Community pharmacy Topic 6: Smoking cessation

1. Community pharmacyTopic 6:Smoking cessation

2. Background • Smokers most often die from lung cancer, but the second and third most likely cause of death for smokers is COPD ( 15% of who smoke 1 pack/day) and CAD. • Smokers should be aware of cancers that can be caused by smoking. Ex: cancer of larynx, pancreas, kidney, uterus… • The Bp is raised for several hours after each cigarette.

3. Second hand smoke is associated with CHD as well. Kids and infants of smokers are the most affected by second hand smoke. • Second hand smoke causes more than as estimated 202.000 asthma episodes, 790.000 cases of otitis media, and 430 sudden infant death syndrome cases each year.

4. How nicotine is harmful • Cigarettes are full of harmful chemicals including over 4000 chemical compounds and at least 40 known carcinogenic. • Nicotine from smoking can reach the brain in 11 seconds. Next, dopamine is released in the nucleus accumbens and prefrontal cortex. Dopamine, as can be explained to patients, releases feeling of euphoria and pleasure. • Dopamine leaves the system rapidly as well, within minutes

5. The combination of rapid stimulation and exist with dopamine reward pathway stimulate the need for repeat administration until tolerance develops. • Nicotine results in the release of other neurotransmitters such as norepinephrine and acetylcholine. Increased norepinephrine release results in elevated Bp, HR, strokevolume, and cardiac out put. This can lea to cardiovascular problems.

6. The polycyclic aromatic hydrocarbons can stimulate cytochrome P450 metabolism in the liver. It can expedite insulin metabolism and lead to increase insulin requirement for patients with DM. • Carbon monoxide also can interfere with the carbon dioxide/ oxygen transmission in the alveoli of the lungs, leading to decreased oxygenation in the tissues of the lower extremities . Decreased peripheral vascular blood flow and increased risk of neuropathy.

7. High density lipoproteins are decreased, while low density lipoproteins are increased. • Reducing estrogen levels, which increase the risk of osteoporosis over time Benefits of cessation • Circulation improves and walking become easier within 2 weeks to 3 months after quieting.

8. Lung function will increase up to 30 % and within 1-9 months lung cilia will begin to function normally again. • Coughing, shortness of breath, and fatigue begin to decrease within this time period as well. • After1 year, risk of developing CAD decrease to half that of some-one who has continued to smoke. • They will feel better, look better, have more energy, and will have saved money.

9. The risk of being diagnosed with COPD decreases incrementally by a year, and after 5 years the risk of stroke is reduced to the same as one who had never smoked. • Wight: Most former smokers tend to gain a mean increase of 4-5 kg after 12 months of quitting. Food begins to taste better and it is natural that their appetite increases.

10. Barriers • Former smokers would have to gain amount of weight before the benefits of smoking cessation would be offset by the weight gain. • Another common barrier for many older smokers is the preconceived idea that quitting would not benefit. • Smokers who are unwilling to quit at the time it is first approached should not be “pushed” hard at first.

11. The best approach would be to state “ as your pharmacist, I would be glad to discuss smoking cessation with you at later time when you are more ready” • Former smoker are proud that they were able to quit. Many even remember the exact date and time they smoked their last cigarette. • Be always prepared if the patients is likely to relapse.

12. Initial components of assisting with a quit attempt • Establishing a quit date: may link it to an important date, encourage the smoker to circle it on the calendar. • Initial plan: START plan( S: set a quit date within 2 weeks, T:tell every one ,A: anticipate problems, R: remove tobacco products from the environment, T: take action, daily adjustments of behavior and thinking) • Family should be supportive, smokers should be away during the crucial period. they should understand that mood changes could be experienced.

13. Anticipate problems(history of nicotine product use): current daily use of nicotine, how many cigarettes daily at the highest amount, brands used, how many quit attempts have been tried, past use of a cessation medication… • Changing behavior and thinking: smoking in early morning while drinking coffee, smoking while relaxing in front of TV.

14. 3. Practical changes to implement: • Fewer than 5% of people who quit without assistance are successful for longer than a year. • Stress management: for people smoke during times of stress • Switching to brands cigarettesHigh price… less use. • Smoker should not buy cigarettes by carton before the stopping date. • Smoker should attempt to taper nicotine

15. For those using nicotine replacement therapy, the medications should be started on this date. • Symptoms of withdrawal include: “ craving” , anxiety, depression, anger, insomnia, increased appetite, weight gain, difficulty concentrated… • Withdrawal symptoms tend to peak with 24-48 hours after quitting and usually subside within 2-4 weeks.

