Smoking Cess ion & -cig ettes - Wild Apricot · Smoking Cess ion & -cig ettes Drs. Wyatt Gold, Pharm.D. and Kelly Starman, Pharm.D. Boise VA Medical Center PGY-1 Pharmacy Residents

Smoking Cessation & E-cigarettes

Drs. Wyatt Gold, Pharm.D. and Kelly Starman, Pharm.D.

Boise VA Medical Center PGY-1 Pharmacy Residents

Objectives• Review the history of tobacco use in the United

States

• Understand the Health Consequences of tobacco and nicotine use in the individual user and recognize the burden of tobacco use on healthcare resources and costs

• Identify pharmacological and non-pharmacological aids for increasing smoking cessation

• Evaluate the safety and efficacy of E-cigarette use in smoking cessation

A Deadly Habit “Over the past five decades, scientists, researchers, and

policy makers have determined what works, and what steps

must be taken if we truly want to bring to a close one of our

nation’s most tragic battles – one that has killed ten times the

number of Americans who died in all of our nation’s wars

combined” -

Kathleen Sebelius – Secretary of Health and Human Services

U.S. Department of Health and Human Services.The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014 [accessed 2015 March 1].

Test Your Knowledge

When was it discovered that smoking causes lung cancer?

A. This has been common knowledge since day one of tobacco use.

B. During the Great Depression

C. I950

D. Unfortunately, not until the 1980s

Tobacco Timeline

1492

• Christopher Columbus was offered dried tobacco leaves as a gift from the American Indians

• Soon after, the plant was grown all over Europe

1884• Invention of a machine to manufacture cigarettes

1914-18

• WWI

• Cigarettes replace pipe smoking; tobacco in the trenches

1928-29

• 1928 – Cigarette Advertisements begin targeting women

• 1929 – Great Depression

1941-45• WWII

CNN.com. A Brief History of Tobacco. http://edition.cnn.com/US/9705/tobacco/history/. Accessed 3/5/2015. Centers for Disease Control and Prevention. Health Benefitts of Quitting.

http://www.cdc.gov/tobacco/data_statistics/fact_sheets/cessation/quitting/index.htm#benefits. Accessed 3/6/2015

Tobacco Timeline

1950s1950s

• 1950 – Retrospective studies linking tobacco and diseases are published

• 1952 – Reader’s Digests publishes “Cancer By the Carton”

• 1954 – Prospective mortality studies linking cigarettes and lung cancer are published

• 1955 – Marketing of filtered cigarettes

• 1956- Founding of the Council for Tobacco Research

1964 1964 • Release of the U.S. Surgeon General’s

Report on Smoking and Health



Tobacco Timeline

19701970• Cigarette advertisements banned from television

1980s1980s

• 1983 – Increase in the Federal excise tax on cigarettes by 8 cents

• 1986 – Release of the U.S. Surgeon General’s Report on Secondhand Smoke

• 1988 – Nicotine found to be addictive

2000s2000s

• 2009 – Tobacco Control Act gives FDA authority to regulate tobacco products

• Affordable Care Act requires most insurance companies to cover cessation treatments

• 2012 – CDC launches first-ever paid national tobacco education campaign

• 2014 – Increase in the Federal excise tax on cigarettes by $0.94 per pack



U.S. Smoking History

http://ourworldindata.org/data/health/smoking/. Accessed 3/3/2015.

Evolution of Tobacco Use

Centers for Disease Control and Prevention. Consumption of Cigarettes and Combustible Tobacco – United Stares, 200-2011. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6130a1.htm. Accessed 3/6/2014

US Department of Health and Human Services. Ending the tobacco epidemic: a tobacco control strategic action plan for the US Department of Health and Human Services. Washington, DC: Office of the Assistant Secretary for Health; 2010. Available at http://www.hhs.gov/ash/initiatives/tobacco/tobaccostrategicplan2010.pdf . Accessed March 1, 2015.

What About Nicotine

“Smokers Smoke for nicotine….but they die from the smoke” –

American Council on Science and Health

Laugesen, M. Nicotine and Health. American Council on Science and Health New York, NY.. 2013. Available at:http://www.scribd.com/doc/195347257/Nicotine-and-Health. Accessed 3/6/15.

