Smoking and Withdrawal:

1. Smoking and Withdrawal: How to be your patient’s advocate Megan M. Martin DeSales University

2. Nicotine • Used as an insecticide and plant spray when in liquid form • Considered a very poisonous alkaloid: colorless, oily liquid in its pure state • Amount used in cigarettes is not enough to cause (immediate, direct) death. • Nicotine in tobacco can cause indigestion, increase blood pressure, and dull appetite.

3. Action of Nicotine • Nicotine is absorbed through the skin, GI tract, and respiratory mucous membrane • Action of drug is dose-related • Temporarily stimulates both sympathetic and parasympathetic ganglia; also stimulates skeletal muscle • Following stimulant phase, nicotine causes a depressant phase; relaxes skeletal muscle

4. Nicotine in cigarettes: A powerful addiction • Cigarettes are the primary vector of nicotine ingestion. • Others are chew, cigars, and pipe smoking • Cigarettes become addicting after approximately two weeks of smoking ten cigarettes per day • Initial rush of nicotine initiates a temporary feeling of well-being by increasing activity of dopamine in the brain • Considered as addictive as heroine; same action

5. Addiction • The DSM-IV criteria for substance dependence are shown below: • Maladaptive pattern of substance use leading to clinically significant impairment or distress, manifested by three or more of the following within a 12-month period: • Presence of tolerance to the drug; presence of withdrawal symptom • Substance taken in larger amounts/longer period of time than intended • Unsuccessful or persistent desire to cut down or control use… • Varcarolis, 1998

6. Withdrawal • Occurs after a period of continued use • Stopping or reducing use results in specific physical and psychological signs and symptoms • Occurs approximately four hours after last cigarette, peaks in 3-5 days, lasts at least two weeks

7. PHYSICAL Tingling in hands and feet Sweating Intestinal disorders, primarily constipation and/or upset stomach Headache S/S of colds and respiratory problems initially Weight gain MENTAL Insomnia Mental confusion Vagueness Irritability Tension, perceived unbearable Depression, mimics grief Anxiety Physical and Mental Side Effects of Nicotine Withdrawal:

8. First two weeks of withdrawal • Critical in determining failure rate • If smoker cheats in this period, highly likely to return to habit within six months • After five days, the smoker is undergoing the most severe physical effects of withdrawal • Emotional effects are carried for approximately 1-3 months after quitting

9. Success Rates of Quitting • 47 million people in U.S. smoke; 28% of males, 23% of females • 3,000 young people start smoking every day • Although about 25% of adults smoke, 70% of them want to quit • 1/3 will try seriously to quit • Only 6% will be successful within one year • Those who continue to try have 50% success rate

10. Reasons smokers relapse; fail to quit permanently • Depression: Cigarettes relieve minor depression, fits of anger, enhance sense of well being, enhance concentration • Physical effects over long-term seem abstract; “won’t happen to me; I’ll quit” • Weight gain: quitting smoking/withdrawal causes body’s basal metabolic rate to drop for 3-6 months before return to normal. • Average weight gain: 10-25 lbs.

11. Nursing’s relation to the smoking patient • Patients are ill to begin with; withdrawal symptoms can exacerbate their sense of illness • Be your patient’s advocate!! If you know you’re patient is a smoker, call the physician: • Request some form of nicotine replacement unless contraindicated • Request an oral replacement/antidepressant, e.g. Zyban®

12. Nicotine Replacements • Nicotine Patch: Available in several dosages: 21mg-7mg Dosages should gradually be decreased over min. of 6 wks. • Absorbed transdermally • Should be worn 24hrs/day • Adverse SE: pruritus/erythema under patch, nausea, dizziness, myalgias, coughing, difficulty sleeping, nightmares • Recommend that patient change sites daily

13. Nicotine Gum • Absorbed through buccal mucosa • Dosage: 2mg, repeated prn up to 30 pieces of gum/day. • Gum not chewed, rather bitten into and held in the cheek • Adverse SE: injury to mouth, teeth, dental work. Rare: irregular heartbeat • Largest complaint: Gum has peppery taste

14. Nicotine Nasal Spray • Administers 1 mg/2 sprays to the nasal membrane • Faster onset of action than patch or gum • Should be used for at least three months, no longer than six months • Adverse SE: belching, tachycardia, mild H/A, increased appetite, increased watering of mouth, sore mouth or throat

