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NICOTINE NICOTINE REPLACEMENT REPLACEMENT
THERAPYTHERAPYNRTNRT
Dr. Debbie Thompson; Dr. Jane DumontetDr. Debbie Thompson; Dr. Jane DumontetClinical Pharmacy Specialists for Fraser HealthClinical Pharmacy Specialists for Fraser Health
Feb 2008Feb 2008
ObjectivesObjectives
Understand the difference between Understand the difference between cessation and withdrawalcessation and withdrawal
Review the various Nicotine Review the various Nicotine Replacement Therapy optionsReplacement Therapy options
Contrast the symptoms of nicotine Contrast the symptoms of nicotine toxicity versus those of withdrawal, toxicity versus those of withdrawal, psychiatric symptoms, caffeine side psychiatric symptoms, caffeine side effectseffects
Nicotine WithdrawalNicotine Withdrawal
Patients without access to cigarettes Patients without access to cigarettes abruptly due to non-smoking policies abruptly due to non-smoking policies will experience withdrawal symptomswill experience withdrawal symptoms
Initial Goal/PriorityInitial Goal/Priority to make patients as comfortable as to make patients as comfortable as
possible by preventing withdrawal possible by preventing withdrawal symptomssymptoms
Thank-you for not smoking here!Thank-you for not smoking here!
Secondary Goal Secondary Goal Cessation Cessation
Physiological Physiological ConsiderationsConsiderations
WithdrawalWithdrawalNonspecific symptomsNonspecific symptoms
Vary in intensity and Vary in intensity and durationduration
Begin within hoursBegin within hours Peak in 2 to 3 daysPeak in 2 to 3 days Last weeks to monthsLast weeks to months
SymptomsSymptoms Irritability, frustration Irritability, frustration
or angeror anger Anxiety, restlessnessAnxiety, restlessness Dysphoria or Dysphoria or
depressed mooddepressed mood Difficulty Difficulty
concentratingconcentrating Increased appetite or Increased appetite or
weight gainweight gain InsomniaInsomnia Decreased heart rateDecreased heart rate
Nicotine WithdrawalNicotine Withdrawal
ImmediateImmediate Nicotine Replacement TherapyNicotine Replacement Therapy
Gum, Lozenge, (Inhaler)Gum, Lozenge, (Inhaler) PatchPatch
DelayedDelayed BupropionBupropion VareniclineVarenicline
Keep Nicotine Levels Close Keep Nicotine Levels Close to Comfort Zoneto Comfort Zone
http://www.esr.cri.nz/competencies/populationhealth/NRT.htm
Nicotine Levels/24 HoursNicotine Levels/24 HoursContinuous SmokingContinuous Smoking
http://images2.clinicaltools.com/images/tobaccofree/nicotine_levels.gif
NicotineNicotine Cigarettes contain 6 to 11 mg of nicotineCigarettes contain 6 to 11 mg of nicotine
Smokers absorb between 1 to 3mg from Smokers absorb between 1 to 3mg from each cigarette i.e. average 2mgeach cigarette i.e. average 2mg
If a pack contains 20 cigarettesIf a pack contains 20 cigarettes 20 cigarettes x average 2mg each = 20 cigarettes x average 2mg each =
40mg/day40mg/day (1 PACK = 1 x 21 mg PATCH)(1 PACK = 1 x 21 mg PATCH)
1 Habitrol 21 patch is designed to provide 21 1 Habitrol 21 patch is designed to provide 21 mg over 24 hours of which only about 76% mg over 24 hours of which only about 76% reaches the bloodstream i.e. about 16mgreaches the bloodstream i.e. about 16mg
High Risk Smokers - High Risk Smokers - Mentally IllMentally Ill
More likely to smoke longer, be heavy More likely to smoke longer, be heavy users, smoke high tar brands with high users, smoke high tar brands with high nicotine contentsnicotine contents
And smoke that cigarette to the bitter And smoke that cigarette to the bitter endend
So likely getting more than 2mg out of each So likely getting more than 2mg out of each cigarettecigarette
Psych Services 1999. 50:1346-50
NRT FH ProtocolNRT FH Protocol
Nicotine patchNicotine patch 7 mg patch - low nicotine dependence7 mg patch - low nicotine dependence 14mg patch - moderate nicotine dependence 14mg patch - moderate nicotine dependence 21mg patch - high nicotine dependence21mg patch - high nicotine dependence
+ for moderate or high nicotine + for moderate or high nicotine dependence Nicotine 2 or dependence Nicotine 2 or 4 mg 4 mg gum or lozenge prn to a maximum of gum or lozenge prn to a maximum of 8/10 pieces respectively /24 hours8/10 pieces respectively /24 hours
DETAILED FAGERSTRŐM ASSESSMENT DETAILED FAGERSTRŐM ASSESSMENT 1. How soon after waking do you have your first cigarette?1. How soon after waking do you have your first cigarette?
