Percent of tobacco users (12+) in the population

Use rates of cigarettes:

30.4%

24.9% are cigarette users

1. estimated cost of smoke related illnesses:

2. percent of total deaths in the US are caused by smoking:

1. >75$ bil/yr

2. 20%

1. Lung cancer

2. head and neck cancer

3. COPD

4. Heart disease

1. dec risk of CV events

2. All-cause mortality dec risk 10-25 yrs

3. COPD-dec disabilty or death by dec the rate of fall in FEV1

Ganglionic cholinergic receptor agonist: both cns and pns stimlulate and relax

1.resp stimulation

2. skeletal muscle relaxation

3. catecholamine release by the adrenal medulla, 4.peripheral vasoconstrcition

5. increased BP HR CO and o2 consumption, inc alertness and cognitive funx, stimulate reward system in high doses

6. leads to dependence (77-92%)

7.withdrawl: craving, nervousness, restlessness, irritability, anxiety, sleep disturbia, weight gain

Interventions by multiple providers yielded increased cessation rates

should be made to all smokers interested in quitting

Choice should be guided by patients: past experience and personal experience

1. ASK, ADVISE, ASSESS

2. if willing to quit: 5A's (add assist and arrange)

3. not willing to quit: 5R's (revelance, risks, rewards, roadblacks, repitition)

4. Have quit: relapse prevenntion

treatment options:

1. behavior therapy

2. Nicotine replacement therapy: gum, inhaler, nasal spray, patch

3. Bupropion

4. Varenicline

5.Second line pharmacotherapeutic options: Clonidine, nortiptyline

1. Supportive groups

2. Behavioral modification program (up to 30% one year quit rates)

Nicotine replacement therapy: (NRT) characteristics

1. funx

2. use

3. CI

First line therapy: supplies low levels of nic. to help diminish withdrawl symp

Used as part of a comprehensive smoking-cessation program

doubles quit rates when used with behav. therapies

Not recommended in active smokers or pregnancy or lactation

Recommended dosing of transdermal nic system

for Habitrol:

6 wks: 21mg/day

2wks: 14mg/day

2wk: 7mg/day

8-12 wk duration

6wk: 21mg/day

2wk: 14mg/d

2wk: 7mg/d

8-12 wks total

12wk: 15mg/day

2wk:10mg/d

2wk: 5mg/d

14-20 wks total

4-8wk: 22mg/day

2-4wk: 11mg/d

6-12 wks total

1. Habitrol

2. Nicoderm

3. Nicotrol

4. ProStep

1. first cig in AM

2. diff to refrain from smoking where its forbidden

3. What cig time would be hardest to give up

4. How many cigarettes per day do you smoke

5. do you smoke more frequent in AM than PM

6. Do you smoke when you are so ill that you are in bed most of the day

Higher the score = higher degree of dependence

Nicotine Polacrilex (Nicotine gum) characters:

1.proper chewing

2. plan

1. buccal absorption of nicotine-chew piece slowly, park b/w side of mouth and gym, cont. to chew and park for 30 min

2. gradullly reduce strength and number of pieces to avoid withdrawl

Nicotine inhaler (Nicotrol inhaler)

1. delivery

2. dose

1. delivers 4mg of nicotine to buccal space similar to nic. gum

2. ihale prn, most use 6-16 cartridges daily for 3 mo, then gradually taper over next 6-12 wks

Dose recommendation for nicotine gum

1. >25 cig/day

2. <25cig/day

1. 4mg (9-12pieces/d max 20)

2. 2mg (9-12pieces max 30)

Nicotine lozenge (commit)

1.dose:

2. timing

3.duration

4. Avoid:

1. based on "time of first cig"

-1st cig ,30min of awakening, = 4mg

>30min of awak = 2mg

2. one every 1-2 hours for 6 wks

then one every 2 to 4 hours from weeks seven through nine,

then one every 4-8 hours from wks ten through 12

3. Allow to diisolve for 20-30 min

4. Acidic beverages 15 min prior to using lozenge

1. nasal

2. inhaler

3. gum/losenge

4.patch

Non nicotine aide to smoking cessation

atypical antidepresent

MOA thought to be mediated by noradrenergic or dopaminergic mechanism (inhibits neuronal reuptake of both)

1.Contraindications of bupropion:

2. Precautions

1. Hx of seizure disorder, coadministration with MAOI, current or prior diagnosis of bulimia or anorexia nervosa.

2. no wellbutrin or wellbutrin SR (bupropion as antidepressant)

1. Carbamazepine (dec serum concentration bup)

2. Cimetidine: (inc serum concentrations of bup)

3. MAO inhibitors: (inc toxicity of bup)

150mg SR po qd x3days

then inc. to 150 mg SR bid for 7-12wks

initiate 7 days prior to quit date

can be combine with NRT

dec. dose by 50% in patients with renal or hepatic insufficiency

Alpha-4-beta-2 nicotinic acetylcoline receptor agonist

Varenicline (Chantix)

selectively blocks nicotine binding to alpha 4 beta 2 nicotinic acetylcholine receptors and also stimulate the receptor meciated activity at a significantly lower level than nicotine

1. dec withdrawl symp, dec cravings

2. can smoke while on it: the sensation of smoking a cig may dec

coadmin with nicotine patch 21mg/day = inc. nausea, HA, Vomiting, dizziness, dyspepsia, and fatigue, compared to nic replacement patch alone

Safety and efficacy of coadmin varenicline with other smoking cessation aids has not been established

MC: nausea, sleep disturbance, headache, abnormal dreams, constipation, flatulence, vomiting, change in taste

Unusual violent behavior

suicidal thoughts

change in behavior

may be linked to MI, seizures, DM, dizziness and confusion

Preg c

start one wk before the set stop smoking date and cont. for 12 wks

day 1-3: 0.5mg qday
say 4-7: 0.05 mg bid

day8 end: 1mg twice daily

adjust dose if crcl <30 ml/min

1. Nic nasal spray

2. Varenicline

3. bupropion

4. nic gum

5. nic inhaler

6. nic lozenge

7. nic patch