Smoking Cessation Pauline Pizzey RPh Additional Prescribing Authority

Smoking Cessation Pauline Pizzey, RPh, Additional Prescribing Authority, CDE, Certificate in Travel Health (ISTM) Nicotine Replacement Therapies and Bupropion (Zyban) and Varenicline (Champix)

Other Medications • People who quit smoking may need to cut back on other medications: Caffeine – Levels may increase 2 to 3 times Benzodiazepines – Ativan, Rivotril, Xanax etc. Olanzapine – Zyprexa Flovoxamine – Luvox Insulin – diabetics Tri-cylic antidepressants – amitriptyline (Elavil) Acetaminophen

Success Rates at 6 months • • • Placebo 14 Nicotine Replacement Therapy 26 Bupropion 24 Varenicline (Champix) 26 to 33 Bupropion plus NRT 33 Patch plus gum or lozenge 37

Impact of Treatment • • No intervention … limited Success Counseling only … 1. 5 to 2 times increase Drugs only…about 2 times increase Counseling and Drugs…about 3 times increase

Who should not use NRT 1. Immediate post-myocardial infarction period – 2 weeks (heart attack) 2. Life threatening arrhythmias (heart beat) 3. Severe or worsening angina pectoris (chest pain) 4. Recent cerebral vascular accident (stroke) 5. Patches – generalized skin disorders

Pregnancy and Breastfeeding • NRT is safer than smoking for the pregnant woman and her fetus if she is unable to quit smoking with a behavioural intervention…it should be considered under doctor’s care.

Is Nicotine Replacement Addicting? • Cigarettes are far more addictive than nicotine replacement products primarily because of the way in which they deliver nicotine.

Nicotine is harmful? • It is not nicotine, but the thousands of toxins present in tobacco and its combustion products, that are responsible for the vast majority of tobacco-caused disease.

Nicotine Doses • Smokers should be in control of how they use NRT and should vary the dose according to their own needs. Like smoking, it takes time to learn how best to use NRT in a manner that maximizes its benefits.

NRT and smoking at the same time: • NRT can be used by people who are not yet ready or able to quit as, for some individuals, being tobacco-free is not a foreseeable goal. NRT may help these smokers take a “cigarette holiday” or, in some cases, substantially reduce their smoking as an interim, achievable step toward quitting.

Nicotine Overdose • • Cold sweat Nausea, vomiting , abdominal pain, diarrhea Salivation Headache Dizziness Disturbed hearing and vision Tremor Mental confusion

Nicotine Patch • Price - box of 7 $19. 99 to $30. 99 • Provides a steady release of nicotine • Monitor side effects or difficulty in quitting and adjust dose accordingly • Skin irritation, abnormal dreams, nausea and stomach upset • Do not reuse same site for one week

Tips for patch • New patch everyday – clean, dry, hairless, new site (1 week) • Remove old patch • Do not use lotion or moisturizing soap • Soap increases absorption, as does strenuous exercise • Nightmares – wear patch for 16 hours

Patch • Highest compliance rate, but it does not treat acute cravings • Up to 50% have a local skin reaction, usually mild, use hydrocortisone cream and rotate sites…only 5% need to stop use. • Can be used with other forms of NRT

Dose • If smoke 16 or more per day, start with Step 1 for 4 to 6 weeks, if successful go to Step 2 for 2 to 4 weeks, then to Step 3 for 2 to 4 weeks • If weigh less than 99 pounds (45 kg) or smoke less than 16 cigarettes per day, start with Step 2 for 6 weeks, then decrease as successful • Box says maximum 3 months, but actually no limit…

Nicotine Inhaler Price – box of 42 cartridges $33. 99 to $39. 99 Immediate release Short acting, allows for flexible dosing Mild local irritation of mouth and throat 40%, coughing 32% and runny nose 23% , hiccups, may get better with continued use • Can be used with other forms of NRT • •

Inhaler • Not a true inhaler; the nicotine is absorbed through the lining of the mouth • Designed to be puffed on, hold vapor in mouth for a few seconds before breathing out • Each cartridge delivers 4 mg over 80 - 160 inhalations – flexible dosing ( 10 puffs = 1 puff of cigarette) • 20 minutes continuous puffing, 5 min/time x 4, 10 min/time x 2 • Hand-mouth activity is preferred by some quitters • Good for those who cannot chew gum • Most successful users use 6 cartridges/day

Inhaler Dose • Available in 10 mg cartridge that delivers 4 mg • Use at least 6 cartridges per day, use every 20 minutes as needed • Best effects with frequent puffing • Maximum is stated as 12 cartridges per day • Recommended duration is 6 months (taper last 3 months) • Temperature below 4 degrees

Inhaler • Avoid acidic beverages and food (juice, pop, coffee) within 15 minutes of inhaler, interfere with absorption…water is okay • Menthol allergy…avoid inhaler • Check if ulcer, chronic throat disease or asthma

Nicotine Gum Price – 2 mg 105/box $19. 99 to $36. 99 Immediate release Short acting allows for flexible dosing Mouth soreness, hiccups, stomach upset and jaw ache – generally mild and often alleviated by correct chewing technique • Can be used with other NRT • Shown to reduce or delay weight gain • •

