 it requires a prescription from the provider. If someone comes and they are 16 years old you need to get a prescription from their provider before giving them that product

Recommended treatment is behavioral counseling

Question 12

It’s better to use nicotine replacement therapy than to smoke. Pts who had cardiovascular disease or had an MI in the past two weeks…a serious arrhythmia or having angina that’s bad and very symptomatic or progressively getting worse but all of those are okay if they are getting care…if they never go to the doctor or getting treatment then its really not good

Question 13

One of the things to look at to show if its showing effectiveness of smoking cessation is we don’t have a lot of data comparing these products against each other…each of these is just comparing itself against the placebo so the yellow bar is always against blue bar next to each other but you can’t say the varenicline versus the lozenge or anything like that…its just yellow versus blue…the nicotine gum is about 30% better than placebo or something like that and the graph in particular is looking at monotherapy when you use it alone

Question 14

Products in combination that patch and lozenge…the combination of the two is better than either one alone

Question 15

When recommending self care its best to use the combination of long acting and short acting so the idea is you give long acting baseline nicotine with a short acting for breakthrough so that’s been shown to be the most effective and it gives patients the most chance for success which ultimately is your goal…so your goal is not to give the lowest amount of nicotine your goal is to get them off cigarettes

Question 16

When your using nicotine you initially chew it like gum but then you park like chewing tobacco…so you chew it slowly and as soon as you get a peppery taste in your mouth or tingling you park it so its called a chew and park technique so you chew and you get the tingling…park it btwn your gums and cheek and then when you don’t feel that taste anymore you chew it again and then put it on the other side…you don’t want to swallow the nicotine and the nicotine is meant to absorb through the mucosa in your cheek but in the last lecture the nicotine is absorbed through the cheek if you have a cigar and it can absorb it through your cheek

Question 17

If pt keeps chewing it then that can effect side effects so if you ask pt a question and they said they had been on the gum but they had a lot of side effects an important question would be how did you use it and they said they chewed like gum and they had a lot of upset stomach that would likely be why it doesn’t mean they can’t be on the gum again they just need to use it properly…its absorbed through the mucosa… and the chew and park is recommended

Question 18

How to dose nicotine gum is based on what time the pt had their first cigarette in the morning so if after they wake they had their first cigarette right away that indicates a strong addiction to nicotine so a need for the nicotine so they would get the higher dose if they go a long time so over 30 minutes before having their first cigarette they can get the lower dose…when your using monotherapy you want them to have your giving them a steady nicotine supply throughout the first few eeks and you don’t want them to get a period where they don’t have any nicotine in their system so in the first few weeks of the quit attempt you are going to have them take a piece chew and park every 1 to 2 hours,even if they feel they don’t need a cigarette its to keep it so they don’t get cravings we don’t want pt to have withdrawal symptoms…they are keeping the baseline nicotine steady and that’s the goal for monotherapy for the gum

Question 19

After the first 6 weeks they would decrease to every 2 to 4 hours and then at 10 weeks they would decrease to every 4 to 8

Question 20

You do not want your pts to go faster so if they are week 4 and like I’m doing great I can go every 2 to 4 hours you don’t want pt to go faster and if they are at week 6 and they are like I’m not feeling very comfortable with going every 4 hours I feel like I need to stay where Iam and they can stay where they are for a little longer if they have a high school reunion and they feel like they need to stay at there then that’s fine

Question 21

Jojo smokes 1 pack per day and has first cigarette every 40 minutes after waking in the morning. What dose of gum is appropriate?

Answer 21

2mg

Question 22

Nicotine gum may reduce weight gain and you can titrate up and down as needed so there is some personal control in that which is good

Question 23

Disadvantages of nicotime gum is you are doing a lot of frequent dosing and requires proper chewing technique in order to avoid adverse events
The major side effects is upset stomach and hiccups and that’s due to swallowing the nicotine

Question 24

Lozenges would be appropriate for people who can’t chew the gum like maybe they might have dentures and they can’t use nicotine gum…delivers 25% more nicotine that gum so it has a lower maximum number per day so the lozenge has 20 lozenges per day that you can use versus 24 pieces for the gum
Nicotine lozenge is a “wet and park method”

Question 25

Do NOT swallow lozenge because it will cause upset stomach and hiccups, dyspepsia and you keep it between your cheek and your gums and after a few minutes you wet it and put it to the other side of your mouth and no food or beverage before because it can affect the pH of your mouth and you wouldn’t be absorbing it through your cheek anymore and your more likely to swallow it

Question 26

Nicotine lozenge can stop some of the weight gain and you can titrate it yourself and it can be used in combination with other longer acting products

Question 27

Disadvantages of lozenge is adherence is an issue

Question 28

What is maximum number of gum and lozenges per day?

