Nicotine Replacement Therapy and Smoking Statistics
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Questions and Answers

What percentage of the U.S. population smokes?

  • 30%
  • 14% (correct)
  • 10%
  • 20%

    • What is the annual economic cost of smoking in the U.S. due to direct medical expenses?

  • $50 billion
  • $100 billion
  • $200 billion
  • $96 billion (correct)

    • What is a major disadvantage of nicotine transdermal patches?

  • Cannot titrate dose to control cravings (correct)
  • Increased risk of overdose
  • Requires frequent application
  • Limited availability

    • Which of the following is NOT a common adverse effect of nicotine replacement therapy?

    <p>Nausea</p> Signup and view all the answers

    What percentage of smokers want to quit?

    <p>70%</p> Signup and view all the answers

    How many cigarettes per day is cited among smokers attempting to quit?

    <p>10 cigarettes/day</p> Signup and view all the answers

    What is the percentage of smokers that attempt to quit each year?

    <p>44%</p> Signup and view all the answers

    What is an advantage of using nicotine transdermal patches?

    <p>Once daily dosing for better adherence</p> Signup and view all the answers

    What is a major disadvantage of the nicotine patch?

    <p>Cannot titrate dose to control cravings</p> Signup and view all the answers

    Which of the following statements about nicotine gum is correct?

    <p>It may stick to dental work.</p> Signup and view all the answers

    What is one of the advantages of using the nasal spray form of nicotine replacement therapy?

    <p>It has rapid nicotine delivery.</p> Signup and view all the answers

    Which nicotine replacement therapy method mimics a 'hand-to-mouth' ritual?

    <p>Inhaler</p> Signup and view all the answers

    What is a potential risk associated with varenicline (Chantix)?

    <p>Cardiovascular events</p> Signup and view all the answers

    Which statement about the lozenge form of nicotine replacement therapy is accurate?

    <p>It is suitable for smokers with poor dentition.</p> Signup and view all the answers

    What is a known contraindication for varenicline?

    <p>Severe skin reactions</p> Signup and view all the answers

    Which of the following is a disadvantage of using the inhaler for nicotine replacement therapy?

    <p>It requires frequent dosing or puffing.</p> Signup and view all the answers

    What is the maximum number of nicotine lozenges one can use in a day?

    <p>20 lozenges</p> Signup and view all the answers

    At which time should nicotine lozenges not be used?

    <p>Within 15 minutes of eating/drinking</p> Signup and view all the answers

    What is a key advantage of using nicotine lozenges?

    <p>Delays weight gain</p> Signup and view all the answers

    Which of the following is an adverse effect of nicotine lozenges?

    <p>Flatulence</p> Signup and view all the answers

    For someone with high dependence on nicotine, what is the recommended dose of a lozenge?

    <p>4 mg</p> Signup and view all the answers

    How often should a nicotine lozenge be used during the first week of treatment?

    <p>Every 1-2 hours</p> Signup and view all the answers

    During which weeks is the frequency of lozenge use decreased to 1 every 4-8 hours?

    <p>Weeks 10-12</p> Signup and view all the answers

    What is the recommended gum dosage for someone with low dependence on nicotine?

    <p>2 mg per piece</p> Signup and view all the answers

    What warning regarding varenicline was removed in 2016?

    <p>Black box warning for serious neuropsychiatric events</p> Signup and view all the answers

    What is the initial dosing regimen for varenicline starting 7 days before the quit date?

    <p>0.5 mg daily</p> Signup and view all the answers

    What should a patient do if they experience agitation or suicidal thoughts while taking varenicline?

    <p>Stop varenicline and notify a healthcare provider</p> Signup and view all the answers

    How did the CATS trial contribute to the understanding of varenicline's safety in cardiovascular risk?

    <p>It indicated no significant increase in CV events</p> Signup and view all the answers

    What should be monitored when a patient is prescribed varenicline?

    <p>Neuropsychiatric events and mood changes</p> Signup and view all the answers

    What is the effect of varenicline on neuropsychiatric events according to the EAGLES trial?

    <p>No significant increase compared to placebo</p> Signup and view all the answers

    What aspect of varenicline's contraindications must be taken into account for patients with cardiovascular disease?

    <p>It is considered safe for stable CVD patients.</p> Signup and view all the answers

    What is the appropriate way to take varenicline?

    <p>With a full glass of water after meals</p> Signup and view all the answers

    What is the primary goal of medication preloading for smokers who are not ready to quit immediately?

    <p>To reduce satisfaction derived from smoking</p> Signup and view all the answers

    Which of the following therapies is suggested for a duration of less than or equal to 3 months?

