Tobacco Cessation
Which of the following tobacco cessation therapies reduces nicotine cravings and other withdrawal symptoms by blocking dopamine and norepinephrine reuptake? A) Bupropion B) Nicotine inhaler C) Varenicline D) Nicotine patch E) Nicotine lozenge
A) Bupropion Bupropion blocks neuronal reuptake of dopamine and norepinephrine resulting in reduced cravings and other withdrawal symptoms. It is contraindicated in combination with linezolid, methylene blue and within 14 days of MAO inhibitor use.
LB is a female patient who is starting bupropion for tobacco cessation. Which of the following statements concerning bupropion are correct? (Select ALL that apply.) A) Bupropion should be started at least 1 week before her desired quit date. B) Her dose should be titrated to 450 mg daily. C) Doses should be taken at least 8 hours apart. D) It is safe to use in patients taking Forfivo. E) Do not use if she has either anorexia or bulemia.
A) Bupropion should be started at least 1 week before her desired quit date. C) Doses should be taken at least 8 hours apart. E) Do not use if she has either anorexia or bulimia. Both Zyban and Chantix should be started at least 1 week before the patient quit date.
BH starts the nicotine patch and gum to try and quit smoking. Which of the following should the pharmacist include when she counsels BH? (Select ALL that apply.) A) Counseling and medication are more effective when used together. B) You may experience vivid dreams while using the patch. C) You may continue to wear the patch if you have an MRI procedure. D) You should apply the patch to the same site daily. E) You should not use nicotine products if you recently had a heart attack.
A) Counseling and medication are more effective when used together. B) You may experience vivid dreams while using the patch. E) You should not use nicotine products if you recently had a heart attack. Medication and counseling are more effective when used together; this applies to all tobacco cessation medications. The patch should be applied to a different site daily and needs to be removed before an MRI. There is a warning to avoid nicotine products in patients with arrhythmias, worsening angina or if they recently had a myocardial infarction.
HG is a 17-year-old female who is interested in tobacco cessation. She asks about starting on nicotine gum. What advice should the pharmacist offer? A) Encourage her to start behavioral counseling first. B) Encourage her to start behavioral counseling and the nicotine gum at the same time (to improve success rate). C) Encourage her to start behavioral counseling, nicotine gum and bupropion at the same time (to improve success rate). D) Encourage her to start behavioral counseling, nicotine gum and varenicline at the same time (to improve success rate). E) She is a good candidate for the nicotine inhaler.
A) Encourage her to start behavioral counseling first. FDA prohibits sale of nicotine products to individuals younger than 18 years of age (REMS). Adolescents, pregnant women and light smokers should use behavioral counseling before pharmacologic treatment is considered.
Which of the following agents would be useful for a patient who needs to treat both depression and a smoking addiction? A) Forfivo XL B) Bactroban C) Chantix D) Sarafem E) Viibryd
A) Forfivo X Forfivo XL is bupropion.
What are the most common side effects of bupropion therapy? A) Insomnia and dry mouth B) Rash and itching C) Sedation and lethargy D) Weight gain and increased blood glucose E) Anxiety and depression
A) Insomnia and dry mouth Insomnia and dry mouth are two of the most common side effects with bupropion.
Which of the following products is/are available over-the-counter? (Select ALL that apply.) A) Nicorette gum B) Nicorette lozenge C) Nicoderm CQ D) Nicotrol inhaler E) Nicotrol nasal spray
A) Nicorette gum B) Nicorette lozenge C) Nicoderm CQ Nicotine gum, lozenge, and patch are all available OTC. The nasal spray and inhaler are Rx only.
What is the advantage of using the nicotine patch and nicotine gum together? (Select ALL that apply.) A) There is a higher chance of success with combination therapy. B) Patients may experience less tachycardia. C) Patients may experience less nighttime insomnia. D) The gum may be useful to control breakthrough cravings. E) There is no advantage to using both together.
A) There is a higher chance of success with combination therapy. D) The gum may be useful to control breakthrough cravings. Combination therapy will work better than just one form of nicotine replacement alone.
BL is a 50 year-old male who has stopped smoking since starting the nicotine patch two weeks ago. He now complains of insomnia. What advice should the pharmacist offer? A) Inform him that insomnia is a temporary side effect and will go away with time. B) Advise him to wear the patch during waking hours (for 16 hours, instead of 24 hours). C) Advise him to cut the patch in half and wear each portion for 12 hours (to decrease amount of drug in his system). D) Advise him to place the patches further away from his head such as his legs. E) Inform him that this is not an expected side effect; this is due to normal smoking withdrawal.