16. Cognitive technique • Include: • Using positive thinking. • Thought control techniques: distracting self or few minutes until graving resolved. • Relaxation and stretching exercises • Abdominal breathing: sitting comfortably back on a chair with feet flat on floor, and one hand on abdomen with closing eyes. Inhale slowly and deeply from nose, hold breath for 2 seconds, exhale slowly through nose, repeat at least for 5 minutes , twice daily.

17. Tips to prevent relapsing • Pay attention to the important rule: there is no such thing as “ just one cigarette” • Avoid triggers and other urges: avoid stress as possible, take a walk, watching movie, using nicotine gum or lozenges • Finding ways to pamper self: mini shopping, rewarding self without cigarettes… • Active exercises then overcome with erge.

18. Medication management • The three classes: • NRT • Psychotropics • Nicotine agonist • Patients who are pregnant or breast feeding, smoking fewer than 10 cigarettes/day, have medical contraindications or adolescents should not be offered pharmacotherapy

19. A 2012 review, which included the Cochrane review, reported that there was good evidence that community pharmacists can deliver effective smoking cessation campaigns, and that structured interventions and counselling were better than opportunistic intervention (Brown et a! 2012). • It should be noted that relapse is a normal part of the quitting process, and occurs on average three to four times. If a smoker has made repeated attempts to stop and failed, or has experienced severe withdrawal, or has requested more intensive help, then referral to a specialist smoking cessation service should be considered.

20. Using medications for “ craving” • Tolerance to the effects of nicotine is rapid. Once plasma nicotine levels fall below a threshold, patients begin to suffer nicotine withdrawal symptoms and will crave another cigarette • Bupropion, varenicline, nicotine patches. • If patient use these medications, adding short acting NRT I a reasonable way to combat breakthrough craving. • If NRT is the only medication used, it should not bused as needed. Rather, the patient should be counseled to “scheduled” each dose of NRT. • While making a quit attempt, patients should be aware of usual life events that may cause stress

21. Nicotine replacement therapy • OTC: nicotine gum, lozenges, patches • Prescriptions : nasal spray, inhalers. • All forms of cessation medications are twice effective as placebo . Patients are far less likely to develop dependence on OTC medication in comparison to the present tobacco use. • The ultimate goal for successful quit attempt is for the patient to neither be smoking nor using cessation medications after a certain time period.

22. All NRT formulation deliver nicotine more slowly and lower concentrations. With transdermal therapies have the lowest absorption. • Caution should be taken for smokers with underlying cardiovascular disease such as MI, life-threatening arrhythmia, or severe angina, pregnancy, lactation( nicotine is category D)….. licence restrictions

23. Side effects with NRT are rare and are either normally limited to gastrointestinal (GI) problems associated with accidental ingestion of nicotine when chewing gum, or local skin irritation. Headache, nausea and diarrhoea have also been reported.

24. Nicotine gum • Two strength: 4 and 2 mg • If used as monotherapy, the gum should be chewed on fixed schedule and tapered appropriately. • The gum should not be chewed in response to craving alone , and not should not chewed like ordinary gum, as raid release of nicotine results in GI upset. It should be chewed slowly. • Most of nicotine in the gum is gone within 30 minutes. • Patients should not to eat or drink for 15 minutes before or while using nicotine gum – esp. coffee., acidic beverages can lower the pH of saliva and reducing the efficacy of buccal absorption.

25. Nicotine patch • It delivers transdermal nicotine in an steady over a 24 hour period. • Strength: 7, 14, 21 mg. patients who smoke<10 cigarettes/day are suggested to start with 14 mg. • Tapering dose 21 mg for 6 weeks … 14 mg for 2 weeks…. 7 mg for 2 weeks • Side effects: skin irritation (50%)…. Changing brand or using hydrocortisone cram, itching, tingling.

27. Nicorette • Nicorette is available as gum (2 and 4 mg), inhalation cartridge ( 10 and 15 mg), microtab (2 mg), nasal spray (10 mg) patches (5, 10 and 15 mg or 'invisipatches' 10, 15 and 25 mg) mouth spray (1 mg/spray) lozenge (2 mg) and combination packs (patch and gum). • Gum • Nicorette gum is available as either fruit or mint flavours (unflavoured gum leaves a bitter taste in the mouth). The strength of gum used will depend on how many cigarettes are smoked each day.

