Smoking Cessation FSHP Slide.ppt...Fiore et al. (2008). Treating Tobacco Use and Dependence 3/2/2016 2 Prevalence of Tobacco Use • Each day 4,000 minors, ages 12 to 17, smoke their

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1

Smoking Cessation Pharmacotherapy

Melodie Merzier-Michel

PGY-1 Pharmacy Resident

Memorial Regional Hospital

www.fshp.org

Disclosure

• The author of this presentation has nothing to

disclose concerning possible financial or

personal relationships with commercial

entities that may have a direct or indirect

interest in the subject matter of this

presentation.

2

Objectives

• Discuss the prevalence of tobacco use in the United

States (U.S.)

• Describe the health risks associated with smoking

• Describe the health benefits of smoking cessation

• Define smoking cessation

• Recognize the 5 “A’s” to promote smoking cessation

• Highlight the role of nicotine replacement therapy in

smoking cessation

• Identify the use of other pharmacotherapies in

smoking cessation

3

Prevalence of Tobacco Use

• In 2014, nearly 17 of every 100 U.S. adults 18

years or older (16.8%) or an estimated 40

million adults in the U.S., smoked cigarettes

• Each year there are 480,000 deaths attributed

to smoking in the U.S

• Largest avoidable source of mortality

4

Economic Facts About U.S Tobacco Production and Use. Centers for Disease Control and Prevention. Fiore et al. (2008). Treating Tobacco Use and Dependence

3/2/2016

2


• Each day 4,000 minors, ages 12 to 17, smoke

their first cigarette

• Approximately 1,200 children and adolescents

become daily cigarette smokers

• More than 16 million Americans live with a

smoking-related disease

5



• Cigarettes account for greater than 90% of

tobacco use

• Smokeless tobacco accounts for less than 5%

• Pipes and cigars account for less than 1%

6

Stead LF et al. Nicotine replacement therapy for smoking cessation.American Psychiatric Association, (2000). Diagnostic and Statistical Manual for Mental Disorders - V

Second Hand Smoke

• Smoke that has been exhaled, or breathed

out, from burning tobacco products, such as:

• Cigarettes

• Cigars

• Pipes

7Second Hand Smoke. Centers for Disease Control and Prevention. Updated 2015

Second Hand Smoke

• Accounts for approximately 2,500,000 deaths

in nonsmokers

• Results in nearly 34,000 heart disease deaths

each year

• Associated with more than 7,300 lung cancer-

related deaths each year

8Second Hand Smoke. Centers for Disease Control and Prevention. Updated 2015

3/2/2016

3

Costs of Tobacco Use

• $96 billion dollars per year in direct medical

expenses

• $156 billion dollars lost in work wages

• $193 billion dollars in annual health-related

economic losses

• $300 billion dollars in total economic cost

of smoking

9


Health Consequences of

Smoking

10

What’s in a Cigarette?

11Stead LF et al. Nicotine replacement therapy for smoking cessation

http://resources0.news.com.au/images/2013/02/09/1226574/531308-nnd-whats-in-a-cigarette.jpg

Health Consequences of Smoking

12

SmokingSmokingCancerCancer

Respiratory Effects

Respiratory Effects

Cardiovascular Effects

Cardiovascular Effects

Reproductive effects

Reproductive effects

Other DiseasesOther Diseases

Health Effects of Cigarette Smoking. Centers for Disease Control and Prevention.Fiore et al. (2008). Treating Tobacco Use and Dependence.

3/2/2016

4

Health Consequences of Smoking

13https://upload.wikimedia.org/wikipedia/commons/9/92/Risks_form_smoking-smoking_can_damage_every_part_of_the_body.png

Tobacco Dependence

• Smoking within 30 minutes of awakening

• Smoking more than 20 cigarettes per day

• Awaking at night to smoke

14American Psychiatric Association, (2000). Diagnostic and Statistical Manual for Mental Disorders – V

Assessment Tools for Tobacco

Dependence

• Fagerstrom Tolerance Questionnaire (FTQ)

• Fagerstrom Test for Nicotine Dependence

(FTND)