Addiction

• Nicotine is addictive substance found in tobaccoo Not by itself harmful to the body

• Stimulates brain nicotinic cholinergic receptors, releasing dopamine and other neurotransmitterso Activate the brain rewards

system

InfoImagination and TobaccoFreedom.org. http://www.tobaccofreedom.org/issues/addiction/. Accessed 3/6/2014.


Nicotine • Alkaloid, nitrogen-containing compound

• Officially recognized as addiction agent in the 1988 US Surgeon General’s report

• Nicotine has a 2 hour half-lifeo Reaches brain within 7 seconds of taking a puff of smoke

o First cigarette of the day boost brain nicotine 10-fold

• Latency to withdrawalo Length of time the last cigarette keeps the urge to smoke at bay

o Shortens over time

• Eventually approximates the 2-hour half-life of nicotine

• 50% of smokers will say they max time they can last without a

cigarettes is ≤ 2 hours


Nicotine Content• Mean content of of US cigarette is 10mg

o Nicotine delivery is 1-2mg per cigarette

o Lethal dose is 40-60mg

• Smoking ≥ 4 cigars per day is equivalent to the amount of smoke in 10 cigarettes

• 5mL electronic cigarette liquid bottle contains 90mg of nicotine

• One can of tobacco is equivalent to 3 packs of cigarettes o oral snuff similar to cigarette content

o Chewing tobacco has somewhat lower nicotine concentration


What are Tobacco Users Really

Smoking?• Tobacco smoke contains

more than 7,000 chemicalso 600 are added to enhance flavor

and nicotine absorption

o At least 69 of them can cause

cancer

• Polycyclic aromatic

hydrocarbons (PAHs)

• Tobacco-specific nitrosamines

• formaldehyde

• Acetaldehyde

Photo via: http://b4tea.com/food-health/disadvantages-of-smoking-tobacco/. Accessed 3/5/2015.Centers for Disease Control and Prevention. Health Benefitts of Quitting. http://www.cdc.gov/tobacco/data_statistics/fact_sheets/cessation/quitting/index.htm#benefits. Accessed 3/6/2015

Test Your KnowledgeSmoking cigarettes has been linked to an increased risk for developing which of the following diseases/conditions (may chose as many as apply)?

A. Diabetes

B. Lung Cancer

C. Rheumatoid Arthritis

D. Hip Fractures

E. Congestive Heart Disease

F. Stroke

Tobacco

Cancer Pathogenesis


Lung Cancer • Leading cause of cancer death in the United

Stateso Smoking causes more than 85% of lung cancers

• Inhaling chemicals induces tissue injury

• Introduction of filtered cigarettes (1950s) has led to increased risk of adenocarcinomao Deeper inhalations

o Shortened frequency between cigarettes

o Increased number of cigarettes smoked to fix nicotine cravings

• Cigar and pipe tobacco products produce large particles that only reach the upper airwayso Lower cancer risk


Other Cancers• Sufficient evidence to

infer a causal relationship between smoking and:o Liver cancer

o Colorectal cancer

• Sufficient evidence that cigarette smoking may cause breast cancer

• In patients who smoke and have/had cancer:o Increased risk fro second primary

cancers

o Increased all-cause mortality and cancer-specific mortality

Photo via: http://medicalxpress.com/news/2012-07-people-cancers.html/ . Accessed 3/5/2015.