Within 5 minutes (3 points) Within 5 minutes (3 points) 6- 30 mins (2 6- 30 mins (2 points) points) 31- 60 mins 31- 60 mins (1 point) (1 point) More than 1 More than 1 hour (0 points)hour (0 points)
2. Do you find it difficult to refrain from smoking in places 2. Do you find it difficult to refrain from smoking in places where it is forbidden?where it is forbidden? Yes (1 point) Yes (1 point) No (0 points) No (0 points)
3. Which cigarette would you be most unwilling to give up?3. Which cigarette would you be most unwilling to give up? First in morning (1 point) First in morning (1 point) Any others (0 points) Any others (0 points)
4. How many cigarettes, on average do you smoke per day?4. How many cigarettes, on average do you smoke per day? 31 or more 31 or more (3 points) (3 points) 21-30 (2 points) 21-30 (2 points) 11-20 11-20
(1 point) (1 point) 10 or less (0 points) 10 or less (0 points)5. Do you smoke more frequently during the first hours 5. Do you smoke more frequently during the first hours
after waking than during the rest of the day?after waking than during the rest of the day? Yes (1 Yes (1 point)point) No (0 points) No (0 points)
6. Do you smoke even if you are so ill that you are in bed 6. Do you smoke even if you are so ill that you are in bed most of the day?most of the day? Yes Yes (1 point) (1 point) No No (0 points) (0 points)
7. Assign Score: 7. Assign Score: SCORE = _________ SCORE = _________7-10 points = high 7-10 points = high nicotine dependence 4-6 points = moderate nicotine nicotine dependence 4-6 points = moderate nicotine dependencedependence
0-3 points = low nicotine dependence0-3 points = low nicotine dependence
8. Ask the patient if they feel they need assistance with 8. Ask the patient if they feel they need assistance with smoking abstinence in hospital (may not be needed if low smoking abstinence in hospital (may not be needed if low nicotine dependence).nicotine dependence). Yes Yes No No
Ottawa Heart ProtocolOttawa Heart Protocol
> 20 cigarettes/day = 21mg patch> 20 cigarettes/day = 21mg patch 10-20 cigarettes/day = 14mg patch10-20 cigarettes/day = 14mg patch < 10 cigarettes/day = 7mg patch< 10 cigarettes/day = 7mg patch
+ prn gum or inhaler+ prn gum or inhaler
Monitor for withdrawal Monitor for withdrawal symptomssymptoms
Within first day to see how they are doing, Within first day to see how they are doing, particularly if very heavy smokerparticularly if very heavy smoker
May have to increase dose of patch – doctor’s May have to increase dose of patch – doctor’s orderorder Increase by 7mg at a time and reassess Increase by 7mg at a time and reassess
Encourage use of prn gum, lozenge if not using Encourage use of prn gum, lozenge if not using and having cravings/withdrawal symptomsand having cravings/withdrawal symptoms
If smoking while on NRT it is likely the dose is If smoking while on NRT it is likely the dose is likely not high enough! likely not high enough! (or if behaviourally they have absolutely no intention (or if behaviourally they have absolutely no intention
of quitting and are accessing cigarrettes every of quitting and are accessing cigarrettes every chance they get – the patch may not be the chance they get – the patch may not be the withdrawal method of choice)withdrawal method of choice)
Nicotine Transdermal Nicotine Transdermal PatchPatch
Well absorbed Well absorbed through the skin through the skin
Onset 1-2 hoursOnset 1-2 hours Peak Peak
Habitrol® 5 to 6 Habitrol® 5 to 6 hourshours
Nicoderm® 4 hoursNicoderm® 4 hours Peak concentration: Peak concentration:
6-12 hrs6-12 hrs Plateau: 8-10 hrsPlateau: 8-10 hrs
http://www.quitsmoking.com/books/knowsmoking/chapter5.htmhttp://learn.genetics.utah.edu/units/addiction/drugs/delivery.cfm
Nicotine Transdermal Nicotine Transdermal PatchPatch
Plasma levels fall 1-2 hours after Plasma levels fall 1-2 hours after removing patchremoving patch
