Title: Smoking Cessation: A Practical Overview of Pharmacotherapy
1Smoking CessationA Practical Overview of
Pharmacotherapy
- Joseph Saseen, Pharm.D., FCCP, BCPS
- Professor
- University of Colorado
- Joseph.Saseen_at_ucdenver.edu
2Learning Outcomes
- Apply recommendations from guidelines to
customize clinical interventions to patients who
use tobacco - Compare and contrast advantages and disadvantages
of various tobacco cessation pharmacotherapy
products to
3U.S. Department of Health and Human Services
Public Health Service (May 2008)
- Clinical Practice GuidelineTreating Tobacco Use
and Dependence 2008 Update
http//www.surgeongeneral.gov/tobacco/treating_tob
acco_use08.pd f
4Potential Health Benefits of Smoking Cessation
Time After Smoking
15 yrs Risk of MI and stroke reduce to level of
nonsmoker
20 min BP, HR, peripheral circulation improve
10 yrs Risk of lung cancer reduced 50
24 hrs CO levels drop
48 hrs Nicotine eliminated taste and smell
improve
1 yr Risk of MI reduced 50
3-9 mo SOB and coughing decrease
2-12 wks Lung function can improve 30
5Nicotine Stimulates Dopamine Release
- High nicotine levels achived in 11 seconds from
inhalation
Nicotine and Tobacco Research 19991s121-s125
610 Key Guideline Recommendations
- Repeated intervention and multiple attempts
- Identify and document tobacco use status and
treat every tobacco user - Treatments are effective counseling and
medications - Brief treatment is effective
- Counseling is important practical and social
support
http//www.surgeongeneral.gov/tobacco/treating_tob
acco_use08.pd f
710 Key Guideline Recommendations
- Medications should be used whenever possible
- Combination of counseling and medication more
effective than either alone - Telephone quitline counseling is effective
- Use motivational treatment if patients unwilling
to quit - Insurance plans should include counseling and
medication coverage
http//www.surgeongeneral.gov/tobacco/treating_tob
acco_use08.pd f
8The 5 As Model
http//www.surgeongeneral.gov/tobacco/treating_tob
acco_use08.pd f
9Meta Analysis 2008 (n18 studies)
http//www.surgeongeneral.gov/tobacco/treating_tob
acco_use08.pd f
10First Line Medications
- Nicotine gum
- Nicotine inhaler
- Nicotine lozenge
- Nicotine nasal spray
- Nicotine patch
http//www.surgeongeneral.gov/tobacco/treating_tob
acco_use08.pd f
11Nicotine Gum
- May satisfy oral cravings
- May delay weight gain
- Patients can titrate therapy to manage withdrawal
symptoms
- Gum chewing may not be socially acceptable
- May stick to dental work and dentures
- Proper chewing technique (Chew/Park) needed to
minimize adverse effects - Cannot eat or drink 15 minutes before or while
using the nicotine gum
12Nicotine Inhaler
- Patients can easily titrate therapy to manage
withdrawal symptoms - Mimics the hand-to-mouth ritual of smoking
- Initial throat or mouth irritation (in first
week) - Cartridges should not be stored in conditions
gt86oF or lt59oF - Patients with underlying bronchospastic
conditions should use with caution
13Nicotine Lozenge
- May satisfy oral cravings
- Easy to use and conceal
- Patients can titrate therapy to manage withdrawal
symptoms
- Gastrointestinal side effects (nausea, hiccups,
heartburn) may be bothersome - Must allow slow dissolution for 20-30 minutes (no
chewing) - Should not eat or drink for 15 minutes before or
while using the nicotine lozenge
14Nicotine Nasal Spray
- Dose can be easily titrated to rapidly manage
withdrawal symptoms
- Initial nasal or throat irritation can be
bothersome (may last up to 3 weeks) - Higher dependence potential relative to other NRT
formulations - Patients with chronic nasal disorders (e.g.,
rhinitis, polyps, sinusitis) or severe reactive
airway disease should not use
15Nicotine Patch
- Steady-state nicotine levels are achieved
throughout the day - Easy to use and conceal
- Fewer compliance issues are associated with the
patch
- Patients cannot titrate dose
- Allergic reactions to the adhesive may occur
- Patients with underlying dermatologic conditions
(e.g., psoriasis, eczema, atopic dermatitis)
should not use the patch
16Bupropion SR (Zyban)
- Oral formulation given BID that is easy to use
- May be beneficial for patients with coexisting
depression - Initiated before quit date
- No risk of nicotine toxicity if patient continues
to smoke
- Increases seizure risk
- Several contraindications and precautions that
may preclude use - Side effects of insomnia and dry mouth
17Varenicline (Chantix)
- Oral formulation given BID that is easy to use
- Initiate before quit date
- New mechanism of action for persons who
previously failed using other medications
- May induce nausea in up 1/3 of patients (need to
titrate) - Post-marketing surveillance data stimulated FDA
warning
18Varenicline (Chantix)Package Insert Update
- WARNINGS and PRECAUTIONS
- Serious neuropsychiatric symptoms have occurred
in patients being treated with CHANTIX. Some
cases may have been complicated by the symptoms
of nicotine withdrawal in patients who stopped
smoking however, some of these symptoms have
occurred in patients who continued to smoke. All
patients being treated with CHANTIX should be
observed for neuropsychiatric symptoms including
changes in behavior, agitation, depressed mood,
suicidal ideation and suicidal behavior.