Cancer from Tobacco


Smoking and Cardiovascular

Disease (CVD)

• Independent major risk factor for CHDo Women have sixfold increased risk of myocaridal infarction (MI)

o Men have threefold increased risk of MI

• Risk is present even if smoke <5 cigarettes/day

• Risk increases with increased cigarettes/day

• Atherosclerosis in communities (ARIC) study o Smoking associated with a 50% increased progression of atherosclerosis


Pathogenesis of Atherosclerosis

• Adverse effect on serum lipids o Elevated triglycerides and LDL

o Decreased HDL

• Activates sympathetic nerve system o Increased heart rate and blood pressure

• Increased platelet activity and tissue factor expression

• Damages vessel wallso Impairs vasodilation of arteries

• Carbon monoxide is inhaled o Reduces amount of hemoglobin available for oxygen delivery


Smokeless Tobacco

• Chewing tobacco o Long strands of loose leaves, plugs, or twists

• Plugs, wads, or chew

• Snuff o Finely ground tobacco packaged in cans or pouches

• Pinch, dip, lipper, or quid

• Snus (from Sweden and Norway)o Finely ground form of moist snuff

o Steam-heated rather than fermented

American Cancer Society. Smokeless Tobacco – What is spit or smokeless tobacco?. http://www.cancer.org/cancer/cancercauses/tobaccocancer/smokeless-tobacco. Accessed 3/6/2015.

Health Consequences • Mouth, tongue, cheek, gum, and throat cancer

• Stomach, pancreatic, and esophageal cancer

• Leukoplakiao Can become cancerous

• Receding gums and gingivitis

• Bone loss around roots of the teeth

• Cavities and tooth decay/loss

• Stained/discolored teeth

• Bad breath

• Possibly increased risk of heart disease

American Cancer Society. Smokeless Tobacco – What is spit or smokeless tobacco?. http://www.cancer.org/cancer/cancercauses/tobaccocancer/smokeless-tobacco. Accessed 3/6/2015.


True or False?• Studies have shown that it takes near daily exposure

to result in real risk from secondhand smoke exposure

There is no risk-free level of exposure to

secondhand smoke

Second-hand Smoke Exposure

o Smoking during pregnancy results

in >1,000 infant deaths annually

o Causes more than 8.000 deaths

from stroke annually

o Causes more than 7,300 lung

cancer deaths annually

o Children who’s parents smoke

have slower growing lungs and

get more bronchitis and

pneumonia

Centers for Disease Control and Prevntion. Health Effects of Secondhand Smoke. http://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/health_effects/index.htm#overview. Accessed 3/6/2015.

Tobacco Cessation

• Efforts started with 1964 Surgeon General’s Report o Adult smoking rates have fallen from 43% in 1964 to 18% in 2012

o 42 million Americans still smoke

o Tobacco has killed more than 20 million people prematurely since the first

Surgeon General’s report in 1964

• 2.5 million were nonsmokers exposed to secondhand smoke

• 100,000 were babies how died of SIDS or other complications

• Affordable Care Act of 2010 requires health insurers cover tobacco cessation services

• ASCO and AACR are pushing for FDA to regulate e-cigarettes and cigars (2014-2015)

American Socity of Clinical Oncology. Tobaco Cessation and Contorl Resources. http://www.asco.org/advocacy-category/tobacco?page=2gra. Accessed 3/16/2015.

Surgeon General’s Warnings

• Comprehensive Smoking Education Act of 1984


Kicking the Habit

• 1997 – US Federal Trade Commission started publishing tar and nicotine ratings for cigarette brands o Studies in 2005 showed very similar amounts of lung carcinogen

breakdown products in the urine of those smoking regular, light, and

ultralight brands

• Nicotine replacement therapy o Gum approved in 1984

o Patch approved in 1992 – OTC in 1996


Via: http://www.cdc.gov/tobacco/data_statistics/fact_sheets/cessation/quitting/. Accessed 3/6/2014

Tobacco Control Funding

Tobacco Cessation Interventions

Outline

• Benefits of Tobacco Cessation

• Counseling & Behavioral Therapy

• Medications used in Tobacco Cessation

• Managing Relapse and Nicotine Withdrawal

• Role of E-cigarettes in smoking cessation

QUITTING: HEALTH BENEFITS

Lung cilia regain normal function

Ability to clear lungs of mucus increases

Coughing, fatigue, shortness of breath decrease

Excess risk of CHD decreases to half that of a

continuing smokerRisk of stroke is reduced to that of people who have never smoked

Lung cancer death rate drops to half that of a

continuing smoker

Risk of cancer of mouth, throat, esophagus, bladder,

kidney, pancreas decrease

Risk of CHD is similar to that of people who have never smoked

2 weeks to

3 months

1 to 9 months

1year

5years

10years

after15 years

Time Since Quit Date

Circulation improves, walking becomes easier

Lung function increases up to 30%

Rx for change. The Regents of the University of California. 2004-2015.