B) Advise him to wear the patch during waking hours (for 16 hours, instead of 24 hours). The patches should not be cut and can be worn for 16 hours in patients who have problems with insomnia.
Women who smoke have an increased risk for cardiovascular disease if they are aged 35 or older and take which type of medication? A) A selective serotonin reuptake inhibitor B) An oral contraceptive C) A blood pressure lowering agent D) A loop diuretic E) A glucagon-like peptide 1 agonist
B) An oral contraceptive Women aged 35 and older who smoke should not use oral contraceptives due to the risk of thromboembolism and cardiovascular events.
Which of the following immunizations can be recommended for BH? A) Annual influenza vaccine; Pneumovax 23 once after age 65 B) Annual influenza vaccine; Pneumovax 23 now and again after age 65 C) Annual influenza vaccine; Prevnar 13 now; Pneumovax 23 after age 65 D) Prevnar 13 now; Pneumovax 23 in 12 months and then again after age 65 E) Prevnar 13 now; Pneumovax 23 after age 65
B) Annual influenza vaccine; Pneumovax 23 now and again after age 65 Smoking is a criteria for Pneumovax 23 vaccination between ages 19-64 years. Patients should receive a second dose after age 65 as long as it has been at least five years since the last dose. Refer to the Immunizations chapter for additional information.
Which of the following products is not currently recommended as a smoking cessation aid? A) Behavioral counseling B) E-cigarettes C) Nicotine inhaler D) Nicotine nasal spray E) Bupropion
B) E-cigarettes E-cigarettes are not recommended for smoking cessation.
Which of the following drug levels would increase in a patient who stops smoking? A) Gemfibrozil B) Theophylline C) Clonazepam D) Ziprasidone E) Aripiprazole
B) Theophylline Smoking induces the metabolism of caffeine, theophylline, olanzapine and clozapine, and some other agents. If a patient suddenly stopped smoking but continued to take these medications, the concentration would increase as the induction effect wears off.
MT smokes 1 pack of cigarettes per day, with the first cigarette within 45 minutes of waking up in the morning. What strength of lozenge should he use at the initiation of nicotine replacement therapy? A) 8 mg B) 6 mg C) 4 mg D) 2 mg E) 1 mg
D) 2 mg If the first cigarette is smoked greater than 30 minutes after waking up, use the 2 mg lozenge.
BS, who has smoked an average of 12 cigarettes per day for the last year, is interested in tobacco cessation using the patch. What dose should the pharmacist recommend? A) Use 21 mg/24 hr patch for 6 weeks, then the 14 mg/24 hr patch for 4 weeks, then 7 mg/24 hr patch for 4 weeks B) Use 21 mg/24 hr patch for 6 weeks, then the 14 mg/24 hr patch for 2 weeks, then 7 mg/24 hr patch for 2 weeks C) Use 14 mg/24 hr patch for 6 weeks, then 7 mg/24 hr patch for 4 weeks D) Use 14 mg/24 hr patch for 6 weeks, then 7 mg/24 hr patch for 2 weeks E) Use 7 mg/24 hr patch for 6 weeks
B) Use 21 mg/24 hr patch for 6 weeks, then the 14 mg/24 hr patch for 2 weeks, then 7 mg/24 hr patch for 2 weeks >10 cigarettes/day: 21 mg patch on weeks 1-6, then 14 mg patch on weeks 7-8, then 7 mg patch on weeks 9-10
In addition to the nicotine patch, BH is interested in the nicotine gum after hearing about its potential impact on weight. Which of the following counseling statements concerning the nicotine gum are correct for BH? A) Chew each piece slowly until a "flavored" taste emerges, then remove the gum and use another piece in 30 minutes. B) For best results, use one piece of gum every 4-6 hours in the first 6 weeks. C) BH should chew one piece of the 4 mg gum every 1-2 hours. D) BH will need to use the gum for approximately 6 months. E) BH should use a maximum of 9 pieces of gum per day.
C) BH should chew one piece of the 4 mg gum every 1-2 hours. Patients who smoke the 1st cigarette of the day within 30 minutes of awakening OR patient who smoke at least 25 cigarettes per day should use the 4 mg gum. This is also the dose of gum and lozenge that has been shown to delay weight gain. A minimum of 9 pieces per day is recommended in the 1st 6 weeks (chewing one piece every 1-2 hours). When the tingling/flavored taste appears, the gum should be parked between the cheek and the gums.
Choose the correct counseling statement for the Nicotrol inhaler: A) The hand to mouth action when using the inhaler increases cravings for real cigarettes. B) This is the preferred tobacco cessation treatment if you have asthma. C) This medication may cause mouth and throat irritation. D) To quit effectively, take one puff of the inhaler every 20 minutes. E) This medication can cause nasal irritation.