• Diagnostic and Statistical Manual (DSM)

• Cigarette Dependence Scale (CDS)

• Nicotine Dependence Syndrome Scale (NDSS)

• Wisconsin Inventory of Smoking Dependence

Motives (WISDM)

15Piper et al. (2006). Nicotine & Tobacco Research

Nicotine Addiction

16http://jerushaellis.ca/wp-content/uploads/2014/05/ellis_jerusha_SmokingCessation_Addiction.jpg

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Nicotine Withdrawal Symptoms

• Anxiety

• Craving

• Cognitive and attention deficits

• Depression

• Decreased heart rate

• Increased appetite or weight gain

• Irritability, frustration, anger

• Sleep disturbances

17American Psychiatric Association, (2000). Diagnostic and Statistical Manual for Mental Disorders – V

http://cf.chucklesnetwork.com/items/5/6/2/6/original/not-sure-if-hates-all-of-you-or-just-nicotine-withdrawal.jpg

Tobacco Dependence

• 70 % of adult tobacco users report wanting to

quit each year

• 44% of adult tobacco users report they try to

quit each year

• Only 4-7% of tobacco users who attempt to

quit are successful

18Lavinghouze et. al. Trends in Quit Attempts Among Cigarette Smokers. MMWR, October 16, 2015.

Fiore et al. (2008). Treating Tobacco use and Dependence

5 A’s Model for Treating Tobacco Use and

Dependence

19

ASKASK

ADVISEADVISE

ASSESSASSESS

ASSISTASSIST

ARRANGEARRANGE

Fiore et al. (2008). Treating Tobacco Use and Dependence

Methods for Enhancing Motivation to Quit

The 5 R’s

RepetitionRepetitionMany people need 7 to 10 attempts before they are successful

RoadblocksRoadblocksWhat barriers do you have to quitting tobacco?

RewardsRewardsWhat are the benefits you may have if you stop smoking?

RisksRisksWhat are the negative things you think about smoking?

RelevanceRelevanceWhat’s the most important reason for you to consider quitting?

20Fiore et al. (2008). Treating Tobacco Use and Dependence

3/2/2016

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21http://obamacarefacts.com/wp-content/uploads/2014/08/cdc-quit-smoking-facts-1024x643.jpg

Treatment

22

Who Should Receive Treatment?

• All tobacco users trying to quit, except:

• Contraindication to pharmacotherapy

• Specific populations with insufficient

evidence of effectiveness

– Adolescents

– Light smokers (<10 cigarettes a day)

– Pregnant women

– Smokeless tobacco users

23Fiore et al. (2008). Treating Tobacco use and Dependence.

Considerations for Treatment Selection

• Adverse effects

• Cost

• Patient characteristics

– History of depression

– Weight gain concerns

– Breastfeeding

• Patient preference

• Precautions and contraindications

• Previous patient experience

24Fiore et al. (2008). Treating Tobacco use and Dependence

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Pharmacotherapy

25

First Line Agents

• FDA-approved

• Nicotine Replacement Therapy (NRT)

– Nicotine Transdermal Patch (OTC)

– Nicotine Gum (OTC)

– Nicotine Lozenge (OTC)

– Nicotine Inhaler (Rx)

– Nicotine Nasal Spray (Rx)

• Buproprion SR (Zyban®, Wellbutrin SR®) (Rx)

• Varenicline (Chantix®) (Rx)


Second Line Agents

• Non FDA-approved

– Clonidine (Catapres®, Catapres-TTS®)

– Nortriptyline (Pamelor®)


Nicotine Replacement Therapy (NRT)

28

Fiore et al. (2008). Treating Tobacco use and DependenceSilagy, C., et al. (2004),. Cochrane Database Syst Rev CD000146

http://www.pharmahost.org/support/images/f/fd/Nicotine_mechanism_of_action.gif

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Nicotine Replacement Therapy (NRT)

29

Options

Patch

Slow Absorption

Gum, Inhaler, Lozenge

Intermediate Absorption

Nasal Spray

Fast Absorption


Nicotine Containing Products

Plasma Concentrations

30Rx for Change: Clinician-Assisted Tobacco Cessation. San Francisco, CA: The Regent of the University of California, University of Southern

California, and Western University of Health Sciences.;1999-2008

NRT Precautions

• Recent MI (within 2 weeks)

• Serious underlying arrhythmias

• Serious or worsening angina pectoris

• Pregnancy category D

• Breastfeeding

• Adolescents (<18 years)

31

Fiore et al. (2008). Treating Tobacco Use and DependencePharmacist’s Letter/Prescriber’s Letter January 2011.

