Smoking cessation.pdf

Smoking cessation Smoking - Major cause of preventable morbidity and mortality in the developed world. Smoking – diseases Nicotine dependence - Mental, behavioural, or neurodevelopmental disorders due to substance use. - Chronic condition - Characterised by remission and rel...

Smoking cessation Smoking - Major cause of preventable morbidity and mortality in the developed world. Smoking – diseases Nicotine dependence - Mental, behavioural, or neurodevelopmental disorders due to substance use. - Chronic condition - Characterised by remission and relapse à hard to cure. - Development of behavioural, cognitive, and physiological phenomena. o Strong desire to smoke. o Use of tobacco in the face of medical and social detriments. o Persisting use despite harmful consequences. o Need of increased doses of nicotine to obtain the same pleasurable eCects. o Withdrawal state when tobacco use is reduced or ceased. - Presence of at least 2 of the following criteria - Pharmacokinetics of nicotine - Colourless and odourless naturally occurring alkaloid. - Short half-life of 40-120 min. - Whole life up to 20 hours. - Nicotine is the most addictive but not the most harmful substance in a cigarette. - Nicotine plasma concentration range 10-80 ng/ml. - Nicotine plasma concentration range 20-35 ng/ml for regular smokers. - Metabolised by CYP2A6 mainly, CYP2B6, CYP2E1 and CYP1A2. - Cotinine: nicotine’s major non-addictive metabolite. - Induction of CYP1A2 and CYP2B6 by smoking (via chemicals in cigarette smoke such as polycyclic aromatic hydrocarbons). à Major tobacco associated drug interactions. Pathophysiology of dependence. - Absorption of nicotine by the respiratory tract. - Rapid absorption into the pulmonary venous circulation. - Reaches brain in less than 10-20 sec. - Activation of dopaminergic receptors – DA release. - Widespread neuronal activation by nicotine and dopamine. - Release of rewarding neurotransmitters. - Desensitisation and upregulation of receptors with chronic exposure. - Tolerance o Decreased responsiveness to nicotine as body adapts to its presence. o Increasing doses of nicotine required to obtain same eCects. - Dependence o Withdrawal symptoms upon reduction or abstinence. o Strong tendency to relapse post quitting. Pathophysiology of dependence. - Withdrawal symptoms – increased noradrenergic outflow secondary to deactivation of reward system. Smoking risks vs quitting benefits. Chemicals in a cigarette - 4000 tixins inhaled/cigarette smoked. - Hundreds of additives and flavourings. - Detrimental eCects on: o Vital organs o Immune system o Key body functions o Life expectancy Health eNects of smoking Benefits of smoking cessation Smoking cessation in pharmacy Role of pharmacist - Applying the 5As of quitting. o Ask patients if they use tobacco products. o Advise them to quit. o Assess their nicotine dependence level and their willingness to quit. o Assist with pharmacotherapy and counselling. o Arrange follow-up to prevent relapse. - Applying the 5Rs of quitting – For patients unwilling to attempt quitting. o Relevance: why quitting is relevant to their health scenario. o Risks of the ongoing smoking habit. o Rewards: benefits of smoking cessation. o Roadblocks or impediments to quitting (withdrawal symptoms, fear of weight gain, social situations). o Repetition: most need multiple quit attempts. - Applying the AAH o Ask patients if they use tobacco products. o Advise them to quit and advise that using pharmacotherapy and behavioural interventions is the most eCective way. o Help by oCering pharmacotherapy and referral to behavioural pathways such as Quitline. Assessment of Nicotine dependence. - Fagerström test for nicotine dependence. - Heaviness of Smoking Index (HSI). - Expired CO levels using a CO monitor. - Carboxyhaemoglobin levels (COHb). - Urinary, saliva or blood cotinine levels. à nicotine dependence is not determined by how much cigarettes you smoke. Assessment of Willingness to Change - ‘Stages of change’ model Pharmacological interventions - Nicotine Replacement Therapy (NRT) o Gums. o Lozenges and mini lozenges (minis) o Inhalator o Transdermal patch o QuickMist mouth spray o Nasal spray (not available in Australia) - Varenicline - Bupropion - Others: Nortriptyline, Clonidine, Naltrexone Nicotine replacement therapy - Equal eCicacy of all forms of NRT à diCerence is the rate (how fast acting) - Nicotine delivery eCects (in decreasing order) o Gums. o Lozenges and mini lozenges (minis) o Inhalator o Transdermal patch o QuickMist mouth spray o Nasal spray (not available in Australia) - Smoking while on NRT is NOT contraindicated. Instructions for use – Gum - Chew 1 piece of gum slowly, until flavour becomes strong, or a slight peppery tingling sensation is felt. - Park between the cheek and gum. - Chew again when flavour fades. - Repeat until there is no more tingling or for about 30 minutes. Instructions for Use – Lozenge - Place lozenge between the cheek and gum, and suck slowly until taste is strong. - Stop sucking until taste fades, resting the lozenge against the cheek. - Continue to suck again when taste fades. - Move lozenge occasionally from side to side. - Repeat until lozenge has completely dissolved. - The whole process should take 20-30 minutes for lozenges and 10-13 minutes for mini lozenges. Instructions for Use – Inhalator - Insert cartridge into mouthpiece. - Take a shallow puC every 2 seconds or take 4 deep puCs every minute. - Continue for up to 20 minutes. - Replace cartridge. Instructions for Use – Mouth Spray - Point the spray nozzle towards the open mouth, holding it as close as possible. - Press the top of the dispenser to release one spray into the mouth, avoiding the lips. - For best results, avoid swallowing for a few seconds after spraying. Instructions for Use – Patch - Apply the patch in the morning or bedtime. - Remove before bedtime if applied in morning or remove in morning if applied at bedtime (16 hours) or replace next day (24 hours). - Patches should be applied to clean hairless skin on chest or upper arm. - Rotate site each day. - Do not cut patches in half. Swimming and bathing are allowed 1-hour post-application. Nicotine Replacement Therapy - Combination therapy more eCective than monotherapy. - Double successful quit rates with combinational NRT - Established safety. - First line pharmacotherapy = Varenicline Varenicline - CHAMPIX à recalled. Bupropion Pharmacotherapy Combinations Pharmacotherapeutic Considerations - Clinical eligibility - Past experiences and outcomes. - Patient preference/convenience. - Cost. - Compliance and adherence considerations Non-pharmacological interventions - Avoiding triggers. - Changing routines/shifting to reinforcing alternatives. - Adequate rest and relaxation. - Exercise. - Healthy diet. - Avoiding second-hand smoke. Take-Home Message