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Treating Tobacco Use During Pregnancy and Beyond

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Treating Tobacco Use During Pregnancy and Beyond ... Other toxins in tobacco smoke, not nicotine, are responsible for majority of ... – PowerPoint PPT presentation

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Title: Treating Tobacco Use During Pregnancy and Beyond


1
Treating Tobacco Use During Pregnancy and Beyond
  • Pharmacological Aids to Assist Pregnant Women
    With Smoking Cessation
  • Dr. Monica Scheibmeir
  • Associate Professor School of Nursing
  • University of Kansas Medical Center

2
Pharmacologic Intervention
  • Behavioral interventions are first-line treatment
    in pregnant women (the 5 As)
  • Pharmacotherapy has not been sufficiently tested
    for efficacy or safety in pregnant smokers

3
Smoking and nicotine
  • Other toxins in tobacco smoke, not nicotine, are
    responsible for majority of adverse health
    effects
  • gt 4000 different chemicals
  • tar, carbon monoxide, irritant and oxidant gases
  • gt 40 carcinogens (9 group 1 carcinogens)

4
Smoking and nicotine
  • The main adverse effect of nicotine from tobacco
    is addiction, which sustains tobacco use
  • Nicotine dependence leads to continued exposure
    to toxins in tobacco smoke

5
Nicotine Replacement Therapy
  • Delivers a small, steady dose of nicotine into
    the body, which helps to relieve the withdrawal
    symptoms
  • Increases the long-term quit rates
  • Should be used in combination with counseling,
    such as health care provider, Quitline, etc.

6
Nicotine replacement therapy
  • Nicotine replacement therapy (NRT) can be used
    instead of tobacco to aid quitting
  • NRT delivers nicotine without the toxins from
    tobacco
  • NRT helps combat the symptoms of withdrawal
  • Nicotine dose from NRT is lower and administered
    more gradually than with smoking and this reduces
    the addictive potential

7
Safety of NRT
  • Risk of cancer from NRT is negligible compared to
    the risk from continued smoking
  • Nicotine per se is not a known cause of cancer
  • Other tobacco smoke constituents are believed to
    be responsible for cancers

8
NRT and pregnancy
  • Maternal smoking is associated with poor
    pregnancy and childhood outcomes
  • Many toxins in tobacco smoke could be responsible
  • Nicotine is a potential fetal teratogen
  • Nicotine may contribute to obstetrical
    complications in pregnant women and to sudden
    infant death syndrome

9
NRT and pregnancy
  • Benefits of NRT outweigh the risks of smoking
    during pregnancy
  • reduce or eliminate the exposure of fetus to
    other toxins in tobacco smoke
  • reduce overall dose and duration of exposure to
    nicotine

10
Pharmacologic Intervention
  • Behavioral interventions are first-line treatment
    in pregnant women (the 5 As)
  • Pharmacotherapy has not been sufficiently tested
    for efficacy or safety in pregnant smokers
  • It may be necessary for heavy smokers (1 or more
    packs per day)

11
High Measure of Dependence
  • 10-20 or more cigarettes per day
  • Smokes within 30 minutes of waking
  • Comorbid psychiatric disorders
  • No previous quit attempt or repeated failed quit
    attempts

12
Suggestions for Use of NRT
  • Clinical Recommendations
  • Use NRT in combination with behavioral therapy
  • Select dose based on evidence of what is
    effective to achieve quit
  • Individualize delivery system given patients
    symptoms
  • Use non-continuous delivery mechanisms
  • Start NRT as early as possible in pregnancy

13
Choosing a Pharmacological Agent
  • Patient preference
  • Patients previous experience with medications
  • Compliance/costs
  • Clinician familiarity with medication

14
NRT Products
  • Polacrilex Gum Nasal
    Spray Nicorette (OTC)
    Nicotrol NS (Rx)
  • Generic nicotine gum (OTC)
  • Lozenge
    Inhaler
  • Commit (OTC)
    Nicotrol (Rx)
  • Transdermal Patches
  • Nicoderm CQ (OTC)
  • Nicotrol (OTC)
  • Generic nicotine patches (OTC, Rx)

15
The Nicotine Patch
  • Published studies with pregnant women
  • Rx in 1991 OTC in 1996
  • Supplies a steady amount of nicotine to the body
    through the skin
  • usually lower plasma nicotine levels than seen
    with smoking
  • Low potential for dependence

16
Transdermal Nicotine Patch Comparisons
17
Transdermal Nicotine Patch Dosing
18
Issues/Side Effects of the Nicotine Patch
  • Use upper body area when applying the patch
  • Same site should not be used for at least 1 week
  • Skin irritation Patient must rotate patch site
    each time a new patch is applied
  • Often disturbs sleep at night (vivid dreams)