Pharmacologic Product Guide: FDA-Approved medications for Smoking Cessation

Efficacy of NRT

• All NRT forms increase quit rates at 6-12

months by 50-70% compared to placebo

• No significant difference between NRT forms– 4mg gum is more effective in highly dependent smokers

– Higher dose patches do not show additional benefit

• The intensity of additional advice and support

does not increase the effectiveness of NRT

• A combination of NRT products is more

effective than one product alone

32


Stead et al. (2008). Cochrane Database Syst Rev 2008(1)

3/2/2016

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Nicotine Transdermal Patch

(NicoDerm CQ®, etc.)

33

Product Adverse Effects

• NicoDerm CQ® or generic

• 7mg, 14mg, 21mg (24-hour

release)

• Local skin reactions

• Headache

• Sleep disturbances





34

Dosing Counseling Points

If >10 cigarettes/day:

• 21 mg/day x 4-6 weeks

• 14 mg/day x 2 weeks


If <10 cigarettes/day:



• 4 weeks, then 2 weeks, then 2

weeks

•Worn for 24hr (16hr if having

trouble sleeping)

•Apply upon awakening on quit

date





35

Advantages Disadvantages

• Once daily dosing improves

adherence

• Less visible

• Can be used in combination

with other agents

• Delivers consistent nicotine

levels over 24 hours

• Cannot be titrated to acutely

manage withdrawal symptoms

• Not recommended for use in

patients with dermatologic

conditions (e.g., psoriasis,

eczema, atopic dermatitis)

• Allergic reactions to adhesive



Nicotine Gum (Nicorette®, etc.)

36


• Nicorette® or generic

• 2mg, 4mg

• Original, cinnamon, fruit, and

mint flavors

• Dyspepsia

• Sore mouth

• Hiccups

• Jaw ache

• Hypersalivation



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37


< 25 cigarettes/day: 2mg

≥ 25 cigarettes/day: 4mg

• 1 gum every 1-2 hours x 6

weeks


weeks


weeks

• Maximum 24 pieces/day

• Use up to 12 weeks

• Chew each piece slowly

• Park between cheek and gum

when peppery or tingling

sensation appears (~15-30

chews)

• Resume chewing when tingling

fades

• Park in different areas of mouth

• Avoid acidic beverages 15

minutes before and after

chewing




38


• Oral substitute for tobacco

• Titrated to manage withdrawal

symptoms

• Used in combination with other

agents to manage craving

• Variations in flavors

• Frequent dosing can

compromise adherence

• Proper chewing technique is

necessary for effectiveness and

to minimize adverse effects



Nicotine Lozenge

(Commit®, Nicorette®)

39


• Commit® or generic

• 2mg, 4mg

• Cherry or mint flavor

• Nausea

• Sore throat

• Hiccups

• Heartburn

• Headache

• Flatulence

• Insomnia



Nicotine Lozenge


40


1st cigarette < 30 minutes after

waking: 4mg

1st cigarette > 30 minutes after

waking: 2mg

•Weeks 1-6: 1 every 1-2 hours



•Maximum 20 lozenges/day

•Used for at least 12 weeks

• Allow to dissolve slowly (20–30

minutes)

• Nicotine release may cause a

warm, tingling sensation

• Do not chew or swallow

• Rotate to different areas of the

mouth

• No food or beverages 15

minutes before or during use



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Nicotine Lozenge


41


• Can serve as an oral substitute

for tobacco

• Can be titrated to manage

withdrawal symptoms


with other agents to manage

craving



• Gastrointestinal side effects



Nicotine Inhaler (Nicotrol Inhaler®)

