Nicotine Addiction

nicotine gum directions

Chew each piece very slowly several times Stop chewing at first sign of peppery, minty, or citrus taste or slight tingling in mouth (~15 chews, but varies) "Park" gum between cheek and gum (to allow absorption of nicotine across buccal mucosa) Resume slow chewing when taste or tingle fades When taste or tingle returns, stop and park gum in different place in mouth Repeat chew/park steps until most of the nicotine is gone (taste or tingle does not return; generally 30 minutes) NOT TO BE CHEWED LIKE ORDINARY GUM

nicotine lozenge side effect

Nausea Hiccups Cough Heartburn Headache Flatulence Insomnia

nicotine lozenge

To improve chances of quitting, use at least nine lozenges daily during the first 6 weeks The lozenge will not provide the same rapid satisfaction that smoking provides The effectiveness of the nicotine lozenge may be reduced by some foods and beverages: Coffee Juices Wine Soft drinks Do NOT eat or drink for 15 minutes BEFORE or WHILE using the nicotine lozenge.

nicotine lozenge directions

Use according to recommended dosing schedule Place in mouth and allow to dissolve slowly (nicotine release may cause warm, tingling sensation) Do not chew or swallow lozenge. Occasionally rotate to different areas of the mouth. Lozenge will dissolve completely in about 2030 minutes.

pharmacotherapy

"Clinicians should encourage all patients attempting to quit to use effective medications for tobacco dependence treatment, except where contraindicated or for specific populations* for which there is insufficient evidence of effectiveness."

nicotine lozenge dosing

Dosage is based on the "time to first cigarette" as an indicator of nicotine addiction Use Commit Lozenge 2 mg: If you smoke your first cigarette more than 30 minutes after waking up Use Commit Lozenge 4 mg: If you smoke your first cigarette of the day within 30 minutes of waking up

Pharmacologic methods for quitting

FDA-approved medications

1950

First modern reports linking smoking and cancer

quitlines

Free cessation services, including counseling, self-help kits, and cessation information Success rates double for patients who use a quitline, compared with quitting on their own 1) Identify triggers: re-learn daily routines; 2) Recognize how powerful nicotine addiction is; 3) Engage social support

NRT

Reduces physical withdrawal from nicotine Eliminates the immediate, reinforcing effects of nicotine that is rapidly absorbed via tobacco smoke Allows patient to focus on behavioral and psychological aspects of tobacco cessation doubles quit rates

nicotine gum disadvantages

Need for frequent dosing can compromise compliance. Might be problematic for patients with significant dental work. Patients must use proper chewing technique to minimize adverse effects. Gumchewingmightnotbe socially acceptable.

nicotine lozenge disadvantages

Needforfrequentdosing can compromise compliance. Gastrointestinalside effects (nausea, hiccups, and heartburn) may be bothersome.

nicotine gum

Resin complex Nicotine Polacrilin Sugar-free chewing gum base Contains buffering agents to enhance buccal absorption of nicotine Available: 2 mg, 4 mg; original, cinnamon, fruit, mint (various), and orange flavors Dosing based on number of cigarettes/day (25)

cigars

Nicotine content of cigars varies greatly (10 - 444 mg) One cigar can deliver enough nicotine to establish and maintain dependence Cigar smoking is not a safe alternative to cigarette smoking

transdermal nicotine patch

Nicotine is well absorbed across the skin Plasma nicotine levels are lower and fluctuate less than with smoking or short-acting NRTs (gum, lozenge) keeps a steady concentration of nicotine in the body

nicotine lozenge

Nicotine polacrilex formulation Delivers ~25% more nicotine than equivalent gum dose Sugar-free mint (various), or cherry flavor Contains buffering agents to enhance buccal absorption of nicotine Available: 2 mg, 4 mg

transdermal nicotine patch disadvantages

Patients cannot titrate the dose to acutely manage withdrawal symptoms. Allergic reactions to the adhesive may occur. Patients with dermatologic conditions should not use the patch.