    <p>Nicotine patch</p> Signup and view all the answers

    Which medication has been studied and shown to significantly increase quit rates when used for gradual reduction?

    <p>Varenicline (Chantix®)</p> Signup and view all the answers

    What duration of use is recommended for nicotine nasal spray?

    <p>Less than or equal to 6 months</p> Signup and view all the answers

    Among long-term quitters, what percentage reportedly continued using nicotine gum after 12 months according to the Lung Health Study?

    <p>About one-third</p> Signup and view all the answers

    What is the maximum recommended dose of Bupropion SR in patients with hepatic dysfunction?

    <p>150 mg every other day</p> Signup and view all the answers

    What is a common side effect of Bupropion SR experienced by 35-40% of users?

    <p>Insomnia</p> Signup and view all the answers

    Which of the following is an advantage of Bupropion SR?

    <p>Ease of use with BID dosing</p> Signup and view all the answers

    When should Bupropion SR be started in relation to the quit date for smoking cessation?

    <p>7 days before the quit date</p> Signup and view all the answers

    What should be done if a patient experiences agitation or suicidal ideation while taking Bupropion?

    <p>Stop Bupropion and notify a healthcare provider</p> Signup and view all the answers

    Which statement is true regarding the combination therapy options for smoking cessation?

    <p>Varenicline can be combined with a single NRT product.</p> Signup and view all the answers

    Which of the following is a contraindication for using Cytisine (Tabex)?

    <p>Severe hypertension</p> Signup and view all the answers

    What is a rare but serious side effect of Bupropion SR?

    <p>Seizure</p> Signup and view all the answers

    Study Notes

    Smoking Cessation Pharmacotherapy

    • Objectives: Understand tobacco use epidemiology, assess tobacco use using a patient-centered approach, apply pharmacotherapy principles for selection, and provide smoking cessation interventions.

    Epidemiology of Tobacco Use

    • Leading cause of preventable death and morbidity in the U.S.
    • Approximately 14% of the U.S. population smokes (~30 million).
    • Approximately 440,000 premature deaths annually.
    • $96 billion in direct medical expenses annually.

    Epidemiology of Smoking Cessation

    • 70% of smokers desire to quit.
    • 44% attempt to quit annually.
    • Fewer than 10% of quit attempts are successful.
    • With effective counseling: ~16% success rate.
    • With effective pharmacotherapy: ~19-36% success rate.

    Patient Assessment & Interventions

    • Tobacco Cessation Treatment Pathway: Ask, Assess, Advise, Offer & Connect to Treatment, Follow-up.
    • Ask about patient's smoking status.
    • Assess the extent of nicotine dependence and willingness to quit. Methods include Fagerstrom Test and Heaviness of Smoking Index.
    • Advise the patient about the importance of quitting and provide information on health benefits and risks.

    Extent of Nicotine Dependence

    • Fagerstrom Test: A questionnaire to assess nicotine dependence. Includes questions about cigarettes per day and time to first cigarette. Higher score indicates greater dependence.
    • Heaviness of Smoking Index: Similar to Fagerstrom Test, assessing dependence based on cigarettes per day and time to first cigarette after waking. Higher score indicates greater dependence.

    Transtheoretical Model of Change

    • Stages of Change: Precontemplation, Contemplation, Preparation, Action, Maintenance, Relapse. Illustrates a patient's progress toward quitting.

    Tobacco Cessation Treatment Pathway - Advise

    • Consequences of not quitting: shortened lifespan, increased risk of cancer, COPD, cardiovascular disease, even light smoking is harmful.
    • Health benefits of quitting: reduced risk of death by 90% within age 40, reduced lung and heart disease risk within 10 years.

    Motivational Interviewing

    • The 5 "Rs": Relevance (relate smoking to comorbidities), Risks (consequences of not quitting), Rewards (health and financial benefits), Roadblocks (factors hindering quitting), Repetition (ongoing support). Helps the patient determine the process of change.

    • DARES: Develop discrepancy (highlighting the differences between behavior and goals), Reinforce patient's change talk (motivating patient to take action), and strengthen commitment and Avoid argumentation. Encourages action.

    • Roll with resistance: Understanding and supporting resistance to change with empathy, questions, reflective listening, and patient choices.

    Patient Accepts Treatment

    • Set a quit date (2 weeks from now).
    • Tell family and friends (support system).
    • Anticipate barriers (develop a plan).
    • Remove tobacco products from environment.
    • Prescribe Rx pharmacotherapy.

    Set a Quit Date

    • Timeline: Specify medication start date and quit date.
    • Disposal: Instructions for discarding cigarettes, ashtrays, and lighters.
    • Alternatives: Availability of nicotine-free products as needed.
    • Support: Contact information for the clinic regarding specific questions.