42


• Nicotrol Inhaler® or generic

• 10 mg cartridge delivers 4mg

inhaled nicotine vapor

• Local irritation of mouth and

throat

• Cough

• Headache

• Dyspepsia

• Rhinitis




43


• 6–16 cartridges/day

• Individualize dosing

• Initially use 1 cartridge every

1–2 hours

• Use for up to 6 months

• Continuous puffing for 20 minutes

• Nicotine is depleted after 20

minutes of active puffing

• Inhale into back of throat or puff in

short breaths

• Do NOT inhale into the lungs (like a

cigarette) but “puff” as if using a

pipe

• Open cartridge retains potency for

up to 24 hours

• No food or beverages 15 minutes

before or during use




44



withdrawal symptoms

• Mimics hand-to-mouth ritual of

smoking



cravings



• Cartridges might be less

effective in cold environments

• Throat and mouth irritation

• Caution in patients with

bronchospastic disease



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Nicotine Nasal Spray (Nicotrol NS®)

45


• Nicotrol NS® or generic

• Metered spray 10mg/ml

aqueous nicotine solution

• Nasal irritation

• Nasal congestion

• Transient changes in taste and

smell

• Headache

• Cough

• Sneezing




46


• 1–2 doses/hour

(8–40 doses/day)

One dose = 2 sprays (one in

each nostril); each spray

delivers 0.5 mg of nicotine to

the nasal mucosa

• Maximum: 5 doses/hour or 40

doses/day

• Use up to 3-6 months

• Prime prior to use

• Tilt head back slightly

• Do not sniff, swallow, or inhale

through the nose as spray is

being administered

• Wait 2 to 3 minutes before

blowing nose




47



withdrawal symptoms



situational urges



• Development of dependence

• Patients with chronic nasal

disorders or reactive airway

disease should not use spray

• Nose and throat irritation



Bupropion SR (Zyban®)

• Atypical antidepressant which inhibits dopamine and

norepinephrine reuptake and possibly acts as a

nicotinic antagonist

• Contraindications

– Seizure disorder

– Current or prior diagnosis of bulimia/anorexia

– Abrupt discontinuation of alcohol or

sedatives/benzodiazepines

– MAO inhibitors in preceding 14 days

48

Hughes J et al (2004). Cochrane Database Syst Rev: CD000031Zyban® (Summary of Product Characteristics). 2009. GlaxoSmithKline

3/2/2016

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• Precautions

– Hepatic impairment

– Concomitant therapy with

medications/conditions known to lower the

seizure threshold

– History of seizure

– Pregnancy category C

– BLACK-BOXED WARNING for

neuropsychiatric symptoms

49

Efficacy of Bupropion SR (Zyban®)

• Combining bupropion SR with an NRT has

been shown to increase short-term smoking

abstinence rates

• Combination of bupropion SR and nicotine

patch have shown no significant increase for

long-term (>6months) abstinence rates

compared to nicotine patch alone

50

Croghan IT et al. (2007) Randomized comparison of a nicotine inhaler and bupropion for smoking cessation and relapse prevention.. 2Piper ME et al (2009) Arch Gen Psych


Ebbert et al. (2010). Drugs 2010; 70(6): 643-650


51Hughes J et al (2004). Cochrane Database Syst Rev: CD000031

Fiore et al. (2008). Treating Tobacco Use and DependenceZyban® (Summary of Product Characteristics). 2009. GlaxoSmithKline


• Zyban® or bupropion SR 150mg

(sustained-release tablet)

• Insomnia

• Dry mouth

• Nervousness/difficulty

concentrating

• Nausea

• Dizziness

• Constipation


52Hughes J et al (2004). Cochrane Database Syst Rev: CD000031

Fiore et al. (2008). Treating Tobacco Use and DependenceZyban® (Summary of Product Characteristics). 2009. GlaxoSmithKline