19Varenicline (Chantix)FDA Alert February 1, 2008
- Recommendations and Considerations for Healthcare
Professionals - Monitor all patients taking Chantix for serious
neuropsychiatric symptoms - Serious psychiatric illness (e.g., schizophrenia,
bipolar, major depressive disorder) may worsen - Consider these safety concerns and alert patients
about these risks
http//www.fda.gov/Drugs/DrugSafety/PostmarketDrug
SafetyInformationforPatientsandProviders/ucm106540
.htm
20Varenicline (Chantix)FDA Alert February 1, 2008
- Information for the patient
- Report any history of psychiatric illness prior
to starting Chantix - Be alert to changes in mood and behavior
- Immediately report changes in mood and behavior
- Vivid, unusual, or strange dreams may occur
- Medication Guide (5/16/08)
- http//www.fda.gov/downloads/Drugs/DrugSafety/UCM0
88569.pdf
http//www.fda.gov/Drugs/DrugSafety/PostmarketDrug
SafetyInformationforPatientsandProviders/ucm106540
.htm
21Monotherapy
http//www.surgeongeneral.gov/tobacco/treating_tob
acco_use08.pd f
22Combination Pharmacotherapy
- These combinations are considered effective
according to guidelines
http//www.surgeongeneral.gov/tobacco/treating_tob
acco_use08.pd f
23Cost of Pharmacotherapy
http//www.drugstore.com
24Bottom Line Pharmacotherapy for Smoking Cessation
- All smokers trying to quit should be offered
medication. except when contraindicated or for
specific populations for which there is
insufficient evidence of effectiveness - Pregnant women
- Smokeless tobacco users
- Light smokers
- Adolescents
http//www.surgeongeneral.gov/tobacco/treating_tob
acco_use08.pd f
25Plethora of Resources
- CO Quitline (www.coquitline.org)
- Fixnixer (www.fixnixer.com)
- Become an Ex (www.becomeanex.com)
- My Last Dip (www.mylastdip.com)
- Cigarette is Dead (www.thecigaretteisdeadtimeline.
com) - Quit Doing it Labs (www.quitdoingitlabs.com)
- Raise Smoke Free Kids (www.raisesmokefreekids.com)
26Quit Tips
- Make a quit plan. Pick a date and make a list of
reasons you want to quit. - Prepare for your quit date. This means getting
rid of all tobacco-related items, such as
ashtrays, lighters and matches. - Ask your family and friends to support you in
your quit attempt. Tell them your quit date and
ask them to be supportive and understanding. - Keep a picture of your loved ones. Tape a message
to the picture that reminds you that you are
quitting for them. Look at the picture and read
the message anytime you have an urge to smoke. - When you feel an urge to reach for a cigarette,
try taking a walk, playing with your kids or
running up and down the stairs instead of
lighting up. - For the first few days after you quit smoking,
spend as much free time as possible in public
places where smoking is not allowed.
- Reward yourself when you reach milestones in your
quit attempt, such as buying yourself a new book
or treating yourself to a nice dinner with a
supportive friend. - Keep healthy snacks, gum, mints and toothpicks
around, and drink plenty of water. - Try to avoid people, places or other trigger
habits you typically associate with smoking. - Take deep, slow breaths and imagine your lungs
filling with clean, fresh air. - Create a smoke-free rule for your home and car.
Smoke-free environments can support you in the
quitting process. - Dont give up. Most people have to try several
times to quit smoking. You can do it.
www.myquitpath.com