Chidiebere Eze, PharmD

PGY-1 pharmacy resident

IUH – Ball Memorial Hospital
Smoking Cessation
1 pack = 20 cigarettes

Health benefits with smoking cessation:

After 20 mins HR & BP decrease to normal
~3 months Ease of blood flow; Lung function improves; Immune system improves
~ 9 months Cough, sinus congestion, wheezing and fatigue decreases; lungs have increased ability to handle mucus
At 1 year Risk of heart disease decreases by half of a smoker
At 5 years Stroke risk reduced to that of a non-smoker
At 10 years Risk of lung cancer drops to half that of a smoker; risk of mouth, throat, esophagus, bladder, kidney and
pancreatic CA decreases
At 15 years Risk of coronary heart disease and risk of death similar to non-smoker

Assisting patient with quitting:

 The 5 A’s:
o Ask about tobacco use
o Advice to quit
o Assess readiness (4 stages)
 Stage 1: Not ready to quit in a month
 GOAL: Start thinking about quitting
 5 R’s: Reward, Relevance, Risks, Road blocks, Repetition
 Stage 2: Ready to quit in the next month
 GOAL: facilitate quitting process, set quit date
 Stage 3: Recent quitter within the last 6 months
 GOAL: determine status of patient’s success
 Stage 4: Former user; quit > 6 months ago
 GOAL: remain tobaccos free for life
o Assist with the quit attempt
o Arrange follow-up

Pharmacologic therapy:
 Not indicated for:
o Smokeless tobacco (spit tobacco)
o Adolescents <18 years
o Smoking few cigarettes per day
 Nicotine replacement therapy (NRT)
o Patch:
 Dose:
 ≤ 10 cigs/day
o Step 2: 14mg x 6 weeks
o Step 3: 7 mg x 2 weeks
 >10 cigs/day
o Step 1: 21mg x 4 weeks
o Step 2: 14 mg x 2 weeks
o Step 3: 7 mg x 2 weeks
 Side effects:
 Vivid dreams, headache, skin reactions (rash, irritation, burning, tingling, itching)
 Counseling points:
 Apply to clean dry skin; remove old patch before applying new one; rotate application sites
 Do not leave patch on for > 24 hours; do not cut patches
 Remove patches before MRI procedures
 Advantages: doubles quit rates, C/I in CVD
o Gum:
 Dose:
 2 mg if patient has first cig >30 mins after waking up or smokes <25 cigs/day
 4 mg if patient has first cig <30 mins after waking up or smokes >25 cigs/day
 Dosing schedule:
 Chidiebere Eze, PharmD
PGY-1 pharmacy resident
IUH – Ball Memorial Hospital
 Week 1-6: 1 piece every 1-2hrs
 Week 7-9: 1 piece every 2-4 hrs
 Week 10-12: 1 piece every 4-8 hrs
 Side effects:
 Mouth soreness, jaw ache, hiccups, GERD, N/V, HA, indigestion, light headedness
 Counseling:
 Use min of 9 pieces/day. DNE >24 pieces/day
 Do not eat/drink for 15 mins before or while using gum
 Avoid in patients with dentures
o Lozenge:
 Dose:
 2 mg if patient has first cig >30 mins after waking up
 4 mg if patient has first cig <30 mins after waking up
 Dosing schedule:
 Week 1-6: 1 piece every 1-2hrs
 Week 7-9: 1 piece every 2-4 hrs
 Week 10-12: 1 piece every 4-8 hrs
 Side effects:
 Cough, hiccups, GERD, N/V, HA, indigestion
 Counseling:
 Place in mouth and allow to dissolve slowly (may cause warm, tingling sensation)  20-30 mins
 Do not chew or swallow lozenge
 Rotate to different areas of the mouth
 Use min of 9 pieces/day. DNE >20 pieces/day
 Do not eat/drink for 15 mins before or while using lozenge
 Can use in patients with dentures
o Nasal spray:
 Dose:
 1 dose = 1 mg = 1 spray; Use 1-2 doses per hour an taper down (MAX 40 mg = 80 sprays)
 Re-prime 1-2 sprays if not used for 24 hours
 Rx only
 Side effects:
 Spray may cause tearing, coughing or sneezing, running nose
 May feel hot peppery sensation in back of throat or nose
 Counseling:
 Wait 5 mins before operating heavy machinery
 Has high dependence potential
o Inhaler:
 Dose:
 1 dose = 1 inhalation = 4 mg nicotine vapor (1 cartridge = 10 mg nicotine)
 Start with 6 cartridges/day during first 3-6 weeks (MAX 16 cartridges/day)
 Duration: 3 months; but gradually reduce daily dose over following 6-12 weeks
 Rx only
 Side effects:
 Mild irritation of mouth or throat, cough, HA, rhinitis, dyspepsia
 Less often: taste disturbances, N/D, hiccups
 Counseling:
 Mimics hand-to-mouth ritual
 Do not eat/drink for 15 mins before or while using inhaler
 Bupropion:
o MOA:
 Atypical antidepressant that affects various brain NTs (dopamine, norepinephrine).
 Works to decrease cravings, and decrease symptoms to nicotine withdrawal
o Dose:
 150 mg QAM x 3 days, then 150 mg BID x 7-12 weeks (doses must be 8 hours apart)
 Begin 1-2 weeks prior to quit date
o Contraindications:
 Chidiebere Eze, PharmD
PGY-1 pharmacy resident
IUH – Ball Memorial Hospital
 Avoid in patients with seizure disorder (patients taking wellbutrin, MAOi in past 14 days)
 Avoid in patients with diagnosis of anorexia or bulimia nervosa
 Avoid in patients undergoing abrupt discontinuation of alcohol or sedatives including benzodiazepines
o Side effects:
 Insomnia (consider taking 2nd dose earlier long before bedtime)
 Dry mouth, HA, changes in mood (depression and mania)
o Warnings:
 Neuropsychiatric symptoms, suicidal risk, psychosis/hallucinations/paranoia/delusions, agitation,
aggression
o Pearls:
 Doesn’t require titration to discontinue
 Try alternative therapy if ineffective by the 7th week.

 Varenicline
o MOA:
 Binds with high affinity and selectivity at the alpha-4-beta-2 neuronal nicotinic acetylcholine receptors
 Competitively inhibits nicotine binding and blocks reward system with smoking, decrease withdrawal risk
o Dose:
 0.5 mg daily x 3 days, 0.5 mg BID x 4 days, then 1 mg BID x 11 weeks
 Begin 1 week prior to quit date
 Take after meals with full glass of water
o Warnings:
 Neuropsychiatric symptoms, suicidal risk, psychosis/hallucinations/paranoia/delusions, agitation,
aggression
o Side effects:
 N/V, constipation, flatulence
 Insomnia (consider taking 2nd dose earlier long before bedtime), vivid dreams
o Counseling:
 Insomnia and Nausea are usually temporary
 Use caution when driving or operating heavy machinery

Recommendations:
 Combination therapy: Patch + gum/lozenge; Bupropion + NRT; Varenicline + patch
 Counsel + medication
 Options:
o Quit cold-turkey – Good support system
o Telephone programs (1-800-QUITNOW)
o Websites: www.smokefree.gov, www.quitnet.com, www.becomeanex.org
o Apps?