• 150 mg every morning x 3 days,

then 150 mg twice a day

• Do not exceed 300 mg/day

• Begin therapy 1–2 weeks prior

to quit date

• Allow at least 8 hours between

doses

• Avoid bedtime dosing to

minimize insomnia

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53


• Twice daily oral dosing is

associated with fewer

adherence problems

• Might delay weight gain

• Beneficial in patients with

depression


with NRT agents

• Increased seizure risk

• Several contraindications and

precautions

• Patients should be monitored

for potential neuropsychiatric

symptoms

Hughes J et al (2004). Cochrane Database Syst Rev: CD000031Fiore et al. (2008). Treating Tobacco Use and Dependence

Zyban® (Summary of Product Characteristics). 2009. GlaxoSmithKline

54

• Randomized trial of nicotine replacement therapy (NRT), bupropion and NRT plus bupropion for smoking cessation: effective in clinical practice

TitleTitle

• Self-reported cessation over 6 months with biochemical verification at 1 and 6 months

OutcomesOutcomes

• Open-label randomized controlled trial with 6 month follow up

• Participants: smokers (n=1071), NRT product of participant choice (n=418), bupropion (n=409), NRT plus bupropion (n=244)

MethodsMethods

• Abstinence rates for bupropion (27.9%) and NRT (24.2%) were not significantly different

• Abstinence rates for bupropion and NRT (24.2%) was similar to monotherapy

• Bupropion appears more beneficial than NRT in those with a history of depression (29.8 versus 18.5%)

ResultsResults

• Evidence has shown that bupropion is more beneficial than nicotine replacement therapy for smokers with a history of depression

• There is no difference in smoking cessation effectiveness among bupropion, nicotine replacement therapy, or their combination

ConclusionConclusion

Stapleton J et al. Addict. 2013;108(12):2193-2201

Varenicline (Chantix®)

55http://www.euroclinix.co.uk/images/pages/how-varenicline-work.gif

Efficacy of Varenicline (Chantix®)

• Existing data indicates that varenicline is more

effective than bupropion and some forms of

NRT in achieving abstinence, and is

recommended for use as a first line therapy

56Zwar N, et al (2007) Smoking cessation pharmacotherapy: An update for health professionals.

3/2/2016

15


• Precautions

– Use with caution and lower dosage in patients

with CrCl <30 mL/min or those on dialysis

– Pregnancy category C

– Cardiovascular events

– BLACK BOX WARNING for neuropsychiatric

symptoms

• Contraindications

– Hypersensitivity to varenicline


Cahill K et al (2007). Cochrane Database Syst Rev: CD006103https://smokingcessationoption.com/images/img-recommended-dosing.gif


58Varenicline (Chantix) Package insert. Accessed January 19, 2016



• Chantix ® 0.5mg and 1mg • Nausea

• Sleep disturbance

• Vivid/strange dreams

• Headaches

• Constipation

• Vomiting

• Neuropsychiatric symptoms


59


• Day 1-3: 0.5mg daily

• Day 4-7: 0.5mg twice daily

• Day 8-end of treatment: 1mg

twice a day

• Take after eating with full

glass of water to decrease

nausea

• Take second pill at dinner

rather than bedtime to reduce

insomnia

Varenicline (Chantix) Package insert. Accessed January 19, 2016Fiore et al. (2008). Treating Tobacco Use and Dependence


60


• Twice daily oral dosing is

associated with fewer

adherence problems

• Different mechanism of action

for patients who have failed

other agents

• Should be taken with food or a

full glass of water to reduce the

incidence of nausea

• Requires monitoring for

potential neuropsychiatric and

cardiovascular symptoms

Varenicline (Chantix) Package insert. Accessed January 19, 2016Fiore et al. (2008). Treating Tobacco Use and Dependence

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61

• Efficacy of varenicline combined with nicotine replacement therapy vs. varenicline alone for smoking cessation

TitleTitle

• Primary outcome was the 4-week abstinence rates from smoking for weeks 9 through 12 of treatment

• Secondary outcome included point prevalence abstinence at 6 months, continuous abstinence rate from weeks 9 through 24, and adverse events

OutcomesOutcomes

Koefelenberg CFN et al. J Am Med. 2014. 312(2):155-161

62

• Randomized, blinded, placebo-controlled clinical trial with a 12-week treatment period and 12-week follow-up