19
Nicotine Gum
  • Published report with pregnant smokers
  • Rx in 1984, OTC in 1996
  • Chewing gum releases nicotine into the
    bloodstream through the lining of the mouth
  • Sugar free base
  • Available in 2mg and 4mg doses regular, mint,
    orange

20
Nicotine Gum Directions for Use
  • Must park and chew
  • Have patient stop chewing when minty, peppery, or
    tingling sensation occurs
  • When sensation fades, start chewing gum slowly
    again
  • Initially chew gum for 30 minutes
  • Frequent use initially (15-20 per day)
  • Great for triggers

21
Nicotine Gum Dosing
  • Recommended Schedule for Gum

22
Issues/Side Effects of Nicotine Gum
  • Not appropriate for patients with TMJ
  • Not appropriate for patients with dental work
  • Absorption is slow peaks around 15 minutes

23
Issues/Side Effects of Nicotine Gum
  • Requires alkaline pH no soda, coffee, juice at
    least 15 minutes before or during use of the gum
  • Not to use more than 24 pieces/day
  • If swallowed, causes heartburn
  • Mouth sores can occur

24
Nicotine Lozenge
  • No published studies in pregnancy
  • Available in 2002 OTC
  • Delivers about 25 more nicotine than gum
    equivalent
  • Available in 2mg and 4mg strengths

25
Nicotine Lozenge
  • Dosage based upon time to first cigarette not
    number of cigarettes/day
  • If patient smokes within 30 minutes of awakening,
    suggest 4mg lozenge
  • If patient smokes her first cigarette more than
    30 minutes from awakening, suggest 2 mg lozenge
  • Dosing schedule is identical to gum

26
Nicotine Lozenge
  • Instruct patient to allow lozenge to dissolve
  • Do not chew or swallow the lozenge
  • The lozenge will dissolve 20-30 minutes
  • Do not have the patient eat or drink 15 minutes
    before or during use of the lozenge
  • Should use 9 lozenges/day to improve changes of
    quitting

27
Issues/Side Effects of Nicotine Lozenge
  • Common side effects include nausea, hiccups,
    heartburn, cough, headache, and flatulence
  • An advantage is easy to conceal
  • May help with oral cravings

28
Nicotine Nasal Spray
  • No published studies in pregnant women
  • Rx in 1996
  • Quicker than patch or gum reduce cravings in
    minutes of use
  • Each metered dose delivers 0.5 mg nicotine

29
Nicotine Nasal Spray
  • One 0.5mg dose in each nostril (up to 40 per
    day)
  • Start with 1-2 doses per hour
  • Increase prn to maximum of 5 doses per hour
  • Patients should use at least 8 doses/day for the
    first 6-8 weeks
  • Need to taper over 4-6 weeks

30
Issues/Side Effects of Nicotine Nasal Spray
  • Not recommended for patients with nasal or sinus
    conditions
  • Watering eyes and nose
  • Burning sensation in nose
  • Irritated throat
  • Sneezing and coughing

31
The Nicotine Inhaler
  • No published studies with pregnant women
  • Rx in 1997
  • Delivers 4m nicotine vapor
  • May satisfy strong oral or hand-mouth urges
    (feels like smoking)

32
The Nicotine Inhaler
  • Initially, use 6 cartridges/day up to the max of
    16 cartridges/day
  • Not to use gt 12 weeks duration
  • Tapering may take an additional 6-12 weeks
  • Instruct patient to inhale deeply or puff using
    quick breaths
  • Cartridge doesnt have to be used all at once
  • Is less effective in very cold/hot temperatures

33
Issues/Side Effects of the Nicotine Inhaler
  • Slower onset, like gum
  • Throat and mouth irritation
  • Coughing
  • Not for patients with bronchial problems, such as
    asthma

34
Tobacco Cessation Aids that Do Not Contain
Nicotine
  • Bupropion (Zyban-sustained release formula)
  • Available only by prescription
  • Category B drug in pregnancy
  • GlaxoSmithKline Pregnancy Registry
  • (1-800-336-2176)
  • Dose is 150mg (one dose per day, 2 doses after 3
    or 5 days). Should start using 1 week before quit
    date.

35
Issues/Side Effects of Bupropion
  • Greatest risk is seizures
  • Dry mouth
  • Insomnia
  • Dizziness
  • Not for patients with eating disorders

36
Pharmacotherapies for smoking cessation during
pregnancy
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