15. Nursing Considerations • Instruct client to take exactly as directed • Instruct the client of the importance of NOT smoking at all while using nicotine replacement therapy; could lead to nicotine toxicity • Give client information of smoking cessation support groups relative to their area • Instruct family if possible of patient needs and support

16. Nursing Diagnoses • Anxiety-Nurses teach deep breathing • Self-esteem disturbance-Nurses teach coping mechanisms • Noncompliance-Nurses support patient throughout withdrawal process • Sleep-pattern disturbance (r/t withdrawal and Zyban/ nicotine replacement)-Nurses teach it is temporary effect; recommend decrease in caffeine, increase in exercise • Constipation-Nurses teach patient about better diet, high in fiber, increase in exercise will decrease occurrence

17. Oral agents; Zyban® • Zyban, also Wellbutrin (bupropion HCl) is an oral agent used to curb the most severe side effects of nicotine withdrawal • Only available through prescription • Actually an antidepressant, Zyban acts as a weak serotonin reuptake inhibitor, also acts on dopamine and norepinephrine centers of the brain

18. Zyban... • When used on people not previously depressed, has no effect on mood • Instruct patient that its primary function is to prevent depression, not an upper • Dosages for smoking cessation differ from dosage used for depressive disorders • Patient usually starts with 150 mg QD X 3days, then 150 mg BID X 7-12 wks.

19. Zyban... • Contraindicated in patients with seizure disorders, MAOI’s, eating disorders • Adverse SE: Weight loss/weight gain, agitation, dry mouth, blurred vision, headache, dizziness, tremor, nausea, vomiting, constipation, insomnia, vivid dreams • SEIZURES with overdose (>450mg/day)

20. Zyban... • Instruct patient that the full antidepressant effect of drug may not be realized for up to 4 wks • Patient is to pick a target date for cessation, stick to it. • Patient may continue smoking while taking Zyban for up to two weeks • It is recommended that the patient consider nicotine replacement in conjunction

21. Nursing Teaching Points... • It is important that the patient be READY to quit, otherwise will be unsuccessful • NEVER push a patient to quit. This will only hurt your relationship with that patient. • Respect the patient’s wishes. Only instruct about the effects of smoking, the values of quitting. Be a support system to your patient. • Remember the effects of Nicotine withdrawal. Be empathetic with the patient’s needs. Be an advocate!

22. Stage-of-Readiness Model for Smoking Cessation

23. Physical Response to Quitting

24. Nursing Teaching: Diet • Encourage your patient to increase the amount of fruits, vegetables, whole grains, and fiber-rich foods. • Encourage the patient to drink large amounts of water • Teach the patient about oral cravings; encourage healthy snacks such as carrots, apples, celery. Also recommend sugar-free gum.

25. Exercise • Quitting may be harder for women than men due to body image perceptions • Encourage patient to increase levels of activity; recommend taking walks during times of craving • Remind patient that if weight is gained, it will most likely come off in time • Teach deep breathing exercises. This helps to mimic feeling of smoking; induces relaxation

26. Conclusion • Smoking is a common addiction • Nurses must be aware of the effects of nicotine both physically and mentally on their patients • Nurses MUST be patient advocates. • Encourage patient to quit • Never push • Speak to the physician about possibility of smoking cessation aide • Continue to have a positive, supportive relationship with patient. Nothing helps more than understanding

27. References • Guthrie, C. (2001). Kick butts now! Online. Available: http://my.webmd.com/content/article/1689.50430 • Ignatavicius, D.D., Workman, M.L., & Mischler, M.A. (1999). Medical-Surgical nursing across the health care continuum (3rd ed.). Philadelphia: W.B. Saunders Company. • McKenry, L.M. & Salerno, E. (1998). Pharmacology in nursing. (20th ed.). St. Louis: Mosby. • Miller, B.F & Keane, C.B. (1997). Encyclopedia & dictionary of medicine, nursing, and allied health. (6th ed.). Philadelphia: W.B. Saunders Company.

28. References (con’t) • Varcarolis, E.M. (1998). Foundations of psychiatric mental health nursing. (3rd Ed). Philadelphia: W.B. Saunders Company • WebMDHealth. (2001). Smoking. Online. Available: http://my.webmd.com/content/article/1680.51953. • Wilson, B.A., Shannon, M.T. & Stang, C.L. (2001). Nursing drug guide 2001. New Jersey: Prentice-Hall, Inc.