NRT usage

Patients should stop using all forms of tobacco upon initiation of the NRT regimen. NRT regimens are generally recommended for < 12 weeks.

nrt precautions

Patients with underlying cardiovascular disease Recent heart attack (within past 2 weeks) Serious heart rhythm problems Serious or worsening chest pain

Spit tobacco health risks

Peridontal effects: gingival recession, bone attachment loss, dental caries, Oral leukoplakia Cancer: -oral cancer -pharyngeal cancer

NRT products

Polacrilex gum Nicorette (OTC) Generic nicotine gum (OTC) Nasal spray Nicotrol NS (Rx) Lozenge Inhaler Commit (OTC) Generic nicotine lozenge (OTC) Transdermal patch NicoDerm CQ (OTC) Generic nicotine patches (OTC, Rx) Nicotrol (Rx)

transdermal nicotine patch advantages

Provides consistent nicotine levels. Easy to use and conceal. Once daily dosing associated with fewer compliance problems.

2006 report of surgeon general

Second-hand smoke causes premature death and disease in nonsmokers Children: risk of sudden infant death syndrome, acute resp infections, ear problems, and severe asthma adults: immediate adverse effects on cardiovascular system, increased risk for heart disease and lung cancer Indoor spaces: separating smoking areas, cleaning the air, and ventilation are INEFFECTIVE Eliminating smoking fully protects nonsmokers

transdermal nicotine patch

Side effects to expect in first hour: Mild itching Burning Tingling Additional possible side effects: Vivid dreams or sleep disturbances Headache

pharmacotherapy not recommended for

Smokeless tobacco users No FDA indication for smokeless tobacco cessation Individuals smoking fewer than 10 cigarettes per day (more of the habit, not the nicotine addiction) Adolescents Nonprescription sales (patch, gum, lozenge) are restricted to adults 18 years of age NRT use in minors requires a prescription

pharmacotherapy in pregnancy

The Clinical Practice Guideline makes no recommendation regarding use of medications in pregnant smokers Insufficient evidence of effectiveness

Tobacco industry

The biggest opponent to tobacco control efforts. For every $1 spent by the states, the tobacco industry spends $18 to market its products

transdermal nicotine patch

Water will not harm the nicotine patch if it is applied correctly; patients may bathe, swim, shower, or exercise while wearing the patch Do not cut patches to adjust dose Nicotine may evaporate from cut edges Patch may be less effective Keep new and used patches out of the reach of children and pets Remove patch before MRI procedures

Nicotine absorption

absorption is pH dependent

other

appetite suppression, increased metabolic rate, skeletal muscle relaxation

Teen targets

candy-flavored tobacco products and e-cigarretes

summary

cigarettes are, by far, the most common form of tobacco use in the US, other forms of tobacco exist and are increasing in popularity. All forms of tobacco are harmful Attention to all forms of tobacco is needed

forms of tobacco

cigarettes, spit tobacco, pipes, cigars, clove cigarettes, bidis, hoookah, e-cigarettes, dissolvable tobacco

2-3 weeks to 3 months

circulation improves, walking becomes easier, lung function increases by 30%

addiction

compulsive drug use, with medical purpose, in the face of negative consequences is a form of chronic brain disease resulting from an alteration in brain chemistry

factors contributing to tobacco use

environment, physiology, pharmocology

Nicotine in alkaline

nonionized, well absorbed across membranes

dissolvable tobacco

pellet, film, sticks, strips cured tobacco and flavorings, melt within 3-30 min, 0.6-3.1 mg NIC delivered

tobacco dependance

physiological and behavioral

central nervous system

pleasure,arousal, enhanced vigilance, improved task performance, anxiety relief

after 15 years

risk of heart disease is similar to that of people who have never smoked

5 years

risk of stroke is reduced to that of people who have never smoked

american cigarettes

sold in packs (20 cigs per pack) smoker's nicotine yield per cigarette ~1.2 mg

10 years

lung cancer death rate drops to half that of a continuing smoker, risk of cancer of mouth, throat, esophagus, bladder, kidney pancreas decrease

