1. Nicotine Addiction Pharmacy Practice II Winter 2005

2. Tobacco Use Interview When did you start? When did you start? Why? Why? How much, how often? How much, how often? What do you like? What do you like? What don’t you like? What don’t you like? Health risks? Health risks? Quitting experience? Quitting experience? What would it take to quit? What would it take to quit?

3. Pharmacist’s Role Ask Ask Advise Advise Assess Assess Assist Assist Arrange Arrange

4. Stages of Change Precontemplation Precontemplation Contemplation Contemplation Preparation Preparation Action Action Maintenance Maintenance

5. Precontemplation Unaware, unwilling, too discouraged Unaware, unwilling, too discouraged Won’t change in the next six months Won’t change in the next six months Listen, empathy, identify barriers Listen, empathy, identify barriers Focus on benefits of change Focus on benefits of change Interview questions Interview questions

6. Contemplation Open to information, thinking about quitting in next 6 months Open to information, thinking about quitting in next 6 months Provide information, emotional support Provide information, emotional support Encouragement Encouragement Resources Resources Information about options Information about options What it will take, who is available What it will take, who is available

7. Preparation Getting ready o try new behavior within 30 days Getting ready o try new behavior within 30 days Goal setting, praise readiness, enlist support of others Goal setting, praise readiness, enlist support of others Goals Goals Resources Resources Options Options Who can help Who can help

8. Action Taking steps, needing willpower Taking steps, needing willpower Habituating behaviors Habituating behaviors Stimulus control, reinforce + behaviors, continuing emotional support Stimulus control, reinforce + behaviors, continuing emotional support Action plans Action plans Other support Other support Product information Product information Positive effects Positive effects

9. Maintenance Engaged for at least six months Engaged for at least six months Continue emotional support Continue emotional support Relapse prevention Relapse prevention Reinforce benefits Reinforce benefits Relapse – encouragement, persistence Relapse – encouragement, persistence

10. Treatment options Behavior modification Behavior modification Nicotine lozenges Nicotine lozenges Nicotine gum Nicotine gum Nicotine patches Nicotine patches Nicotine inhaler Nicotine inhaler Nicotine nasal spray Nicotine nasal spray Bupropion SR Bupropion SR

11. Treatment options Nicotine polacrilex lozenges 2 mg (1 st cig > 30 min after waking) 2 mg (1 st cig > 30 min after waking) 4 mg (1 st cig < 30 min after waking) 4 mg (1 st cig < 30 min after waking) Allow to slowly dissolve (20-30 min) Allow to slowly dissolve (20-30 min) Do not chew, eat, or drink Do not chew, eat, or drink < 20 lozenges/d < 20 lozenges/d CI: pregnancy, CVD, PUD CI: pregnancy, CVD, PUD SE: hiccups, sore mouth, sore throat, nausea SE: hiccups, sore mouth, sore throat, nausea 12 weeks 12 weeks

12. Treatment options Nicotine polacrilex gum 2 mg ( 24 cigs/d) 2 mg ( 24 cigs/d) Bite and park Bite and park Avoid eating, drinking while chewing Avoid eating, drinking while chewing Acid decreases release Acid decreases release SE: hiccups, nausea, sore throat, sore mouth SE: hiccups, nausea, sore throat, sore mouth CI: pregnancy, CVD, esophagitis, PUD CI: pregnancy, CVD, esophagitis, PUD 12 weeks 12 weeks

13. Treatment Options Transdermal nicotine 7, 14, 21 mg, 24-hour 7, 14, 21 mg, 24-hour 5, 10, 15 mg, 16-hour 5, 10, 15 mg, 16-hour Usage guidelines p.1166 Usage guidelines p.1166 SE: local skin reaction, insomnia SE: local skin reaction, insomnia CI: pregnancy, CVD, derm. problems CI: pregnancy, CVD, derm. problems 8 weeks 8 weeks Must not use tobacco Must not use tobacco

14. Rx Nicotine replacement Nicotine Inhaler Nicotine Inhaler SE: local irritation of mouth & throat SE: local irritation of mouth & throat Up to 6 months Up to 6 months Nicotine Nasal Spray Nicotine Nasal Spray SE: nasal irritation SE: nasal irritation Up to 6 months Up to 6 months

15. Bupropion SR Wellbutrin, Zyban Wellbutrin, Zyban Antidepressant, dopamine reuptake inhibitor Antidepressant, dopamine reuptake inhibitor Start 1 week before quitting Start 1 week before quitting 150 mg q am x 3 d, then increase to bid (may take second dose mid afternoon) 150 mg q am x 3 d, then increase to bid (may take second dose mid afternoon) CI: History of seizure, eating disorders CI: History of seizure, eating disorders SE: insomnia, dry mouth SE: insomnia, dry mouth Can use with nicotine replacement Can use with nicotine replacement

16. What’s new? Rimonabant (Acomplia) Rimonabant (Acomplia) Cannabanoid Receptor Antagonist Cannabanoid Receptor Antagonist Weight loss, tobacco cessation Weight loss, tobacco cessation Phase III clinical trials Phase III clinical trials

17. Other considerations Costs Costs Irritability Irritability Weight gain Weight gain Proper disposal of products Proper disposal of products Abstinence rates Abstinence rates 14-30% vs 8-20% placebo 14-30% vs 8-20% placebo

18. References See Blackboard links See Blackboard links Treating Tobacco Use and Dependence, www.cme.wisc.edu/online/ctri/index.htm University of Wisconsin Medical School and center for Tobacco Research and Intervention Treating Tobacco Use and Dependence, www.cme.wisc.edu/online/ctri/index.htm University of Wisconsin Medical School and center for Tobacco Research and Intervention www.cme.wisc.edu/online/ctri/index.htm