Smoking Cessation

Detrimental effects of smoking and benefits of smoking cessation

  • Detrimental effects:  various cancers, CV, respiratory, reproductive, death
  • Dependence:  abrupt discontinuation leads to withdrawal; need the substance to maintain homeostasis
  • Addiction: drug seeking behavior for continued use; compulsive use despite negative effects
  • Tolerance:  diminished effect of a drug upon repeated use
  • Reinforcement:  reminder of the good feelings tat should be repeated
  • Benefits of smoking cessation:
    • BP, Pulse/Heart rate & temperature of extremities should normalize in 20 minutes
    • Blood carbon monoxide & dioxide should decrease (but not necessarily to normal baseline) within 8 hours
    • Blood oxygen & smoker’s breath should normalize within 8 hours
    • MI risk decreases within 24 hours
    • Nerve regeneration should occur within 48 hours
    • Smell & Taste senses should return within 48 hours
    • Lung capacity opens up within 72 hours
    • Circulation should improve & walking should become easier within 2-3 weeks
    • Lung capacity should continue to improve within 2-3 weeks
    • Pulmonary ciliary should re-grow (decrease congestion, SOB) within 1-9 months
    • Overall body energy should improve within 1-9 months
    • Risk of coronary heart disease decreases by half within 1 year
    • Risk of heart attacks decreases to near normal within 2 years
    • Lung & GI cancer decreases by half within 5 years
    • Risk of stroke significantly decreases within 5 years
    • Risk of lung cancer decreases to near normal within 10 years

Pathophysiology of addiction caused by nicotine

  • Dopamine at the Nucleus accumbens produces a positive experience  (dopaminergic pathway)

First-line and second-line smoking cessation agents

  • 1st line:  must be proven to be safe & effective; requires FDA approval
    • Selection is based on normal stuff:  safety, effectiveness & preference
  • 2nd line:  must be shown to be effective;  NOT FDA approved
    • More safety concerns in comparison to 1st line meds

Smoking cessation techniques & effects

  • It’s most difficult to stay smoke-free for the first 3 months after quitting
  • Changes in nicotine habit may alter medications
  • Want to slow down the pharmacokinetics of nicotine absorption (use a patch vs. an inhaled dosage form(tapering of smokes doesn’t work))
  • Pregnant smokers should try to quit w/o meds b/c they haven’t been shown to be effective & they are a prego category D
  • Don’t want to do nicotine replacement therapy in people w/ CV risks: just had a MI, serious arrhythmia or unstable angina pectoris
  • Nicotine Patch
    • May use for 16-24 hours/day
    • Don’t use on open sores (don’t cut, etc)
  • Nicotine gum
    • Each piece usually lasts for about 30 minutes
    • To increase success rate, at least 9 pieces per day for the first 6 weeks
    • Stop chewing the gum when you notice a peppery taste or tingle
    • Precautions:  stomach ulcers, diabetes (sugar)
    • Don’t use more than 24 pieces/day
    • Avoid acidic foods/drinks for 15 minutes before or during chewing in order to maximize absorption
  • Nicotine Lozenges
    • Don’t chew or swallow lozenges (allow them to completely dissolve in mouth for 20-30 minutes)
    • Same first 2 rules as gum & don’t use more than 20 lozenges/day
  • Nicotine inhaler
    • At least 6 cartridges the first 3-6 weeks
    • Max of 16 cartridges/day
  • Bupropion Sustained-Release (Zyban–not the same as Wellbutrin)
    • Inhibits neuronal uptake of NE & dopamine
    • Initiate treatment 1-2 weeks before quit date
    • SE:  watch out for suicide ideation
    • Avoid in patients with a past history of seizures, eating disorders, or have used MAOIs in the past 2 weeks
    • ******Buproprion SR & the nicotine patch is the only combination that FDA has approved for smoking cessation*******
  • Varenicline (Chantix)
    • Partial agonist of nicotine receptors in the brain
    • Stimulates release of dopamine to reducing craving
    • Watch out for suicide ideation & for patients with a past history of psychiatric illnesses
    • Start 1 week prior to quitting
  • Clonidine is also used as a 2nd line therapy (not FDA approved) b/c of its SE most notably a rapid rise in BP (rebound HTN)
  • Nortriptyline is another 2nd line therapy (not FDA evaluated) which should be started 10-28 days before quitting.  Don’t use in patients w/ CV issues or who are on MAOIs

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