Gum • Used in response to immediate urge to smoke, can be used in a “reduce to quit” fashion in place of cigarettes • Sugar free • Avoid acidic beverage and food (coffee, juice, pop) by 15 minutes, water is okay • Rinse mouth with water if have eaten within 15 minutes before using gum

Gum Dosing • Use 10 to 12 pieces per day ( 2 mg or 4 mg) • At least 1 piece every 1 to 2 hours for 1 to 3 months, gradually reduce by 1 piece per day each week, as withdrawal symptoms allow, complete by 6 months • 2 mg if < 25 cigarettes/day • 4 mg if > 25 cigarettes/day

Gum technique • Use 1 piece at a time • Chew and park for 30 minutes to release all of nicotine – “bite-park” • Bite slowly till peppery – park - bite again once peppery dissipates – park – and so one for 30 minutes or until no taste • Check if ulcer, or stomach problems

Nicotine Lozenge Price – 88/box $35. 99 Immediate release Short acting allows flexible dosing Nausea, hiccups, heartburn, headache, coughing, mouth and throat irritation • Used in response to immediate urge to smoke • Absorbed through lining in the mouth • •

Lozenge Dosing • Use one lozenge ( 2 or 4 mg) every 1 hour for up to 6 weeks, then every 2 to 4 hours for 2 weeks then every 4 to 8 hours for 2 weeks • 2 mg for those who do NOT smoke in the first 30 minutes after awakening • Minimum 9/day, Maximum 25/day • Do not chew or swallow • Dissolve over 20 – 30 minutes move side to side

Lozenge • Slowly suck until there is a strong taste, then rest lozenge in your cheek. Wait 1 minute or until taste fades. Repeat • Do not eat or drink for 15 minutes before lozenge except water • Useful for poor oral health or dentures and for those who cannot chew gum • Can use with other NRT

Nicotine Mist • • • $33. 99 - $37. 99 for one container (150 doses) Immediate release (60 seconds) Tingling lips, Hiccups, Strong Taste Used in response to immediate urge to smoke Absorbed through lining in the mouth

Nicotine Mist • Use one spray first and if cravings do not disappear in a few minutes use a second spray • If 2 sprays are required, use 2 sprays as future dose • Most smokers use 1 or 2 sprays every 30 minutes to 1 hour • Maximum 2 sprays at a time, 4 sprays per hour, 64 sprays per day

Nicotine Mist • Point the spray nozzle towards the open mouth, holding it as close as possible • Press to top of the dispenser to release one spray into the mouth avoiding the lips • For best results, avoid swallowing for a few seconds after spraying • Avoid acidic beverage and food (coffee, juice, pop) by 15 minutes, water is okay

Bupropion • Price $0. 92/day • Blocks neural reuptake of dopamine and norepinephrine (cravings and withdrawal) • Difficulty sleeping 35 -40%, dry mouth 10% • May be used with NRT (blood pressure) • May be beneficial for smokers with history of depression • Delays weight gain

Bupropion Dosing • Take 150 mg for 3 days then 150 mg twice daily for 7 to 12 weeks, up to 1 year for maintenance • Begin taking medication 1 to 2 weeks before selected quit date • 7 to 8 week trial to see if effective, if not then stop

Bupropion Contraindications History of seizures Eating disorder Bipolar Use of MAOI – phenelzine (Nardil), tranylcypromine (Parnate), moclobemide (Manerix), selegiline (Eldepryl) • Alcoholism • Severe Liver problems • •

Bupropion Cautions • Tell doctor immediately if unusual feelings of agitation, hostility, aggression, depressed mood, hallucinations, changes in behaviour or suicidal thoughts • Stop taking if you have thoughts of self-harm or harm to others

Bupropion Tips • If troubles sleeping, take the second dose earlier ( at least 8 hours after the first dose) • Consider taking once daily (just as effective, less side effects) • Alcohol only in moderation

Varenicline (Champix) • Price $2. 57/day • Reduces withdrawal and cravings, prevents pleasurable effects of smoking • Nausea; sleep disturbance; abnormal, vivid or strange dreams; and skin reactions; headache; impairment in ability to drive • Should NOT be combined with NRT because of increased risk of side effects

Varenicline Dosing • 0. 5 mg daily for 3 days, then twice daily for 4 days, then 1 mg twice daily for 12 weeks • Additional 12 weeks may be needed • Quit smoking 1 to 2 weeks after starting medication

Varenicline • Tell doctor immediately if experience any unusual feeling of agitation, hostility, aggression, depressed mood, hallucinations, changes in behaviour or suicidal thoughts • Stop taking if any symptoms that are not typical for you, or if you have thoughts of selfharm or harm to others

Varenicline Tips • Always take with a meal and glass of water, to reduce nausea • Take second pill at supper rather than bedtime to reduce insomnia • Works just as well at 0. 5 mg twice daily as compared to 1 mg twice daily • Alcohol – unknown • Can be used with antidepressants

Electronic Cigarettes • No evidence that benefit smoking cessation • In Canada to be legally sold…have to be nicotine free and make no health claims • Contain numerous ingredients (vegetable oil, flavoring, etc…) • Combustion may produce harmful substances when inhaled…studies show may cause harm

Final Word • • • Nicotine Replacement Therapy (NRT) NRT plus NRT Bupropion plus NRT Varenicline