Counseling & Behavioral Therapy

• Intervention Sessionso Can be done by any clinician

o Used in addition to medications

• Dose-effect responseo Intervention intensity increased by extension of length and

number

• 4 – 30 min sessions can double chances of abstinence

• >30 min can triple chances of abstinence

• 2 – 3 sessions increases abstinence by 1.5 fold

• 4 – 8 sessions increases abstinence by 2 fold

Treating Tobacco use and dependence: 2008 update. Clinical practice guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service. Retrieved from http://bphc.hrsa.gov/buckets/treating tobacco.pdf

Patient Encounter

• The 5 A’s of Smoking Cessation:

o Ask about tobacco use at each encounter

o Advise patient to quit, using clear, strong, and personalized statements

o Assess readiness to quit in the next 30 days

o Assist with quit attempt: medications, quit date, support, barriers

o Arrange follow up encounters


Enhancing Motivation

• The 5 R’s of smoking cessation:

o Relevance specific to the patient

o Risks of continued smoking

o Rewards of smoking cessation

o Roadblocks identified and options to overcome

o Repetition of the 5 R’s at each visit to keep patient on track


Assessing Nicotine Dependence

• The Fagerström Testo How soon after waking do you smoke your 1st cigarette?

o Do you smoke/chew more frequently in the hours after waking?

o Do you find it difficult not to smoke/chew?

o Which cigarette would be the hardest to give up?

o How many cigarettes do you smoke in a day?

o Do you still smoke even when you are ill?

• Scored 0 – 10

• Rates dependence Low to High

Heatherton TF, Kozlowski LT, Frecker RC, Fagerström KO. The Fagerström test for Nicotine Dependence: a revision of the Fagerström Tolerance Questionnaire. British Journal of Addiciton. 1991. 86(9): 1119-1127.

Poll Question

Have you or someone you know ever

attempted to quit tobacco products?

What methods have they tried?

Medication Index• Nicotine Replacement Therapies:

o Nicotine Patch (Nicoderm CQ®)

o Nicotine Polacrilex Gum (Nicorette®)

o Nicotine Polacrilex Lozenge (Nicorette®)

o Nicotine Inhaler (Nicotrol®)

o Nicotine nasal spray (Nicotrol®)

• Non-Nicotine Therapies:

o Bupropion SR (Zyban®)

o Varenicline (Chantix®)

Medications• Very effective in maintaining abstinence rates

compared to quitting cold turkey

• Help minimize withdrawal symptoms and cravings

• More successful when combined with counseling

• Goals: eliminate need for NRT wile maintaining tobacco abstinence

• Medication selection dependent on patient history, preference, and level of addiction


Nicotine Replacement Therapy

Nicotine Transdermal PatchHow Supplied Precautions Dosing Adverse Effects

• OTC as NicodermCQ, and Generic

• Rx as generic

Step 1: 21mgStep 2: 14 mgStep 3: 7 mg

• Recent Heart attack (2 weeks)

• Serious heart arrhythmias• Serious or worsening

angina (chest pain)• Pregnancy and

breastfeeding• Adolescents (<18 years)

If > 10 cigarettes/day:• STEP 1: 21 mg/day x 4 – 6

weeks• STEP 2: 14 mg/day x 2

weeks• STEP 3: 7 mg/day x 2 weeks

If < 10 cigarettes/day:• STEP 2: 14 mg/day x 2

weeks• STEP 3: 7 mg/day x 2 weeks

• Local skin reactions(redness, itching, burning)

• Headache• Sleep disturbances

(insomnia, vivid dreams) – may remove patch at night to minimize

Advantages Disadvantages Price/day

• Provides consistent nicotine levels over 24 hrs• Easy to use and conceal• Once daily dosing, helpful for compliance