1 to 9 months

lung cilia regain normal function, ability to clear lungs of mucus increases, coughing fatigue shortness of breath decrease

nicotine metabolism

metabolized in liver, excreted unchanged in urine (occurs through kidneys)

clove cigarettes

mixture of tobacco and cloves imported from indonesia use is more prevelant among young smokers two times the tar and nicotine content of standard cigarettes hazards of ordinary tobacco cigarettes plus others due to cloves`

E cigarette

more nicotine in this cartridge "smoking alternative" not for smoking cessation nicotine is addictive, toxic by inhalation, may cause drowsines and disiness, fda had found carcinogen and toxic chemicals in these

nicotine withdrawl

most symptoms manifest within the first 1-2 days, peak within the first week, and subside within 2-4 weeks irritability/frustration/anger anxiety dificulty concentrating restlessness/impatience depressed mood/depression insomnia impaired performance increased appetite/weight gain cravings

surgeon general 1988

nicotine is the drug in tobacco that causes addiction

nicotine addiction

nicotine stimulates dopamine release --> pleasurable feelings --> repeat administration --> tolerance develops

bidis

no filter, you have to keep inhaling them much more quickly imported from india resemble marijuana joints, available in candy flavors, cigarettes with training wheels

transdermal nicotine patch

After patch removal, skin may appear red for 24 hours If skin stays red more than 4 days or if it swells or a rash appears, contact health care provider—do not apply new patch Local skin reactions (redness, burning, itching) Usually caused by adhesive Up to 50% of patients experience this reaction Fewer than 5% of patients discontinue therapy Avoid use in patients with dermatologic conditions (e.g., psoriasis, eczema, atopic dermatitis)

nonpharmacologic methods for quitting

Counseling and other non-drug approaches Cold turkey Unassisted tapering (fading) Assisted tapering QuitKey (PICS, Inc.) Computer developed taper based on patient's smoking level Includes telephone counseling support Formal cessation programs - behavioral counseling Individual, group, web-based Telephone Quit Line: 1-800-QUIT- NOW massage therapy

hookah

1 hour of smoking is equivalent to smoking a pack of cigarettes tobacco flavored with fruit pulp, honey and molasses, nicotine tar and CO levels comparable to or higher than those in cigarette smoke

2004 report of surgeon general

1)Smoking harms nearly every organ of the body, causing many diseases and reducing the health of smokers in general 2)Quitting smoking has immediate as well as long term benefits, reducing risks for diseases caused by smoking and improving health in general 3) Smoking cigarettes with lower machine-measured yields of tar and nicotine provides no clear benefit to health 4) the list of diseases caused by smoking has been expanded

Current adult smokers

19.3%, 20% rule 70% want to quit, only 20% are ready to quit

Consumption of cigarettes and combustible tobacco US

33% decrease in cigarette consumption 123% increase in loose tobacco and cigars

Epidemic in INdonesia

37.7% of teens $200M marketing More than 400,000 tobacco related deaths each year

Compounds in tobacco smoke

4,800 compounds -11 proven human carcinogens *Nicotine is the addictive component of tobacco products, but does not cause the ill heath effects of tobacco use

Utah

9.8% mormon faith community

nicotine lozenge advantages

Mightsatisfyoralcravings. Mightdelayweightgain (4-mg strength). Easytouseandconceal. Patientscantitratetherapy to manage withdrawal symptoms. Avarietyofflavorsare available.