Duration of therapyDuration of therapy Habitrol – Taper dose by 7mg Q3-4 weeksHabitrol – Taper dose by 7mg Q3-4 weeks Nicoderm – 6,2,2Nicoderm – 6,2,2
Arbitrary stop date Arbitrary stop date NRT is much preferable and safer than NRT is much preferable and safer than
continued smokingcontinued smoking
Nicotine Transdermal PatchNicotine Transdermal Patch(Nicoderm(Nicoderm®, Nicotrol®, ®, Nicotrol®,
Habitrol®, Generics)Habitrol®, Generics) AdvantagesAdvantages
Easy to useEasy to use UnobtrusiveUnobtrusive Provides steady Provides steady
nicotine levelsnicotine levels Avoids gum side Avoids gum side
effectseffects Non-prescriptionNon-prescription
DisadvantagesDisadvantages Cannot adjust dose for Cannot adjust dose for
cravingscravings Nicotine released more Nicotine released more
slowly than other slowly than other productsproducts
Side effectsSide effects Mild skin irritation or Mild skin irritation or
sensitivitysensitivity Important to rotate sitesImportant to rotate sites Switch brands as neededSwitch brands as needed
Insomnia reportedInsomnia reported
Patch – choice of locationPatch – choice of location Choose an area on skin on upper body or the upper outer part of Choose an area on skin on upper body or the upper outer part of
arm. (UPPER & OUTER)arm. (UPPER & OUTER) To ensure that the patch will stick on well, make sure the skin is To ensure that the patch will stick on well, make sure the skin is
non-hairy, clean (not oily) dry and free of creams, lotions, oils or non-hairy, clean (not oily) dry and free of creams, lotions, oils or powder.powder.
Hair will interfere with the application of the patch and Hair will interfere with the application of the patch and should be clipped away.should be clipped away.
Do not shave the area as this may irritate the skin.Do not shave the area as this may irritate the skin. Do not put a patch on skin that is inflamed, burned, has broken out, Do not put a patch on skin that is inflamed, burned, has broken out,
or is irritated in any way, because these conditions may alter the or is irritated in any way, because these conditions may alter the amount of drug absorbed.amount of drug absorbed.
Women should not apply the patch to their breastsWomen should not apply the patch to their breasts.. Be sure to apply the patch to a different area each day. The same Be sure to apply the patch to a different area each day. The same
area should not be used again for at least one week area should not be used again for at least one week
Patch applicationPatch application Using scissors, carefully cut open the pouch along the edge.Using scissors, carefully cut open the pouch along the edge. Remove any old patches from skin, fold in half with the sticky Remove any old patches from skin, fold in half with the sticky
side inward and dispose of properly in the garbage.side inward and dispose of properly in the garbage. Remove the square shiny protective liner from the adhesive Remove the square shiny protective liner from the adhesive
side of the patch.side of the patch. Immediately apply the sticky side of the patch to the skin and Immediately apply the sticky side of the patch to the skin and
firmly press it on with the palm of your hand for 10 to 20 firmly press it on with the palm of your hand for 10 to 20 seconds.seconds.
Make sure that it is sticking well, especially around the edges.Make sure that it is sticking well, especially around the edges. It helps to clean that area of skin with alcohol wipe before It helps to clean that area of skin with alcohol wipe before
application.application. Medical adhesive tape may be used to help keep the patch on.Medical adhesive tape may be used to help keep the patch on. Wash hands with water only.Wash hands with water only. The patch should be worn for about 24 hours and be replaced The patch should be worn for about 24 hours and be replaced
everyday at about the same time. everyday at about the same time.