• Patients cannot titrate dose to acutely manage withdrawal symptoms

• Allergic reactions to adhesive may occur• Patients with dermatologic conditions should

not use the patch

$1.52 - $3.40 per patch



Nicotine GumHow Supplied Precautions Dosing Adverse Effects

• OTC as Nicorette and Generic

• Original, cinnamon, fruit, mint, and orange

2 mg and 4 mg


• Serious heart arrhythmias

• Serious or worsening angina (chest pain)

• Pregnancy and breastfeeding

• Adolescents (<18 years)

• Temporomandibular joint disease

1st cigarette ≤ 30 mins after waking: 4 mg

1st cigarette > 30 mins after waking: 2 mg

• Mouth/jaw soreness• Hiccups• Dyspepsia• Hypersalivation• Related to poor

chewing technique:o Lightheadednesso Nausea/vomitingo Throat and mouth

irritation

Weeks 1-6: 1 piece every 1-2 hrs



• Maximum of 24 pieces/day

• Chew slowly• Park between cheek and

gum when peppery taste occurs, resume chewing when tingling fades, then repeat

• Park in different areas of mouth

• Avoid food or drink 15 mins before or during use


• Might satisfy oral cravings• Might delay weight gain• Patients can titrate therapy to manage

withdrawal symptoms• Variety of flavors are available

• Need for frequent dosing can compromise compliance• Might be problematic for patients with significant

dental work• Patients must use proper chewing technique to

minimize adverse effects• Gum chewing may not be socially acceptable

$1.89 - $5.48 2 mg or 4 mg(9 pieces)



Nicotine LozengeHow Supplied Precautions Dosing Adverse Effects

• OTC as Nicorette Lozenge, Mini Lozenge, and Generic

• Cherry and mint flavor

2 mg and 4 mg


• Serious heart arrhythmias

• Serious or worsening angina (chest pain)


• Adolescents (<18 years)

1st cigarette ≤ 30 mins after waking: 4 mg

1st cigarette > 30 mins after waking: 2 mg

• Nausea• Hiccups• Cough• Heartburn• Headache• Flatulence• Insomnia

Weeks 1-6: 1 lozenge every 1-2 hrs



• Maximum of 20 lozenges/day

• Dissolve slowly (20-30mins for standard; 10 mins for mini)

• Do not chew or swallow• Rotate to different areas

of mouth• Avoid food or drink 15

mins before or during use


• Might satisfy oral cravings• Might delay weight gain• Patients can titrate therapy to manage

withdrawal symptoms• Variety of flavors are available• Easier to use and conceal than gum

• Need for frequent dosing can compromise compliance

• Gastrointestinal side effects (nausea, hiccups, heartburn) can be bothersome

$3.05 - $4.382 mg or 4 mg(9 pieces)



Nicotine Nasal SprayHow supplied Precautions Dosing Adverse Effects

Rx onlyNicotrol NS0.5mg/ 50mcL

• Recent Heart attack (2 weeks)• Serious heart arrhythmias• Serious or worsening angina

(chest pain)• Pregnancy and breastfeeding• Adolescents (<18 years)• Chronic nasal disorders

(rhinitis, nasal polyps, sinusitis)

• Severe reactive airway disease

• 1–2 doses/hour, MAX 5 doses/hr(8–40 doses/day)

• One dose = 2 sprays (one in each nostril); each spray delivers 0.5 mg of nicotine to the nasal mucosa

• For best results, initially use at least 8 doses/day

• Duration: 3–6 months

• Nasal and/or throat irritation (burning sensation)

• Rhinitis• Tearing• Sneezing• Cough• Headache


• Can titrate therapy to manage withdrawal symptoms

• Frequent dosing can compromise compliance• Nasal/throat irritation• Must wait 5 mins before driving or operating heavy machinery• Should not use in patients with chronic nasal disorders or severe

reactive airway disease

$4.12 (8 doses)



