1. Mini Lesson #1 – Smoking Cessation
Nicholas England
HUSOP – APPE Rotation Block 2 – Administration
Preceptor: Megen Poulin

2. Overview1 Smoking is the leading cause of preventable death in the US
A known cause of multiple forms of cancer, heart disease, COPD, stroke, pregnancy complications, and many other diseases
It’s essential for healthcare providers to ask patients about their tobacco use
All patients willing to cease from smoking have a tobacco quitline phone number: QUIT-NOW ( )
Combination of counseling and medication is a more effective approach than either counseling or medication alone

3. The 5 “A’s” for Treating Tobacco Use & Dependence1,2
Ask about tobacco use
Advise to quit
Assess willingness to make an effort to quit
Assist in the quit attempt
Arrange for a follow-up
Identify and document tobacco use status for every patient at every visit
In a clear, strong, and personalized manner, urge every tobacco user to quit
Is the tobacco user willing to make a quit attempt at this time (or possibly in the near future)?
For the patient willing to make an attempt to quit, offer medication and provide or refer the patient for behavioral counseling. For patients unwilling to quit at this time, provide motivational interventions designed to increase future quit attempts. For a patient who recently quit, or for any patient with remaining challenges to quit smoking, provide relapse prevention
For a patient willing to make an attempt to quit, arrange for a follow-up visit(s) within the first week after the “start” quit date. For those patients unwilling to make a quit attempt at this time, address tobacco dependence and willingness to quit at the patient’s next scheduled visit

4. Exceptions to Drug Treatment2
Pharmacological therapy is NOT recommended for the following patient populations, where behavioral counseling is the preferred method of approach:
Pregnancy
Adolescents
Patients using chewing tobacco, but have no history of cigarette use
“Light” smokers
These patients do not use more than 10 cigarettes per an average day

5. Smoking & Drug Interactions1
Non-nicotine compounds in cigarette smoke are considered as inducers of CYP1A2
Smokers who quit may experience supratherapeutic side effects from the following drugs:
Caffeine
Olanzapine
Clozapine
Women who smoke and are >35 yoa should NOT take any oral contraceptive due to an increased risk of CV events
Not an inclusive list of drugs
Yoa = years of age; CV = cardiovascular

6. Nicotine Replacement Therapy2,3
Nicotine Patch (NicoDerm CQ)
If smoking >10 cigarettes/day, start with the 21mg patch
If smoking <10 cigarettes/day, start with the 14mg patch
SE’s: Vivid Dreams; Skin Irritation
Should be removed before an MRI
OTC Product
SE’s = Side Effects
Cigarette Use
Weeks 1-6
Weeks 7-8
Weeks 9-10
>10 cigarettes/day
21mg Patch
14mg Patch
7mg Patch
<10 cigarettes/day
No Recommendation

7. Nicotine Replacement Therapy [NRT]2,3
Nicotine Patch (NicoDerm CQ) – Counseling Points
At the start of each day, remove a new patch from the pouch
Apply to a clean, dry, and relatively hairless area of the skin  press firmly and hold for ~10 seconds
The patch should be worn for 24 hours, unless vivid dreams are experienced
Discard used patches by folding the sticky ends together and place in the pouch
Wash hands after applying & removing the patch
Rotate patch sites  DO NOT APPLY to the same site within a 1 week period
NEVER cut the patch or wear >1 patch at a given time
OTC Product
Use the pouch to throw away any old and used patches
If vivid dreams occur, or if a patient has trouble sleeping, remove the patch prior to bedtime and apply a new one in the AM
Throw into proper disposal AWAY from children and pets
Rotating patch sites: Mild skin reactions have been seen to occur if applying to the same site, but these generally go away in a few days

8. NRT (Nicotine Gum & Lozenge)2,4
Nicotine Polacrilex Gum (Nicorette) & Lozenge (Nicorette, Nicorette Mini)
If the patient has their first cigarette of a day >30 minutes after waking up  Use 2mg of gum/lozenge
First cigarette <30 minutes after waking up  Use 4mg of gum/lozenge
Generally used for up to 12 weeks
Both the gum & lozenge are sugar-free
The 4mg strength for both the gum & lozenge have been shown to reduce/delay weight gain
OTC Product
Nicotine Gum
Weeks 1-6
Weeks 7-9
Weeks 10-12
1 piece q1-2hrs
1 piece q2-4hrs
1 piece q4-8hrs
Nicotine Lozenge
1 lozenge q1-2hrs
1 lozenge q 2-4hrs
1 lozenge q4-8hrs

9. NRT (Nicotine Gum & Lozenge)2,4
Nicotine Polacrilex Gum (Nicorette) & Lozenge (Nicorette, Nicorette Mini)
Minimum = 9 pieces or lozenges/day for the first 6 weeks
Maximum:
Gum = 24 pieces/day
Lozenge = 20 pieces/day
OTC Product
Generally used for up to 12 weeks
Nicotine Gum
Weeks 1-6
Weeks 7-9
Weeks 10-12
1 piece q1-2hrs
1 piece q2-4hrs
1 piece q4-8hrs
Nicotine Lozenge
1 lozenge q1-2hrs
1 lozenge q 2-4hrs
1 lozenge q4-8hrs