Smoking

Association with poverty 30% rate of smoking White teens most prevalent smokers

epidemiology of tobacco use

At any age, there are benefits to quitting smoking. The biggest opponent to tobacco control efforts is the tobacco industry itself. -about 1 in 5 adults are current smokers nearly half a million us deaths are attributed to smoking annually smoking costs the us 157.7 bil per year

Health consequences of smoking

Cancers, pulmonary diseases, cardiovascular diseases, reproductive effects

nicotine gum

Chewing gum will not provide same rapid satisfaction that smoking provides Chewing gum too rapidly can cause excessive release of nicotine, resulting in side effects Lightheadedness Nausea/vomiting Irritation of throat and mouth Hiccups Indigestion Nicotine gum may stick to dental work

transdermal patch directions

Choose an area of skin on the upper body or upper outer part of the arm Make sure skin is clean, dry, hairless, and not irritated Apply patch to different area each day Do not use same area again for at least 1 week Remove patch from protective pouch Peel off half of the backing from patch Apply adhesive side of patch to skin Peel off remaining protective covering Press firmly with palm of hand for 10 seconds Make sure patch sticks well to skin, especially around edges Wash hands Nicotine on hands can get into eyes or nose and cause stinging or redness Do not leave patch on skin for more than 24 hours— doing so may lead to skin irritation Adhesive remaining on skin may be removed with rubbing alcohol or acetone Dispose of used patch Fold it onto itself, completely covering adhesive area

Difference between marlboro and marlboro lights

Lights have two ventilation lines, no other difference

combination nrt

Long-acting formulation (patch) Produces relatively constant levels of nicotine PLUS Short-acting formulation (lozenge or gum) Allows 'as needed use' for nicotine withdrawal symptoms

nicotine gum advantages

Might satisfy oral cravings. Might delay weight gain (4-mg strength). Patients can titrate therapy to manage withdrawal symptoms. A variety of flavors are available.

Snuff

Moist, dry

Casual relationship

There is ____ between exposure to smoking in movies and young smoking initiation

first-line therapies

Three general classes of FDA-approved drugs for smoking cessation: Nicotine replacement therapy (NRT) Nicotine gum, patch, lozenge, nasal spray, inhaler Psychotropics Sustained-release bupropion Partial nicotinic receptor agonist Varenicline

nictonine gum

To improve chances of quitting, use at least nine pieces of gum daily The effectiveness of nicotine gum may be reduced by some foods and beverages: Coffee Juices Wine Soft drinks Do NOT eat or drink for 15 minutes BEFORE or WHILE using nicotine gum.

Kentucky

Tobacco farms 25.7%

PREPs

Tobacco formulations altered to minimize exposure to harmful chemicals in tobacco Cigarette-like delivery devices Eclipse Modified tobacco products Quest Oral noncombustible tobacco products Ariva, Marlboro Snus, Stonewall, Camel Snus No evidence to prove that PREPs reduce the risk of developing tobacco-related disease

California

Was the first state to ban smoking state-wide 12.9%

1 year

excess risk of heart decreases to half that of a continuing smoker

nicotine dependance

fagerstrom test

financial implication

for every pack of cigarettes bought, there are about $10 worth of taxes toward the population

lobeline

herbal drug for smoking cessation Derived from leaves of Indian tobacco plant (Lobelia inflata) Partial nicotinic agonist No scientifically rigorous trials with long-term follow-up No evidence to support use for smoking cessation

nicotine affects the mind

huma smokers have increased nicotine receptors in the prefrontal cortex

cardiovascular system

inc heart rate, inc cardiac output, inc bloood pressure, vasoconstriction

drug interactions with smoking

interactions result from the combustionproducts of tobacco smoke may enhance the metabolism of other drugs such as caffeine, smokers who use combined oral contracenptives have had an increased risk of serious cardiovascular adverse effects

Nicotine in acid

ionized, poorly absorbed across membranes

Cigarette Smoking

is the chief, single, avoidable cause of death in our society and the most important public health issue of out time

adherance

key to quitting

pipe tobacco

least harmful but still harmful. People dont smoke it as long prevelance is less than 1% increased risk of death due to : cancer, chronic obstructive pulmonary disease cigarettes> pipes=cigars

Chewing tobacco

looseleaf, plug, twist

nicotine addiction circle

tobacco users maintain a minimum serum nicotine concentration in order to prevent withdrawl symptoms. maintain pleasure, modulate mood users self-titrate nicotine intake by: smoking/dupping more frequently, smoking more intensely, obstructing vents on low-nicotine cigaretes