• Four hundred forty-six generally healthy smokers were randomized (1:1); 435 were included in the efficacy and safety analyses

MethodsMethods

• Combination treatment was associated with a higher continuous abstinence rate at 12 weeks (55.4%vs 40.9%) and 24 weeks (49.0% vs 32.6%) and point prevalence abstinence rate at 6 months (65.1%vs 46.7%)

ResultsResults

• Varenicline in combination with NRT was more effective than varenicline alone at achieving tobacco abstinence at 12 weeks (end of treatment) and at 6 months


Koefelenberg CFN et al. J Am Med. 2014. 312(2):155-161

Clonidine (Catapres®, Catapres-TTS®)

63

Mechanism of Action Precautions Adverse Effects

• Stimulates alpha-2

adrenoreceptors in

the brainstem and

reduces

sympathetic

outflow

• Rebound

hypertension

• Pregnancy category

C

• Dry mouth

• Drowsiness

• Dizziness

• Sedation

• Constipation



Clonidine (Catapres®, Catapres-TTS®)

64


• Begin 3 days before quit date or

on the quit date

• Tablet: 0.15-0.75 mg daily

• Patch: 0.1-0.2 mg per 24 hours

(via appropriate strength patch

applied once every 7 days)

• Apply patch to hairless location

between the neck and waist

• Do not discontinue therapy

abruptly



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Nortriptyline (Pamelor®)

65

Mechanism of Action Precautions Adverse Effects

• Blocks reuptake of

norepinephrine and

serotonin

• Risk of arrhythmias

• Use with caution in

cardiovascular

disease

• Avoid co-

administration with

MAOIs

• Pregnancy category

D

• Sedation

• Dry mouth

• Blurred vision

• Urinary retention

• Lightheadedness

• Shaky hands



Nortriptyline (Pamelor®)

66


• Begin 10-28 days before quit

date

• Initially 25 mg daily, gradually

increase to 75-100 mg daily

• Do not discontinue abruptly

because of withdrawal effects



Efficacy of Nortriptyline (Pamelor®)

• Conflicting data exist regarding increased

efficacy with combination therapy using

nortriptyline and NRT compared to

monotherapy

67

Ebbert et al. (2010). Drugs 2010; 70(6): 643-650

Combination Therapy

• Combination of NRT

–Long-acting formulation (patch) + short-acting

formulation (gum, inhaler, nasal spray)

• Bupropion SR + nicotine patch

• Bupropion SR + varenicline

• Varenicline + NRT


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Combination Therapy

• Increased abstinence rates

• Enhanced relief of withdrawal effects

• Considered in highest risk of relapse

– Previously failed monotherapy

– Smokers with high nicotine-dependence

– Heavy smokers (i.e. 20 cigarettes or more

per day)

• Additional cost must be considered

69Ebbert JO, Hays JT, Hurt RD. Combination pharmacotherapy for stopping smoking: what advantage does it offer?

Drugs 2010; 70(6): 643-650

70

• Combination Varenicline and Buproprion SR for Tobacco Dependence Treatment in Cigarette Smokers: A Randomized Trial

TitleTitle

• Primary outcome was the prolonged (no smoking from 2 weeks after the target quit date) and 7-day point-prevalence (no smoking past 7 days), and abstinence rates at week 12

• Secondary outcomes were prolonged and point-prevalence smoking abstinence rates at weeks 26 and 52

OutcomesOutcomes

• Randomized, blinded, placebo-controlled multicenter clinical trial with a 12-week treatment period and 52-week follow-up

• Five hundred six cigarette smoking adults (≥ 18 years) were randomized and 315 (62%) completed the study

MethodsMethods

Ebbert JO et al. J Am Med. 2014.311(2):155-163

71

• At 12 weeks, 53% of the combination therapy group achieved prolonged and 56.2% achieved 7-day point-prevalence smoking abstinence, compared to 43.2% and 48.6% in vareniclinemonotherapy

• At 26 weeks, 36.6% of the combination therapy group achieved prolonged and 38.2% achieved 7-day point-prevalence smoking abstinence, compared to 27.6% and 31.9% in vareniclinemonotherapy