Patch TipsPatch Tips If insomnia or bad dreams occurIf insomnia or bad dreams occur
Take patch off at night or if on multiple patches, Take patch off at night or if on multiple patches, consider taking off one consider taking off one
Nicotine levels will drop overnight so encourage Nicotine levels will drop overnight so encourage use first thing of gum or lozenge until patch kicks inuse first thing of gum or lozenge until patch kicks in
Consider same procedure as with other Consider same procedure as with other patches i.e. extra line on MAR to indicate site patches i.e. extra line on MAR to indicate site and to document removal and to document removal
More nicotine will be released if exercising heavily More nicotine will be released if exercising heavily so suggest removal prior to exerciseso suggest removal prior to exercise
If smoking – likely dose not high enough, if If smoking – likely dose not high enough, if persistent in not choosing to quit (i.e. psychotic) persistent in not choosing to quit (i.e. psychotic) and continuing to smoke perhaps patch not best and continuing to smoke perhaps patch not best choicechoice
Nicotine Gum/Nicotine Nicotine Gum/Nicotine LozengeLozenge
http://www.quitsmoking.com/books/knowsmoking/chapter5.htmhttp://www.ennispharmacy.com/smokers.html
Buccal absorption, Buccal absorption, slowerslower 20 to 30 minutes of 20 to 30 minutes of
chewing releases 50 to chewing releases 50 to 90% of nicotine90% of nicotine
Peak plasma Peak plasma concentrationsconcentrations 15 to 30 minutes after 15 to 30 minutes after
starting chewingstarting chewing
Lozenges deliver 25 to Lozenges deliver 25 to 27% more nicotine than 27% more nicotine than gumgum
Nicotine Gum Nicotine Gum (Nicorette(Nicorette®)®)
AdvantagesAdvantages User controls doseUser controls dose Oral substituteOral substitute Non-prescriptionNon-prescription Sugar freeSugar free Delays weight gainDelays weight gain
Side effectsSide effects GastrointestinalGastrointestinal Oral disturbancesOral disturbances Jaw discomfortJaw discomfort HiccoughsHiccoughs
DisadvantagesDisadvantages Proper chewing Proper chewing
technique requiredtechnique required Cannot eat or drink Cannot eat or drink
while chewing gumwhile chewing gum Can damage dental Can damage dental
workwork Difficult for denture Difficult for denture
wearers to usewearers to use
How to use the gumHow to use the gum Place one piece of gum in mouth and chew very slowly Place one piece of gum in mouth and chew very slowly
once or twice.once or twice. Stop chewing and "Park it" between your cheek and Stop chewing and "Park it" between your cheek and
gums, and leave it there.gums, and leave it there. Wait a minute, and then repeat, "Parking" it again on the Wait a minute, and then repeat, "Parking" it again on the
opposite side of your mouth. BITE, BITE, PARK. BITE, opposite side of your mouth. BITE, BITE, PARK. BITE, BITE, PARK.BITE, PARK.
You may notice a peppery taste, or a slight tingling in You may notice a peppery taste, or a slight tingling in your mouth – this is nicotine being released and your mouth – this is nicotine being released and absorbed.absorbed.
Do not chew continuously or too quickly like ordinary Do not chew continuously or too quickly like ordinary chewing gum. Doing so may result in light-headedness, chewing gum. Doing so may result in light-headedness, nausea, hiccups or stomach upset because you are nausea, hiccups or stomach upset because you are swallowing the nicotineswallowing the nicotine
After about 30 minutes, all the nicotine will be released.After about 30 minutes, all the nicotine will be released. Discard the gum in the garbage.Discard the gum in the garbage.
Gum TipsGum Tips Slow down if you start feeling uncomfortableSlow down if you start feeling uncomfortable Do not chew more than one piece of gum at a Do not chew more than one piece of gum at a
timetime Do not use more than 20 pieces per day.Do not use more than 20 pieces per day. Avoid drinking acidic beverages such as Avoid drinking acidic beverages such as
coffee, tea, pop, alcohol or citrus fruit coffee, tea, pop, alcohol or citrus fruit juices before or during use of gum. Doing juices before or during use of gum. Doing so may affect nicotine absorptionso may affect nicotine absorption..
Consult your dentist or doctor if injury or Consult your dentist or doctor if injury or irritation to the mouth, teeth or dental work irritation to the mouth, teeth or dental work occurs. occurs.
Accidentally swallowing a piece of gum Accidentally swallowing a piece of gum shouldn't harm an adult. shouldn't harm an adult.
Nicotine lozengeNicotine lozenge Place one lozenge in mouth and allow it to Place one lozenge in mouth and allow it to
dissolve slowlydissolve slowly Do not chew or swallow – the lozenge Do not chew or swallow – the lozenge
contains a controlled amount of nicotine, contains a controlled amount of nicotine, which needs to be absorbed slowly and which needs to be absorbed slowly and gradually through the tissues in the gradually through the tissues in the mouthmouth
A tingling, or warm sensation may occurA tingling, or warm sensation may occur Occasionally move the lozenge from one Occasionally move the lozenge from one
side of the mouth to the otherside of the mouth to the other It takes about 20-30 minutes for the It takes about 20-30 minutes for the
lozenge to dissolve completelylozenge to dissolve completely
Lozenge TipsLozenge Tips
Do not eat or drink 15 minutes before Do not eat or drink 15 minutes before using, or while the lozenge is in your mouthusing, or while the lozenge is in your mouth
Do not use more than one lozenge at a time Do not use more than one lozenge at a time or continuously use one lozenge after or continuously use one lozenge after another. Doing so may cause hiccups, another. Doing so may cause hiccups, heartburn, nausea or other side effects.heartburn, nausea or other side effects.