28. In general, if the patient smokes less than 20 then the 2 mg gum should be used. If more than 20 cigarettes per day, then the 4 mg strength may be needed. A maximum of 15 pieces of gum can be chewed in any 24-hour period. • Inhalation cartridge • The inhalator can be particularly helpful to those smokers who still feel they need to continue the hand-to-mouth movement. Each cartridge is inserted into the inhalator and air is drawn into the mouth through the mouthpiece. Inhalators can be used to either reduce the number of cigarettes smoked or as part of a quit attempt. For the 10 mg inhalator a maximum of 12 cartridges per day can be used.

29. Each cartridge can be used for approximately four sessions, with each cartridge lasting approximately 20 minutes of intense use. For the 15 mg inhalator a maximum of six cartridges can be used. Each cartridge can be used for approximately eight 5-minute sessions, with each cartridge lasting approximately 40 minutes of intense use. The amount of nicotine from a puff is less than that from a cigarette. To compensate for this it is necessary to inhale more often than when smoking a cigarette.

30. Microtabs (2 mg) :are licensed for either smoking cessation or smoking reduction. For smoking cessation, the standard dose is one tablet per hour in patients who smoke less than 20 cigarettes a day (doubled for heavy smokers). • This can be increased to two tablets per hour if the patient fails to stop smoking with the one tablet per hour regimen or for those whose nicotine withdrawal symptoms remain so strong they believe they will relapse.

31. Most patients require between 8 and 24 tablets a day, although the maximum is 40 tablets in 24 hours. Treatment should be stopped when daily consumption is down to 1 or 2 tablets a day. For those reducing the number of cigarettes smoked, the tablets should be used in between cigarettes to try and prolong the smoke-free period.

32. Nasal spray (each spray delivers 0.5 mg nicotine) • At the start of treatment one spray should be put into each nostril, twice an hour to treat cravings. The maximum daily limit is 64 sprays; equivalent to two sprays in each nostril every hour for 16 hours. A 3-month treatment programme is advocated in smoking cessation attempts. For the first 8 weeks the patient uses the spray on a when needed basis. After which the patient should aim to reduce usage by half in the next 2 weeks and to nothing after a further 2 weeks.

33. Patches • Nicorette patches are marketed as either Nicorette 'Invisipatches‘ (strengths of 25, 15 and 10 mg) or Nicorette patches (strengths of 15, 10 and 5 mg). The patches are usually applied in the morning and removed at bedtime (a 16 hour patch). Dosing for either product range is the same. Patients who want to stop smoking should start on the

34. Lozenge (2 mg) • Lozenges, like other dose forms, can be used for either smoking cessation or smoking reduction. Most smokers require 8 to 12 lozenges per day (maximum 15 lozenges per day). Reduction strategies are the same as other dose forms in that the lozenges are used when needed between smoking cigarettes to prolong smoke-free intervals and with the intention to reduce smoking as much as possible.

35. Others • Nicotinell • Gum is flavoured and available as fruit, mint or liquorice. • The patches are worn continuously and changed every 24 hours • Lozenge Low strength ( 1 mg) are recommended for those who smoke less than 20 cigarettes a day. • NiQuitin: available as gum (2 or 4 mg), patches (7, 14 and 21 mg} and lozenge (2 and 4 mg or NiQuitin minis, 1.5 and 4 mg).

38. Bupropion • Atypical Antidepressant • Non-nicotine oral tablet • Blocking dopamine or norepinephrine reuptake in CNS • Dose: 150 mg of extended release formulation 1x1 for 3 days, then 150 mg 1x2 for 7-12 weeks. • The quit date should be set for 1-2 weeks of starting Bupropion, as it takes at least 1 week to achieve SS • Drugs interactions: • TCAs, SSRI increased levels while taking Bupropion • Levodopa, monoamine oxidase inhibitors: may increase Bupropion level • Carbamazepine may decrease the concentration

39. Varenicline • Partial agonist on neural nicotinic acetylcholine receptor subunit. • It stimulate dopamine relase and decreases nicotinc graving • Should be started 1-2 weeks prior to the quit date. • Dose: 0.5 mg for 3 days 1x1, then 0.5 mg from day 4-7 1x2, then from day 8 and beyond 1 mg 1x2. • Should be taken for 12 weeks , additional 12 weeks of the therapy can be continued if needed. • S.E: nausea, headache, insomnia abnormal dreams, dyspepsia…. STOP immediately if there is suicidal attempts.

40. References • Community and clinical pharmacy services( a step by step approach ), chapter 9, ashley ellis,2013. • Community pharmacy (symptoms, diagnosis, and treatment), chapter 10, paul rutter,2013