Nicotine InhalerHow supplied Contraindications Dosing Adverse

Effects

Rx only10 mg cartridge,delivers 4mg inhaled nicotine vapor


• Serious heart arrhythmias• Serious or worsening

angina (chest pain)• Pregnancy and

breastfeeding• Adolescents (<18 years)• Bronchospastic disease

• 6-16 cartridges/day• Individualize dosing; initially use 1

cartridge every 1-2 hrs• Cartridge will last 20 mins if actively

puffing• Do not inhale into the lungs (like

cigarettes), puff as if lighting a pipe• Open cartridge retains potency for 24 hrs• Avoid food or beverage 15 mins before or

during use

• Mouth or throat irritation

• Cough• Headache• Stuffy nose/

congestion• Upset stomach• Hiccups


• Can titrate therapy to manage withdrawal symptoms

• Mimics hand-to-mouth ritual of smoking (may also be perceived as a disadvantage)

• Frequent dosing can compromise compliance• Mouth/throat irritation• Cartridges should not be stored in warm places or used in very

cold conditions• Patients with underlying bronchospastic disease should use

with caution

$7.35(6 cartridges)



Non-Nicotine Therapy

Bupropion SRHow Supplied Contraindications Dosing Adverse Effects

Rx onlyZyban® or generic150mg sustained-release tablet

• Current use of medications that lower seizure threshold

• Severe hepatic cirrhosis• Pregnancy and breastfeeding• Adolescents (<18 years)• Black-Boxed Warning:

neuropsychiatric symptoms• Contraindications:

• Seizure disorder• Eating disorder• Abrupt discontinuation of alcohol

or sedatives• MAOI therapy in previous 14 days

• 150mg q AM x 3 days, then 150mg BID

• MAX dose: 300mg/day• Begin therapy 1-2 weeks

before quit date• Allow at least 8 hrs between

doses• Avoid bedtime dosing, can

cause insomnia• Dose tapering not necessary• Can use with NRT

• Insomnia• Dry mouth• Nervousness/diffic

ulty concentrating• Rash• Constipation• Seizures (risk 0.1%)• Neuropsychiatric

symptoms (rare)


• Easy to use, oral form may be better for compliance

• May delay weight gain• Can be used with NRT• Beneficial in patients with depression

• Seizure risk is increased• Patients need to be monitored for potential

neuropsychiatric symptoms

$2.38-$6.22(2 tablets)



VareniclineHow Supplied Contraindications Dosing Adverse Effects

Rx onlyChantix® Brand only0.5mg, 1mg tablet

• Severe renal impairment


• Adolescents (<18 years)• Warnings:

• Black-Boxed: neuropsychiatric symptoms

• Cardiovascular events

Days 1-3: 0.5 mg q AMDays 4-7: 0.5 mg BIDWeeks 2-12: 1 mg BID• Begin therapy 1 week prior to quit

date, quit smoking on day 8 of therapy

• Take with food and full glass of water

• Dose tapering is not necessary• Dose adjust in renal impairment• 12 week course, additional 12 weeks

at providers discretion

• Nausea• Sleep disturbances• Constipation• Flatulence• Vomiting• Neuropsychiatric

symptoms


• Easy to use, oral form better for compliance• New mechanism of action for patients who

have failed multiple other therapies

• May induce nausea in up to 1/3 of patients• Patients need to be monitored for potential

neuropsychiatric symptoms• Combination with NRT or bupropion has not

been studied and is not recommended

$5.96-$6.50(2 tablets)



Combination Therapies

• Nicotine Patch & Nicotine Gum or Lozenge

• Bupropion SR & Nicotine Patch

• Bupropion SR & Nicotine Patch & Nicotine Gum or Lozenge

Case 1• Charles is a 70 year old pipe smoker with history of diabetes, high

blood pressure, high cholesterol, epilepsy, and COPD/asthma. He has been smoking for over 50 years. He recently had a heart attack and his doctor advised him to stop smoking. Charles has wanted to quit for some time now because he doesn’t want his grandchildren to pick up this habit. He has tried gum in the past without success and claims it got stuck in his dentures.