Do not use more than five lozenges in six Do not use more than five lozenges in six hours, or more than 15 lozenges total per hours, or more than 15 lozenges total per day.day.
NRT Side Effects NRT Side Effects
Relatively few side effectsRelatively few side effects Minor side effects mild headache, Minor side effects mild headache,
appetite stimulation, constipation, appetite stimulation, constipation, diarrhea, dizziness, dysmenorrhea, diarrhea, dizziness, dysmenorrhea, flushing, insomnia irritabilityflushing, insomnia irritability
Others include hiccups, jaw ache, sore Others include hiccups, jaw ache, sore throatthroat
Of Note!Of Note! Remember – there is a lot of nicotine left Remember – there is a lot of nicotine left
in a patch (a Habitrol patch that releases in a patch (a Habitrol patch that releases 21 mg actually contains 51 mg total)21 mg actually contains 51 mg total) A 21 mg patch of Nicoderm has 114mg total A 21 mg patch of Nicoderm has 114mg total
2 mg of a 4mg piece of gum 2 mg of a 4mg piece of gum 4mg of a 10mg inhaler cartridge 4mg of a 10mg inhaler cartridge DISPOSE OF SAFELY IN GARBAGEDISPOSE OF SAFELY IN GARBAGE
Very toxic to nicotine naïve – children, animalsVery toxic to nicotine naïve – children, animals WARN parents that this is not innocuousWARN parents that this is not innocuous
Supply and ChartingSupply and Charting
Ensure ready access to gum and patch Ensure ready access to gum and patch on wardon ward Consider initial wardstock supply of bothConsider initial wardstock supply of both
If large anticipated # patients on a ward, If large anticipated # patients on a ward, consider wardstock for prn versus patient consider wardstock for prn versus patient specific specific
Consider providing a few gum or lozenges Consider providing a few gum or lozenges at a time depending upon the compliance at a time depending upon the compliance and understanding of the patientand understanding of the patient How will this be charted? How will this be charted?
Access to the inhaler?Access to the inhaler? Patients with patch allergy?Patients with patch allergy?
ConsiderationsConsiderations
Withdrawal versus toxicityWithdrawal versus toxicity DepressionDepression Drug interactions with smoking Drug interactions with smoking
cessation and resumptioncessation and resumption Cardiac risksCardiac risks Discharge planningDischarge planning
Withdrawal vs. NRT Withdrawal vs. NRT ExcessExcess
Nicotine Intoxication:Nicotine Intoxication: Pallor, diaphoresisPallor, diaphoresis Tremor, headache, Tremor, headache, dizzinessdizziness ConfusionConfusion Tachycardia, PalpitationsTachycardia, Palpitations N/VN/V//D, abdominal painD, abdominal pain HypersalivationHypersalivation
Treatment????Treatment????
Withdrawal vs. Caffeine Withdrawal vs. Caffeine toxicitytoxicity
Sudden cessation of tobacco smoking may Sudden cessation of tobacco smoking may result in reduced caffeine clearance (~ 40%)result in reduced caffeine clearance (~ 40%)
Caffeine-related side effects may occur if use Caffeine-related side effects may occur if use remains the same or increase if drink more remains the same or increase if drink more coffee for something to occupy themcoffee for something to occupy them Nausea, nervousness, irritability, Nausea, nervousness, irritability,
tremors, insomniatremors, insomniaDifferentiate between withdrawal Differentiate between withdrawal symptoms of smoking cessation and symptoms of smoking cessation and excess caffeine!excess caffeine!
