Top 200: Smoking Cessation & Alcohol

• smoking is the single greatest cause of disease & early death in America
• causes 5.4 million deaths per year
• risk of disease is proportional to duration of tobacco exposure
• duration of exposure increases your risk
• over 70% of smokers say they want to quit

• shortness of breath
• asthma/COPD exacerbation
• increased respiratory infections
• fetal harm
• impotence
• infertility
• stroke
• heart attack
• primary cause of COPD
• osteoporosis
• lung cancer
• other cancers
• long-term disability

• counseling (e.g. individual, group or phone)
• quit line network (1-800-QUIT-NOW)
• set achievable goals
• remove triggers
• social support

• first-line prescription drugs:
• -buproprion SR
• -varenicline (Chantix)

• second-line prescription drugs:
• -clonidine
• -nortriptyline

• nicotine replacement therapy:
• -gum
• -inhaler
• -lozenge
• -nasal spray
• -patch

• pregnant women
• adolescents
• smokeless tobacco users
• light smokers (<10 cigarettes per day)

• Ask about tobacco use
• Advise to quit
• Assess willingness to attempt to quit
• Assist by offering medication or referral for counseling or behavioral services
• Arrange follow up

• Recognize danger situations:
• -stress
• -alcohol (avoid/limit)
• -availability of cigarettes

• Develop coping skills:
• -anticipate/avoid temptation
• -change routine

• Recognize withdrawal symptoms:
• -negative mood (e.g. depression)
• -smoking urges
• -poor concentration
• -peak within 1 to 2 weeks and may continue for months
• -psychological desire may never end

• Provide encouragement:
• -replace urge with another hobby or harmless habit (e.g. chewing gum)
• -social support

• Available over-the-counter (OTC)
• Dose: 1 piece every 1-2 hours
• Max dose: 6-15 pieces per day
• Number of cigarettes per day determines starting dose
• Use up to 12 weeks or as needed
• Do not eat or drink 15 minutes before or during use
• Chewing method:
• -chew slowly for ~10 chews
• -will feel tingling sensation
• -park wad under tongue or in cheek to allow nicotine absorption (preferable not to swallow juices, but to have them absorbed via mouth)
• -when you don't feel any tingling, the piece is no good anymore
• -each piece should last ~30 minutes

• Adverse effects:
• -sore mouth
• -stomach ache
• -hiccups

Use caution with dentures

Available prescription only (Rx)

Dose: 6-16 cartridges per day

Use up to 6 months

Taper dose near end of therapy

Adverse effects: mouth & throat irritation

Available OTC

• Dose: 1 lozenge every 8 hours
• Max Dose: 20 lozenges in 24 hours
• Dose depends on how soon after waking the patient normally smokes

Use 3 to 6 months

Do not eat or drink 15 minutes before or during use

• Adverse effects:
• -hiccups
• -cough
• -heart burn

Available OTC or Rx

• Dose: 1-2 squirts per hour
• Max dose: 40 doses per day

• Use 3 to 6 months
• Taper dose near end of treatment

Adverse effects: nasal irritation (subsides with time)

• Caution:
• -avoid in asthma patients
• -may cause dependence/tolerance

Available OTC or Rx

• Dose: 1 patch per day
• Starting dose depends on how many cigarettes patient usually smokes per day

• Delivers continuous dose of nicotine over 16 to 24 hours
• Why 16 hours? Patients can be advised to remove patch before bedtime to decrease adverse effect of insomnia. Note that not all patients experience insomnia, so they have the option of wearing patch 24 hours.

• Use 8 to 12 weeks
• Taper dose near end of treatment

• Adverse effects:
• -local skin irritation
• -insomnia

• Contraindicated with:
• -severe psoriasis
• -severe eczema

• MOA: unknown (for smoking cessation)
• likely due to inhibition of dopamine and NE neuronal uptake

increases dopamine

• Start therapy 1-2 weeks before quit date (the goal)
• Takes about a week for effects to be seen

• Use 2-6 months
• If patient still has not quit after 7 weeks, it probably will not work

• Adverse effects:
• -insomnia
• -dry mouth
• -headache

• Contraindications:
• -current MAOI use
• -history of seizure or eating disorder

Black Box Warning: antidepressants have increased the risk of suicidal ideation in children and adolescents with certain psychiatric disorders

MOA: partial agonist for neuronal nicotinic acetylcholine receptors

• increases dopamine levels, which seems to decrease cravings/withdrawal
• Start 1 week before target quit date (goal)
• Dosing Schedule:
• -days 1-3: 0.5 mg once daily
• days 4-7: 0.5 mg twice daily
• Maintenance (> 8 days): 1 mg twice daily
• Unique: titrate UP instead of down like most other treatments for smoking cessation

If patient successfully quits smoking during the first 12 weeks, he/she may continue pharmacologic therapy to help maintain success.