10. NRT (Nicotine Gum & Lozenge)2,4
Nicotine Polacrilex Gum (Nicorette) & Lozenge (Nicorette, Nicorette Mini) – Counseling Points
Gum:
Should be chewed slowly, until a “Flavored” taste is present in the patient’s mouth, then set against the inside of the patient’s cheek
Should be chewed slowly several times, for a total amount of ~30 minutes
For best results, at least 1-2 pieces should be chewed every 1-2 hours for the first 6 weeks
Lozenge:
Place in mouth and let the lozenge dissolve slowly  Move lozenge from one side of mouth to the other until it has completely dissolved (~20-30 minutes)
Do NOT use >1 lozenge at a time  can lead to SE’s (Hiccups, Heartburn, & Nausea)
For best results, at least 1 lozenge every 1-2 hours should be used for the first 6 weeks
OTC Product

11. Nicotine Inhaler & Nasal Spray2
Both products are Rx only (Nicotrol Inhaler; Nicotrol NS)
SE’s:
Inhaler  Mouth & Throat Irritation, Cough, and Rhinitis
Nasal Spray  Nasal Irritation, Watery Eyes, Sneezing, Transient Changes in Taste & Smell
The Inhaler acts like the “hand-to-mouth” smoking motion, which can provide a coping mechanism for the patient
The nasal spray has the fastest delivery and is useful in rapid relief of withdrawal symptoms
No further information will be discussed about these agents, due to time permitting

12. NRT SE’s & Other Notes2,3
SE’s: Headache, Dizziness, Nervousness, Insomnia, Dyspepsia
The FDA prohibits the sale of nicotine products to any individual <18 yoa
Identification is REQUIRED for purchase
The nicotine patch has the highest adherence rate, although combination therapy of short-acting NRT and pharmacological therapy is the most effective method

13. Bupropion SR (Zyban)2,5
MOA: Blocks neuronal reuptake of Dopamine &/or Norepinephrine resulting in reduced cravings and other withdrawal symptoms
This agent DOES NOT need to be tapered when d/c
Dosing:
Start at least 1 week before the “starting” quit date
150mg PO q AM x 3 days, then 150mg PO BID  Use for <6 months
MAX dose is 300 mg PO QD
If no significant progress is seen by week 7 of therapy, consider d/c
SR = Sustained Release; d/c = discontinued

14. BBW: *Risk of suicidal thinking and behavior is increased in children, adolescents, and young adults taking antidepressants*
Bupropion SR (Zyban)2,5
SE’s: Dry Mouth, Insomnia, Agitation, Headache
2nd dose can be taken 8 hours after the 1st dose to decrease sleeping issues
Do not take if the patient has a seizure disorder, eating disorder, or taking other forms of Bupropion
Swallow tablets whole  DO NOT crush, cut, or chew
If able to quit smoking while on this medication, the patient’s healthcare provider may keep them on this medication for several months to prevent going back to smoking
May delay weight gain
MedGuide is required to be given to patients taking this medication
SR = Sustained Release
Most common SE’s are dry mouth and insomnia  generally mild and generally disappear after a few weeks

15. Varenicline (Chantix)2,6
MOA: A partial α4, β2 Nicotinic Receptor Agonist
Start 1 week before the “starting” quit date
Dosing:
Days 1-3  0.5mg PO QD
Days 4-7  0.5mg PO BID
Days 8 & Beyond  1mg PO BID
Use for 12 weeks, but can be used for another 12 weeks to maintain treatment success
To decrease insomnia, take the 2nd dose before bedtime
Renally adjusted (CrCl <30 mL/min  0.5mg PO QD, titrated to BID

16. Varenicline (Chantix)2,6
SE’s: Dose-dependent Nausea, Insomnia, Headache
Take this medication after eating and with a full glass of water
MedGuide is required to be given to these patients
Decrease the amount of alcohol consumed when starting this medication
Use caution when driving or operating heavy machinery
Some patients have serious reactions to this medication  contact healthcare provider IMMEDIATELY if any of these occur:
Swelling of face, mouth, tongue, or neck
Rash, redness, blistering & peeling of the skin
DO NOT use with other medications that help the patient quit smoking
Nausea occurs in ~30% of patients, and is dose-dependent

17. References
Fiore MC, Baker TB. Treating smokers in the health care setting. N Engl J Med. 2011; 365:
Clinical Guidelines for Prescribing Pharmacotherapy for Smoking Cessation. Agency for Healthcare Research & Quality. providers/guidelines-recommendations/tobacco/prescrib.html. Published December Updated December Accessed July 16, 2018.
com.husson.idm.oclc.org/pharmacology/monograph/435?n=Nicoderm%20CQ