What medication would be most appropriate for

Charles?

a. Varenicline

b. Bupropion

c. Nicotine patches with Nicotine inhaler for cravings

d. Nicotine patches with nicotine lozenges for cravings

e. Bupropion with nicotine patch and nicotine gum for cravings

Case 2• Bessie is a 36 year old woman with depression and seasonal allergies.

Her doctor told her she needs to quit smoking before he writes another prescription for her hormonal birth control due to increased clot risk. She has tried to quit in the past and reports trying nicotine patches with no success. She said they gave her horrible rashes and would get really sick when she would smoke with the patch on. She is also worried about gaining weight during the quitting process. She comes to the pharmacy today for some advice on smoking cessation.

What would you recommend for Bessie?

a. Tell her to buy some nicotine patches and stop

smoking with the patch on

b. Recommend talking to her doctor about using

bupropion

c. Recommend talking to her doctor about using

a nicotine nasal spray

d. Recommend using nicotine gum or lozenges to

overcome cravings

e. Both b and d

Managing Withdrawal

o Chest tightness

o Stomach pain

o Constipation

o Gas

o Cravings/urges

o Depressed mood

o Difficulty concentrating

o Dizziness

o Fatigue

o Hunger

o Insomnia

o Irritability

o Stress

• Physical withdrawal symptoms:

o Begin within 24-48 hours

o Gradually get better over 2-4 weeks

o May persist for months to years

• Symptoms may include:

Managing WithdrawalSymptom Recommendation

Chest tightness (tension created by body’s need for nicotine)

• Practice relaxation techniques• Nicotine replacement therapy might be

helpful

Stomach painConstipationGas

• Drink fluids• Avoid Stress• Increase fiber in diet

Cravings/ urges (from nicotine withdrawal or habit)

• DEADS Strategy• Delay

• Escape

• Avoid

• Distract

• Substitute

Depressed Mood(normal process for a short period)

• Increase pleasurable activities• Get support from family/friends• Discuss with provider


Symptom Recommendation

Difficulty concentrating (due to lack of nicotine stimulation)

• Avoid Stress• Plan workload accordingly

Dizziness (Body is getting extra oxygen)

• Be cautious the first few days

Fatigue (due to lack of nicotine stimulation)

• Take naps• Do not push yourself• Nicotine replacement therapy may be

helpful

Hunger (cigarette cravings can be mistaken for hunger)

• Drink lots of water• Eat low-calorie snacks

Insomnia (nicotine affects brain wave function and sleep patterns)

• Limit caffeine (50% reduction)• Practice relaxation techniques

Managing Withdrawal


Symptom Recommendation

Irritability (body’s craving for nicotine)

• Exercise• Practice relaxation techniques• Take a hot bath

Stress • Exercise• Practice relaxation techniques• Avoid known stressful situations• Plan workload accordingly

Managing Withdrawal

Most withdrawal symptoms go away after a few days to 1-2 months at the most. Cravings and urges are the only symptoms that can persist even after

one year of tobacco cessation.


E-cigarettes

• What are they?o Alternative to conventional

cigarettes

o Can look similar to cigarettes

o Battery powered electronic

nicotine delivery device (ENDD)

o Deliver nicotine to the lung

without tobacco or combustion

• Main Components:o Heater/atomizer

o Battery

o Cartridge/tank filled

with liquid nicotine

Caponnetto et al. Journal of Medical Case Reports 2011, 5:585 Available From: http://www.jmedicalcasereports.com/content/5/1/585

Poll Question

Do you see patients that are using e-cigarettes to quit smoking? Have you seen success stories?

The Controversy• Harm reduction: Do e-cigarettes help smokers stop

smoking, thereby lowering smoking rates and saving lives? o Argue that vapor contains fewer toxins than cigarette

smoke

o For existing smokers that are unable to quit, e-cigarettes may be a way to reduce their exposure to toxins and carcinogens from tobacco

• Renormalization: Or, by making it ok/cool again to smoke, do e-cigarettes get more kids addicted to nicotine and potentially turn them into cigarette smokers?