• At 52 weeks, 30.9% of the combination therapy group achieved prolonged and 36.6% achieved 7-day point-prevalence smoking abstinence, compared to 24.5% and 29.2% in vareniclinemonotherapy

• Participants receiving combination therapy reported more anxiety and depressive symptoms

ResultsResults

• Combined use of varenicline and bupropion, compared with varenicline alone, increased prolonged abstinence but not 7-day point prevalence at 12 and 26 weeks

• Neither outcome was significantly different at 52 weeks


Ebbert JO et al. J Am Med. 2014.311(2):155-163

Pharmacotherapy Use in Pregnancy

• Insufficient evidence for recommendations in

pregnant smokers

• Category C: varenicline, bupropion SR

• Category D: nicotine replacement therapy

• Behavioral interventions are the preferred

treatment


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Pharmacotherapy: Other Special

Populations

• Pharmacotherapy is NOT recommended for:

– Smokeless tobacco users

– Smoking fewer than 10 cigarettes per day

– Adolescents

• OTC sales are restricted to adults 18 years or

older

• Nicotine replacement therapy use in minors

require a prescription


Role of the Pharmacist

• Ask about tobacco use

• Advise patient to quit

• Explain the risks and complications of tobacco

use

• Promote and encourage smoking cessation

• Referral to a formal cessation program

• Encourage and provide support

74Saba M et al. J Clin Pharm and Ther. 2014;39:240-247

Role of the Pharmacist

• Assist in the selection of OTC products

• Counsel on proper use of smoking cessation

medications

• Assist physicians with evidence based

recommendations

• Monitor drug interactions with smoking and

smoking cessation therapy

75Saba M et al. J Clin Pharm and Ther. 2014;39:240-247

Questions

76http://cdn.marksdailyapple.com/wordpress/wp-content/themes/Marks-Daily-Apple-Responsive/images/blog2/brainquestions.jpg

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References

• Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.

• Stead LF et al. Nicotine replacement therapy for smoking cessation. Cochrane Review

2012, Issue 11

• Ebbert JO, Hays JT, Hurt RD. Combination pharmacotherapy for stopping smoking: what advantage does it offer? Drugs 2010; 70(6): 643-650

• Bullen C et al. Electronic cigarettes for smoking cessation: a randomised controlled trial. Lancet Sep 7 2013

• Economic Facts About U.S Tobacco Production and Use. Centers for Disease Control and

Prevention. [Accessed January 25, 2016]. Available at: http://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts

• National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health: The Health Consequences of Smoking. A Report of the Surgeon General.Atlanta, GA, Centers for Disease Control and Prevention, U.S. Department of

Health and Human Services, May 27, 2004. Available at: http://www.cdc.gov/tobacco/data_statistics/sgr/2004/complete_report/index.htm. . Accessed January25, 2016.

77

References

• Silagy, C., et al., Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev, 2004(3): p. CD000146.

• Croghan IT et al. (2007) Randomized comparison of a nicotine inhaler and bupropion for

smoking cessation and relapse prevention. Mayo Clin Proc. 82(2):186-95.

• Piper ME et al (2009) Arch Gen Psych 66(11):1253-1262.

• Baker TB, Breslau N, Covey L, Shiffman S: DSM criteria for tobacco use disorder and tobacco

withdrawal: a critique and proposed revisions for DSM-5. Addiction 107(2):263–275, 2012

• DiFranza, J.R.; Savageau, J.A.; Fletcher, K.; Ockene, J.K.; Rigotti, N.A.; McNeill, A.D.; Coleman,

M.; Wood, C. (2002) “Measuring the loss of autonomy over nicotine use in adolescents: Th e

Development and Assessment of Nicotine Dependence in Youths (DANDY) Study.” Archives of

Pediatric Adolescent Medicine. 156:397-403.

• Heatherton, T.F.; Kozlowski, L.T.; Frecker, R.C.; Fagerström, K.O. (1991). “Th e Fagerström Test

for Nicotine Dependence: A Revision of the Fagerström Tolerance Questionnaire.” British

Journal of Addiction, 86 (9): 1119-27

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