Withdrawal vs. Psychiatry Withdrawal vs. Psychiatry SymptomsSymptoms
Very important to differentiate as Very important to differentiate as many symptoms overlap many symptoms overlap AnxietyAnxiety RestlessnessRestlessness IrritabilityIrritability Mood changesMood changes
DepressionDepression
Current and past depression more Current and past depression more common in smokerscommon in smokers
Experience more depressive symptoms Experience more depressive symptoms during withdrawalduring withdrawal
Increased risk of recurrent depression Increased risk of recurrent depression after stoppingafter stopping
JAMA 1990. 264:1546-9
Smoking Cessation and Smoking Cessation and Drug InteractionsDrug Interactions
Hydrocarbons in tobacco induce Hydrocarbons in tobacco induce drug-metabolizing enzymes (not the drug-metabolizing enzymes (not the nicotine) particularly CYP 1A2nicotine) particularly CYP 1A2 Can take several weeks to get to Can take several weeks to get to
maximum inhibition as well as to return maximum inhibition as well as to return to baseline following discontinuationto baseline following discontinuation
Pharmacotherapy, 1998;18(1):84-112, Psychiatric times, 2005;22(6)
Psychiatric Medications Psychiatric Medications AffectedAffected
Extent of interaction highly variable Extent of interaction highly variable
Examples include;Examples include; CaffeineCaffeine AntidepressantsAntidepressants
Imipramine, clomipramine, Imipramine, clomipramine, fluvoxaminefluvoxamine, , trazodonetrazodone
Variable effect on Amitriptyline and NortriptylineVariable effect on Amitriptyline and Nortriptyline AntipsychoticsAntipsychotics
Fluphenazine, haloperidol, Fluphenazine, haloperidol, olanzapineolanzapine, , chlorpromazine, chlorpromazine, clozapineclozapine
BenzodiazepinesBenzodiazepines Alprazolam, lorazepam, oxazepam, diazepam Alprazolam, lorazepam, oxazepam, diazepam
Desai HD et al. CNS Drugs 2001. 15(6):469-94
Clozapine and Clozapine and OlanzapineOlanzapine
Individual cases of large increases in Individual cases of large increases in serum levels with smoking cessationserum levels with smoking cessation
Consider baseline serum levels Consider baseline serum levels particularly of clozapineparticularly of clozapine
Monitor for increased adverse Monitor for increased adverse effects for the first few weeks after effects for the first few weeks after smoking cessation smoking cessation i.e.i.e. Sedation, increased drooling, Sedation, increased drooling,
dizzinessdizziness
Nicotine, Smoking and Nicotine, Smoking and DiabetesDiabetes
Tobacco smoking is known to aggravate Tobacco smoking is known to aggravate insulin resistance; Insulin absorption is slowed insulin resistance; Insulin absorption is slowed from injection sites.from injection sites.
Cessation of NRT or tobacco smoking may Cessation of NRT or tobacco smoking may decrease blood glucosedecrease blood glucose Stopping smoking will increase subcutaneous Stopping smoking will increase subcutaneous
absorption of insulinabsorption of insulin Recommend monitoring blood glucose Recommend monitoring blood glucose
concentrations when nicotine intake or smoking concentrations when nicotine intake or smoking status changesstatus changes
Dosage adjustments in antidiabetic agents may be Dosage adjustments in antidiabetic agents may be requiredrequired
Nicotine CV riskNicotine CV risk
The use of NRT is not associated with any The use of NRT is not associated with any increase in the risk of MI, stroke or deathincrease in the risk of MI, stroke or death
(N = 33,247 Hubbard 2005)(N = 33,247 Hubbard 2005) Much more rapid absorption of nicotine Much more rapid absorption of nicotine
when smokingwhen smoking Smoking produces higher nicotine peaks Smoking produces higher nicotine peaks
than NRTthan NRT Any patient who is at risk of smoking is Any patient who is at risk of smoking is
safer on NRT than continuing to smokesafer on NRT than continuing to smokehttp://www/quitsmoking.com/books/knowsmoking/chapter6.htm
At DischargeAt Discharge
If an individual resumes smoking at dischargeIf an individual resumes smoking at discharge Levels of medication (particularly clozapine and Levels of medication (particularly clozapine and
olanzapine) are likely to fall potentially resulting in olanzapine) are likely to fall potentially resulting in relapserelapse
PlanPlan Baseline serum levels of clozapine, (olanzapine)Baseline serum levels of clozapine, (olanzapine) Provide information to discharge treatment team of Provide information to discharge treatment team of
smoking statussmoking status Provide education/information to patient of Provide education/information to patient of
potential impact of changes in smoking habits and potential impact of changes in smoking habits and that they should inform their treatment team if they that they should inform their treatment team if they resume or quit smokingresume or quit smoking