Fairchild et al., NEJM, 2014West and Brown, Br J Gen Pract, 2014

Arguments against harm reduction

• Re-normalization of smoking – reverse progress of smoke-free laws and places

• E-cigarette business model requires new and continuing users

• Youth e-cigarette use is rising

Maziak, Am J Prev Med, 2014 Marynak et al., MMWR, 2014

Nicotine Content and Toxins• Toxicants in e-cigs are variable and range from 9-450x lower

than conventional cigarette smoke

• Generally, e-cigs have more toxicants than an FDA approved nicotine inhaler, however some toxicants were shown to have similar levels in both

• Analysis of 10 of the most popular e-liquids found the nicotine content was close to the amount on the label. Some impurities were detected at levels higher than allowed for nicotine-containing medicines, but thought to be below the level that they would cause harm.

• Lorillard studies found that blu e-cigarette vapor was less cytotoxic than vapor from Marlboro or other conventional cigarettes, and exhaled aerosol from e-cigarettes was no different in content of phenolics and carbonyls than regular exhaled breaths from the same smokers

Etter et al., Addiction, 2013 Misra et al., Int J Environ Res Pub Health, 2014Goniewicz et al., Tob Control, 2013 Long GA, Int J Environ Res Pub Health, 2014

Safety Concerns• Propylene glycol (base ingredient) – causes eye and

respiratory irritation

• Flavoring compounds used may cause cytotoxicity and respiratory irritationo Diacetyl – popcorn lung

• Most flavorings do not show cytotoxicityo Cinnamon and coffee flavors have shown cytotoxicity

• Nicotine poisoning can cause vomiting and death in extreme caseso e-cig refill containers can have large quantities

• Calls to poison centers due to e-cig exposure increased from 1 in 2010 to 215 in 2014 (Chatham-Stephens et

al., MMWR, 2014)

Centers for Disease Control and Prevention. Flavorings-Related Lung Disease.

http://www.cdc.gov/niosh/topics/flavorings/exposure.html

Barrington-Trimis et al., 2014 Grana et al., 2014Behar et al., 2014 Romagna et al., 2013

Short term health effects of e-cigarettes

• Some markers of pulmonary inflammation

are elevated, but overall do not see a

reduction in pulmonary function similar to

what is found with cigarette smoking

• There may still be concerns for patients with

lung conditions such as asthma, chronic

bronchitis, and emphysema

Flouris et al., 2013 Grana et al., 2014Hajek et al., 2014 Schober et al., 2013

Long term health effects of e-cigarettes

(UNKNOWN)

• Some researchers speculate that the long-term effects are likely to be less severe than conventional cigarettes due to the lower levels of toxicants

• E-cigarettes have only been around for ~10 years and in widespread use only within the past 5 years.

• Long term effects of use can take decades to develop

Hajek et al., 2014

E-cigarettes as cessation aides

• Few trials completed, generally small sample size, and low quality

• There is very weak evidence that e-cigarettes with nicotine may help people quit smoking compared to placebo e-cigarettes

• E-cigarettes do not appear to be more effective than NRT in supporting abstinence

• E-cigarettes may support dual use of both conventional cigarettes and e-cigarettes, increasing exposure to toxins and related health consequences

67Grana et al., 2014McRobbie et al., 2014

What to do?• Do not recommend e-cigarettes

• Recommend FDA approved cessation aides

• If patient fails or is intolerant to all conventional cessation medications, and insists on trying e-cigarettes, it may be reasonable to support their attempt:

o Explain that although much less toxic than regular cigarettes, e-cigs are unregulated, and have not been proven as cessation aides

o Strongly advise against use in patients with COPD, asthma, or other lung disease

o Advise against using indoors and around children

o There is a lack of long term safety data, so plan to set a quit date for e-cigarettes, taper down nicotine concentration

o Do not use with conventional cigarettes (dual use)

o Provide counseling services • Local groups and programs

• 1-800-QUIT-NOW

Grana et al. Circulation: 2014

Documents

Smoking Cess ion & -cig ettes - Wild Apricot · Smoking Cess ion & -cig ettes Drs. Wyatt Gold, Pharm.D. and Kelly Starman, Pharm.D. Boise VA Medical Center PGY-1 Pharmacy Residents