Strong correlation between counseling and quitting success. (session should be >10 mins and >4 sessions). Smoking causes induction of P450 system. Quitting smoking can experience side effect from supra-therapeutic level of drugs : caffeine, theophylline, fluvoxamine, olanzapine, clozapine. Pharmacologic intervention recommended in patients smoke 10 or more cigarettes/d.
Treatment guideline recommends a therapy with a long acting product with minimal withdrawal symptoms(bupropion, varenicline, transdermal nicotine patch), along with a short acting therapy (nicotine gum, lozenge) to help with breakthrough craving.
5 "A"s
Ask about tobacco use
Advise to quit
Assess the willingness
Assist
Arrange
NRT (nicotine replacement therapy)
FDA prohibits nicotine products sale to age <18. Gum reduce/delay weight gain. Nasal spray has the fastest onset, useful for rapid relief of withdrawal.
Gum should be chewed slowly until a favored taste emerges, then park between cheek and gum for 30 mins or until taste disappears. Avoid eating and drinking beverage for 15 mins before and after. Use 1 piece q1-2 hrs.
Frequent continuous puffing for 20 mins, once a cartridge is opened, only good for 1 day. Effect decrease below 40 F.
Patch is worn for 24 h or 16H to avoid insomnia/vivid dream. If >10 cigs/day, use 21mg x 4 weeks, then 14mg x 2 wks, then 7mg x 2 wks.
bupropion (Zyban)
150mg qd x 3 days, then BID. Takes about 1 week for the med to start working.
BBW: suicidal thinking, neuropsychiatric warning was removed in 2016
SE: dry mouth, insomnia (just like smoking), constipation, no sexual dysfunction like other agents
CI: h/o SZ, eating disorder, use of MAOI w/in 14 days
Do not exceed 450mg daily due to seizure risk
Varenicline (Chantix)
Nicotinic receptor agonist
Start 1 wk before quitting; med guide required, most effective smoking cessation at 12 weeks therapy
0.5mg qd x 3 days, 0.5mg BID x 3 days, then 1 mg BID - PC with a full glass of water to avoid nausea
(BBW: neuropsychiatric events (depression, suicidal ideation) stop if pt become hostile, agitated) warning was removed in 2016.
