Smoking

Question 1

Health benefits of quitting

Answer 1

1. within a day
   almost all nicotine will be out of the bloodstream level of carbon monoxide in the blood will drop and more oxygen will reach the heart and muscles
2. within a week
   the lung’s natural cleaning system will start to recover and become better at removing mucus, tar and dust from the lungs there will be higher blood levels of protective antioxidants (eg vitamin C)
3. within 2 months
   there will be less coughing and wheezing, the immune system will have started to recover, blood will be less thick and sticky and blood flow to the hands and feet will improve, the body will be better at healing cuts and wounds
4. within 6 months
   lungs will no longer produce the extra phlegm caused by smoking
5. after 1 year
   lungs will be healthier and breathing will be easier, making it easier to exercise
6. within 2 to 5 years
   there will be a large drop in risk of heart attack and stroke; this risk will continue to gradually decrease
7. within 5 years
   risk of cervical cancer will return to the same as for a woman who has never smoked
8. after 10 years
   risk of lung cancer will be markedly lower than that of a continuing smoker; this risk will continue to decline (provided the disease is not already present)
9. after 15 years
   risk of heart attack and stroke will be close to that of a person who has never smoked

Question 2

Initial counselling

Answer 2

1. Ask
   Tobacco use
2. Assess motivation and nicotine dependence
   How many do you smoke
   Time to first from waking
   Readiness to quit- attempt in a month, 6 months or not interested
   Any previous quit attempts and perceive reasons for failure this time
3. Advise to quit
   Benefits of quitting- heart attack, stroke, lung cancer, cervical cancer, other cancers, infections, dentition, savings
4. Assist with quitting
   Restate benefit of quitting->if not ready
   Support and information->ready
   Summarise benefit->recently quit
   a. QUIT line
   b. Learn about previous failures->see as learning tool, triggers, danger situations, strategies. Avoid alcohol, avoid being around smokers.
   c. Explore concerns of weight gain, depression and irritability, dealing with stress, habit and cravings
   Deep breath, do something else, drink water, delay
   d. Pharmacotherapy in moderate to severe
5. Arrange follow up
   R/V in a week after quit date
   Monitor for mood changes

Question 3

Level of dependence

Answer 3

1. High
Waking at night, or cigarette within  5 minutes of waking, >30/day
2. Moderate
Within 30 minutes, 20-30/day
3. Low to moderate
>30 minutes after waking, 10-20/day
4. Low
Not needing in first hour,

Question 4

Pharmacotherapy options

Answer 4

1. Nicotine replacement therapy
2. Bupropion
3. Verenicline

Question 5

NRT counselling: suitability, choice and providing

Answer 5

1. All patients, including adolescent.
Avoid in pregnancy and unstable CVD
2. Patients prefer
OTC, PBS
Concerns about others' SEs
Use in pregnancy under supervision
Variety of dosages available
3. Counsel
Benefits of F/U
Skin irritation, sleep difficulties
Support services
Consider combination if withdrawal not controlled
Arrange F/U visits

Question 6

Verenicline counselling: suitability, choice, providing

Answer 6

1. Use
   Not in pregnancy or childhood
   Caution with psychiatric, CVD
   30% have nausea, (vomiting, dyspepsia, constipation, flatulence, abdominal pain, increased appetite, weight increase, headache, taste disturbance, insomnia, abnormal dreams, sleep disorder)
   Reduce dose in renal impairment
2. Patients prefer
   Most effective monotherapy
   PBS
   Lack of drug interactions
3. Counsel
   Initial 4 week, return for second script
   Support services
   R/V progress, problems, nausea and abnormal dreams
   Neuropsychiatric symptoms
   Completion of 12 weeks therapy
   If quit, further 12 weeks available on PBS to reduce relapse
   Arrange further F/U
4. Start taking this medicine for at least a week before you stop smoking because it takes this long for it to become effective.
5. Swallow tablets whole.
6. You may feel nauseous when taking this medicine.
7. Contact your doctor if this is severe, because it may improve with dose reduction.
8. After finishing this treatment, some people have found a temporary increase in cigarette craving, irritability and insomnia. It may be useful to have a fast-acting nicotine product at hand in case you have an overwhelming urge to smoke.

Question 7

Bupropion

Answer 7

1. Use
   Absence of CI such as history seizures, MAOI, pregnancy
   Caution with other medications that lower seizure threshold
2. Patients prefer
   PBS
   Oral non-nicotine preparation
   Relapse in past using NRT
   Evidence of benefit in chronic disease and depression
3. Counsel
   Initial 2 weeks
   Arrange return for second scipt
   Support services
   At R/V progress, HA, insomnia, dry mouth
   Completion of 8 weeks
   Consider combination if W/d not controlled
4. Swallow tablets whole (do not crush, cut or chew).
5. Start taking this medicine for at least a week before you stop smoking because it takes this long for it to become effective. It is best if you start by taking it in the morning for the first few days to minimise sleep disturbance.
6. If you develop a rash, swelling of the lips or mouth, or difficulty in breathing, contact your doctor immediately and stop taking bupropion.
7. Drink only small quantities of alcohol when you are taking this medicine, as it can increase the risk of fits and other unpleasant effects.
8. This medication may have side effects (like dizziness and difficulty in concentrating), which could affect your ability to drive and operate machinery; avoid these activities until you know how bupropion affects you.

Question 8

MOA of bupropion

Answer 8

1. Antidepressant

2. NE, Dopamine ++

Question 9

MOA verenicline

Answer 9

1. Partial nicotine agonist

Question 10

Symptoms in withdrawal

Answer 10

1. Insomnia
2. Poor concentration
3. Breathless bradyC
4. Weight/appetite ++
5. Dysphoria, depressed mood, irritable, anger

Usually resolves in several weeks
Highest relapse in first 2 weeks due to w/d