• If patient does not quit in 12 weeks of therapy, stop medication and reassess factors contributing to failure.
• Adverse effects:
• -abnormal/vivid/strange dreams
• -headache (common)
• -nausea (take with food and full glass of water to avoid GI upset)
• Black Box Warning: possible neuropsychiatric adverse effects. Report include temporally associated events (behavior changes, hostility, agitation, depressed mood, suicidal thoughts and behavior, attempted suicide). Reports still being reviewed by FDA.

Yes. Combination therapy initially produces greater abstinence rates than monotherapy.

• Combination therapy includes:
• patch + buproprion (FDA approved)
• patch + gum
• patch + lozenge + inhaler

Combination therapy with medication and behavioral counseling yielding 1 year of continuous abstinence is < 30%

Preach prevention!!! Being proactive is better than being reactive. Prevention is KEY!!!

• Relevance: encourage patient to identify why quitting is relevant
• Risks: ask patient to identify potential negative consequences of tobacco use
• Rewards: ask patient to identify potential benefits of quitting
• Roadblocks: ask patient to identify potential barriers to quitting
• Repetition: Repeat motivational intervention every time unmotivated patient enters clinical setting

• alcohol has been consumed by humans since prehistoric times
• alcohol and caffeine are the two most widely used drugs in the world
• alcohol is absorbed quickly into the bloodstream
• absorption rates vary depending on contents in the stomach
• high fat and carbohydrates lessen the absorption of alcohol

• beer is ~5% alcohol
• wine is ~12-15% alcohol
• hard liquor is ~45% alcohol

Brain: Absorption of information restricted; memory impaired; inhibitions lowered

Sight: Tunnel vision; difficulty in distinguishing light intensity

Central Nervous System (CNS): Central nervous system impaired; intestinal irritation can lead to ulcers; high levels can lead to coma or death

Liver: Change in fat metabolism, eventually leading to scarring of the liver

Sexuality: Sexual performance inhibited, possibly leading to impotence

Motor Skills: Co-ordination and motor skills impaired; increased swaying

_{Source: Johns Hopkins University}

Each state has its own legal definition of intoxication based on blood-alcohol concentration levels

The legal limit in most US states is between 0.08 and 0.10

• Different levels lead to different effects:
• 0.05: reduced inhibitions
• 0.10: slurred speech
• 0.20: euphoria & motor impairment
• 0.30: confusion
• 0.40: stupor
• 0.50: coma
• 0.60: respiratory paralysis & death

• depresses breathing rate
• depresses heart rate
• impaired motor coordination
• impaired short-term memory
• less ability to drive and perform complex tasks
• prolonged reaction time
• reduced attention span
• reduced inhibitions, which may lead to embarrassing or illicit behavior
• slower thought processes

• alcoholism or alcohol dependence
• chronic liver disease
• increase risk of accidents (falls, drownings, automobile accidents, etc.)
• fetal alcohol syndrome in pregnant women
• cancers (e.g. head, neck, stomach, breast cancers)
• increased risk for suicide and homicide
• risky sexual behaviors, which could lead to unplanned/unwanted pregnancy and/or sexually transmitted diseases (STDs)

• alcohol passes across the placenta to the fetus
• most harmful during the first three months of pregnancy
• fetal alcohol syndrome is a disorder marked by mental retardation and behavior problems

• low birth weight
• decreased muscle tone
• poor coordination
• delayed development
• significant functional problems in three or more major areas (e.g. thinking, speech, movement, social skills) as compared to normal developmental age
• heart defects

• narrow, small eyes
• small head
• small upper jaw
• smooth groove in upper lip
• smooth and thin upper lip