    Tell Family & Friends

    • Support system: Contact information for clinic or pharmacy.
    • Support Groups: Referrals to quit lines (e.g., 1-800-QUIT-NOW), relevant organizations (e.g., American Lung Association).
    • Technology: Websites (e.g., smokefree.gov, quitnet.com), Smartphone Apps (e.g., 553 apps).

    Technology

    • Resources: Variety of available tools for patient use.

    Anticipate Barriers – Types

    • Lifestyle Strategies: Stress management, healthy eating, exercise (to reduce weight gain). Reduce alcohol intake. Limit contact with other smokers. Address previous quitting routines/triggers.
    • Cognitive Techniques: Mental rehearsal (visualization), Positive self-talk (managing thoughts), and Distractive thinking (substituting activities). Committing to stopping smoking.

    Anticipate Barriers - Specifics

    • Review commitment to quit consistently.
    • Addressing mental rehearsal and recognizing and acknowledging obstacles.
    • Identifying cognitive strategies to manage feelings that may cause relapse.

    Roadblocks/Barriers to Quitting

    • Withdrawal symptoms: irritability, anger, depressed mood, anxiety, restlessness, difficulty concentrating, insomnia, chest tightness, increased appetite, constipation, gas, stomach pain, dizziness, fatigue.

    Follow-up

    • Contact within 1 week and 1 month of quit date.
    • Assess for lapses ("slips") or relapse.
    • Encourage recommitment to abstinence.
    • Address barriers to quitting.
    • Assess medication adherence/tolerability.

    Rx Pharmacotherapy: Principles for Selecting Pharmacotherapy

    Pharmacotherapy Efficacy

    • Table with FDA-approved options and their odds ratios (OR) for smoking cessation, comparing them to a placebo. Includes nicotine gum, patch, lozenges, bupropion SR (Zyban), inhaler, nasal spray, combination therapy.

    Combination Therapy

    • Combination therapy options, OR (95% Confidence Interval) for quitting. Includes examples like nicotine patch + gum/spray, patch + inhaler, etc.

    Pharmacotherapy 1st Line Options

    • Nicotine Replacement Therapy (NRT) is a common 1st line option
    • Varenicline is another possible 1st line choice
    • Combination therapies like patch + gum are possible

    Combination NRT

    • Various combinations of nicotine replacement therapy (NRT) products.

    Nicotine Replacement Therapy Precautions/Contraindications/Warnings

    • All NRT: Hypersensitivity, pregnancy (category D), recent myocardial infarction, serious arrhythmias, worsening angina.
    • Additional Formulation-based: Severe eczema or psoriasis, temporomandibular joint (TMJ) disease, caution in denture wearers, hypersensitivity to menthol, bronchospastic disease, severe reactive airway disease, chronic nasal disorders.
    • Recent myocardial infarction and other precautions are important.

    Nicotine Replacement Therapy - Nicotine Transdermal Patch

    • Directions: Daily use. Hairless areas, rotation of placement. Skin irritation avoidance.
    • Dosing Regimen: Vary based on smoking history (light vs heavy smoker). Decreasing patch strength over time.
    • Adverse Effects: Local skin reactions, insomnia, vivid dreams, headache.
    • Advantages: Slow nicotine release, once daily dosing, adherence.
    • Disadvantages: Cannot titrate dose to cravings/withdrawal.

    Nicotine Replacement Therapy - Nicotine Lozenges

    • Directions: Don't use within 15 minutes of eating/drinking. Don't chew or swallow. Lozenge use limit each day.
    • Dosing Regimen: Vary based on dependence (heavy versus low). Gradual decrease in strength over weeks.
    • Advantages: Ease of use & titration to control cravings. Can be used in those with dental challenges
    • Disadvantages: Frequent dosing required..

    Nicotine Replacement Therapy - Nicotine Gum

    • Directions: Avoid usage within 15 minutes of meals. Chewing then allowing the stimulation to cease (parking). Limit usage to 24 pieces daily
    • Dosing regimen: Based on weeks 1-6, 7-9, 10-12 dependence, increasing per day.
    • Advantages: Easy to use, address cravings. Can be used in smokers with poor dentition.
    • Disadvantages: Frequent dosing, May need proper chewing technique, May stick to teeth.

    Nicotine Replacement Therapy - Nicotine Inhaler

    • Directions: Do not use within 15 minutes of eating. Inhale into the back of the throat. Limit puffs to 20 minutes of puffing (duration). No more than 16 cartridges daily
    • Dosing Regimen: Initial dose based on smoking history. Gradually decreasing cartridges over time.
    • Adverse Effects: Mild irritation in mouth or throat (initially), unpleasant taste or cough (initially), runny nose, upset stomach, and hiccups.
    • Advantages: Ease of use & titration to control cravings. Hand-to-mouth routine is mimicked.
    • Disadvantages: Need for frequent dosing and puffing. Visible during use. Device assembly may be difficult.