C) This medication may cause mouth and throat irritation. When using the inhaler, the patient should puff contiuously for a total of 20 minutes. The hand to mouth coordination is actually a good coping mechanism for patients since it mimics the action of smoking a cigarette. The inhaler can worsen bronchospastic diseases, such as asthma and COPD, and can cause mouth and throat irritation. The nicotine nasal spray can cause nasal irritation.
A patient asks the pharmacist for advice on using the Nicorette mini-lozenge. The patient states that she does not feel much benefit after using one. The pharmacist asks how the patient uses the lozenge, and the patient replies she chews it and swallows it. Which of the following counseling statements for the lozenge is correct? (Select ALL that apply). A) The lozenges should be used in combination with Chantix. B) A prescription will be required if the patient wishes to use this beyond 2 weeks. C) Use 1 lozenge every 1-2 hours during the first 6 weeks of treatment. D) Do not eat or drink anything for 15 minutes before or during lozenge use. E) Dissolve the lozenge in the mouth; do not chew.
C) Use 1 lozenge every 1-2 hours during the first 6 weeks of treatment. D) Do not eat or drink anything for 15 minutes before or during lozenge use. E) Dissolve the lozenge in the mouth; do not chew. The lozenge should be allowed to dissolve in the mouth rather than chewing or swallowing it. Acidic beverages (e.g., coffee, juices, soft drinks) interfere with the buccal absorption of nicotine, so eating and drinking anything except water should be avoided for 15 minutes before or during use of the nicotine lozenge.
What is the mechanism of action of varenicline? A) It is a nicotinic receptor antagonist B) It blocks dopamine and norepinephrine uptake C) It inhibits reuptake of serotonin D) It is a partial nicotinic receptor agonist E) It is a dopamine and serotonin receptor agonist
D) It is a partial nicotinic receptor agonist Varenicline is a partial neuronal alpha-4 beta-2 nicotinic receptor agonist.
Which of the following statements is true regarding varenicline use for tobacco cessation? A) Varenicline should be started the day after the patient's quit date. B) Varenicline is contraindicated in pregnancy. C) Varenicline should be taken with food and a full glass of water. D) Varenicline is not associated with any gastrointestinal side effects. E) Varenicline has a boxed warning for seizure risk.
C) Varenicline should be taken with food and a full glass of water. Varenicline should be taken with food and a full glass of water. It is not contraindicated in pregnancy but should be used with caution.
What are the most common side effects of varenicline therapy? A) Dry mouth and blurry vision B) Rash and itching C) Sedation and dizziness D) Nausea and insomnia E) Increased serum creatinine and hypotension
D) Nausea and insomnia Nausea, insomnia and abnormal dreams are a few common side effects of varenicline.
History of Present Illness: BH is a 56 year old female who presents to the clinic for an evaluation so she can quit smoking. The pharmacist reviews her profile before starting the visit. Allergies: Wellbutrin (seizures) Smoking History: Smokes 1.5 packs per day. First cigarette usually smoked 10 minutes after awakening when she has her morning coffee. Height: 5' 5" Weight: 186 pounds Additional Notes: BH is concerned that she will gain more weight when she stops smoking. She is already overweight and struggles because of her depression. Select the tobacco cessation options that is/are preferred for BH? (Select ALL that apply.) A) Chantix B) Zyban C) Zyban plus nicotine patch D) Nicotine patch E) Nicotine patch plus nicotine lozenge
D) Nicotine patch E) Nicotine patch plus nicotine lozenge Zyban (bupropion) and Chantix (varenicline) are not good options for BH due to her history of seizures (with another form of buproprion). Chantix also has a warning for seizures and both drugs can cause psychiatric side effects in patients with a prior history of mental illness.
JE has been successful quitting smoking with bupropion. He has not smoked a cigarette in the past 6 months and is very committed to staying tobacco-free. His provider would like to discontinue his bupropion therapy. What should the pharmacist recommend to safely discontinue JE's bupropion therapy? A) Decrease bupropion dose to 150 mg daily for 4 weeks, then 75 mg daily for 4 weeks, then stop. B) Decrease bupropion dose to 150 mg daily for 2 weeks, then 75 mg daily for 2 weeks, then stop. C) Decrease bupropion dose to 150 mg daily for 2 weeks, then stop. D) Decrease bupropion dose to 150 mg daily for 1 week, then stop. E) Bupropion does not need to be tapered.
E) Bupropion does not need to be tapered. Bupropion does not need to be tapered upon discontinuation.