Answer 28

24 for gum and 20 for lozenges

Question 29

_______________-easiest to use and nicotine is well absorbed, provides continuous nicotine effect for 24 hours, long onset
Ex: Nicoderm

Answer 29

Transdermal Nicotine Patch

Question 30

Nicotine patch is not based on when pt has their cigarette and this is based on how many cigarettes

Question 31

If pt has over 10 cigarrettes/day then you start with step 1 (___mgx______weeks)

Answer 31

(21mgx6 weeks)

Question 32

If pt has 10 or less cigarettes then you start with step 2 (______mgx____ weeks)

Answer 32

14mgx6 weeks

Question 33

Whichever step you begin with that one is for 6 weeks and next step is 2 weeks…if a patient smokes a pack per day so 20 cigarettes per day you would start with step 1 for 6 weeks then you would go to step 2 for 2 weeks and then step 3 for 2 weeks…also you don’t want the pt to go faster but if they felt they need an extra week on step 1 that’s fine

Question 34

Pt will put a new nicotine patch on everyday and they take the old patch off and put a new patch on in the morning and this can cause vivid dreams like nightmares and if pt get that then pt can take off the patch before bed and put a new patch on the next morning which has been shown to be as effective as keeping it on for the full 24 hours so as long as they about 16 hours its just as effective

Question 35

Patch ADR…sometime skin stays red for 24 hours and if it says red for more than 4 days then they may have some kind of infection or reaction and they should have it seen

Question 36

Nicotine Patch causes nightmares or vivid however Smoking DOES NOT why? The advantages of nicotine patch is that it deliver nicotine over 24 hours and its easy to use, adherence is easy, it’s the least obvious of the nicotine replacement therapy and it can be used with other agents and the disadvantages are you can’t titrate up and down with a nicotine patch if you have cravings, issues with pts with skin conditions like eczema or psoriasis

Question 37

Elisa 30 year old woman. She would like to quit smoking before becoming pregnancy.

Allergies:penicillin and adhesive

What questions?
First cigarette on the car-ride into work. About 1 hour after waking

Answer:Pt has adhesive allergy so patch is NOT recommended and pt has first cigarette an hour after waking so we could recommend pt take a 2mg lozenge or the 2mg nicotine gum every 1 to 2 hours and educate pt on chew and park method

Question 38

Steve is a 50 year old man. he has tried everything to quit and he either hated the product or it didn’t work. He currently smokes 1ppd, first cigarette while still laying in bed in the morning. He tried prescription agents and he didn’t like them. He tried the patch, and he was able to quit for a few month but then went back to smoking. He had upset stomach and hiccups with the gum. He wants to know what you recommend.

Answer 38

Answer: Give pt 4mg of nicotine gum, then ask pt how we using the gum and it sounds like pt was getting side effects from swallowing the nicotine so if he told us he was chewing it and not just chewing and parking then that would still be an option but one important thing here is pt tried the patch and was able to quit for a few months that means the patch worked so he had a successful quit with the patch but he went back to smoking so the patch is a good option for pt 😊
So anything that helped pt successful quit smoking is a good option and it doesn’t have to keep

Question 39

Olivia is a 32 year old woman who comes to your pharmacy today to pick up her prescription for antibiotics for her pneumonia. She smokes about 8-10 cigarettes per day. Olivia is nervous because she has sleep issues. and she heard that the patch causes nightmares. What do you tell her?

Olivia has first cigarette which is an hour after she wakes up but she is nervous about side effects she has heard about the patch what do you tell her to do? Remove the patch before bed and apply a new one in the morning

Question 40

Maya is a 40 year old woman who comes to your phamarcy with Step 1 nicotine patch. She is wondering if she can use it. She has a latex allergy.

Answer: Always recommend combination therapy if you can. You would recommend combination therapy as you would with monotherapy so if they were to get the 2mg lozenge or 2mg gum that you would give them 2mg. If you would give them the 4mg then give the pt the 4mg. Most of the studies are done with the 2mg but if pt needs 4mg you give them that just watch for some additional side effects.

Question 41

Some pts will say the cost or the lozenge is high
Compared to the cost of cigarettes versus nicotine replacement therapy pt would end up saving money
A lot of insurances do cover nicotine replacement therapy
No quality studies looking at ZYN product

Question 42

Nicotine pouches: powdered nicotine, no evidence for smoking cessation, people can become dependent on these which isn’t good, difficult for people to come off this