    Nicotine Replacement Therapy - Nicotine Nasal Spray

    • Directions: Do not use within five minutes of driving. Prime. Tilt head back and spray. Don’t inhale. Do not blow nose soon after.
    • Dosage: Weeks 1-8 / Weeks 9-12/14. 1 dose = 2 sprays, 1 spray per nostril; 0.5 mg/spray. Maximum of 40 doses/day.
    • Advantages: Easy to use; can be titrated to cravings, rapid nicotine delivery.
    • Disadvantages: Addiction potential, frequent dosing, visible during usage.

    Varenicline (Chantix®)

    • Contraindications/Warnings: Serious skin reactions, angioedema, accidental injury (somnambulism), severe renal impairment, pregnancy category C, serious psychiatric disorders. Risk of suicidal behavior/thoughts, cardiovascular events. Black-box neuropsychiatric warning removed in 2016, newer guideline/warning statement remains. EAGLES trail.
    • Directions: Take with a full glass of water after meals. Stop varenicline and call the doctor if symptoms arise, like abnormal behavior, thoughts of suicide, or extreme changes in mood. Use caution while operating heavy machinery.
    • Dosage Regime: 7 days before quit date. Daily dosing varies over weeks.
    • Side Effects: Nausea (~33%), Insomnia, abnormal dreams, vomiting, and flatulence.
    • Advantages: Dual action, easy use (twice daily). Combination use with nicotine patch is a possibility.
    • Disadvantages: Serious adverse events possible.

    Bupropion SR (Zyban®)

    • Contraindications/Cautions/Warnings: Seizure disorder, concomitant use of Wellbutrin, anorexia/bulimia, recent discontinuation of sedatives/alcohol, CNS tumor, hepatic cirrhosis, MAO inhibitors, pregnancy (Category C), glaucoma, increased risk of suicide, neuropsychiatric adverse events.
    • Directions: Take doses more than 8 hours apart, not at bedtime. Do not crush, divide or chew. If there are changes in mood, behavior or thoughts of suicide, contact a doctor immediately.
    • Dosage Regimen: 7 days before quit date (initial dose). Dosage increases over time.
    • Side Effects: Insomnia (~35-40%), tremor (rare), rash (rare), and constipation.
    • Disadvantages: Drug interactions.
    • Advantages: Easy to use (twice daily). May delay some weight gain, suitable addition to nicotine replacement therapy.

    Combination Therapy

    • If single-agent therapy isn’t effective, combining varenicline or bupropion with one NRT product can be considered

    Pharmacotherapy for Patients with CVD

    • Preference of therapy. Categorizing what is effective depending on the status of the patient's CVD. Table of first, second, and third lines.

    Gradual Reduction & Medication Preloading

    • Gradual reduction strategies like varenicline-assisted gradual therapy for a 3-month period.
    • Preloading pharmacotherapy: Starting pharmacotherapy while still smoking to reduce smoking satisfaction and the amount of cigarettes per day.

    Duration of Smoking Cessation Therapies

    • Table of suggested durations for various therapies, like nicotine patch, gum, lozenges, inhaler, nasal spray, Bupropion SR, Varenicline.

    NRT Duration & Use While Smoking

    • April 2013 FDA Update: remove warnings against using NRT while still smoking, remove the specific duration use limit. The recommendation is now to consult healthcare providers regarding longer usage times to prevent relapse.

    Vaping and e-Cigarettes

    • Safety concerns related to battery-operated devices containing nicotine and flavors.
    • Regulatory status: E-cigarettes were regulated by the FDA as of 2016.
    • Public health concerns: Significant increase in youth vaping and associated disease risks.

    Clinician Resources

    • List of helpful websites/resources for clinicians.

    Patient Resources

    • Websites and phone numbers to help patients access cessation support.

    Smoking Cessation Case Scenarios

    • Detailed case scenarios for patients with differing histories, including medical issues, smoking history and readiness to quit, along with detailed summaries and notes. The case scenarios are for use in class study.

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    Related Documents

    Smoking Cessation Handout 1 pp Fall 2024 PDF

    Description

    Test your knowledge on nicotine replacement therapy, smoking statistics, and the economic costs associated with smoking in the U.S. This quiz covers various methods of nicotine replacement and their advantages and disadvantages. Challenge yourself to see how much you know about smoking cessation techniques.

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