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QUIT SMOKING - UNDERSTANDING AND PREVENT SMOKE - COURSE

(45) Quit Smoking

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What is the current trend in smoking cessation treatment?

In 2008, the U.S. Department of Health and Human Services (DHHS) published an update of clinical practice guidelines entitled Treating Tobacco Use and Dependence. It provided 10 key recommendations, which are listed here. Guidelines are available online for free at http://www.surgeongeneral.gov/library/reports/preventing-youth-tobacco-use/factsheet.html

The overarching goal of these recommendations is that clinicians strongly recommend the use of effective tobacco dependence counseling and medication treatments to their patients who use tobacco, and that health systems, insurers, and purchasers assist clinicians in making such effective treatments available.

 Ten key Guideline Recommendations

1. Tobacco dependence is a chronic disease that often requires repeated intervention and multiple attempts to quit. Effective treatments exist, however, that can significantly increase rates of long-term abstinence.

2. It is essential that clinicians and healthcare delivery systems consistently identify and document tobacco use status and treat every tobacco user seen in a healthcare setting.

3. Tobacco dependence treatments are effective across a broad range of populations. Clinicians should encourage every patient willing to make a quit attempt to use the counseling treatments and medications recommended in this Guideline.

4. Brief tobacco dependence treatment is effective. Clinicians should offer every patient who uses tobacco at least the brief treatments shown to be effective.

5. Individual, group, and telephone counseling are effective, and their effectiveness increases with treatment intensity. Two components of counseling are especially effective, and clinicians should use these when counseling patients making a quit attempt:

• Practical counseling (problem solving and skills training)

• Social support delivered as part of treatment

6. Numerous effective medications are available for tobacco dependence, and clinicians should encourage their use by all patients attempting to quit smoking. Clinicians also should encourage their use by all patient populations attempting to quit for whom there is insufficient evidence of effectiveness (that is, pregnant women, smokeless tobacco users, light smokers, and adolescents). Seven first-line medications (5 nicotine and 2 non-nicotine) reliably increase long-term smoking abstinence rates:

• Bupropion SR (Zyban or Wellbutrin)

• Nicotine gum

• Nicotine inhaler

• Nicotine lozenge

• Nicotine nasal spray

• Nicotine patch

• Varenicline (Chantix)

Clinicians also should consider the use of certain combinations of medications identified as effective in this Guideline.

7. Counseling and medication are effective when used by themselves for treating tobacco dependence. The combination of counseling and medication, however, is more effective than either therapy alone. Thus, clinicians should encourage all individuals making a quit attempt to use both counseling and medication8. Telephone “quit line” counseling is effective with diverse populations and has a broad reach. Therefore, both clinicians and healthcare delivery systems should ensure patient access to quit lines and promote quit line use.

9. If a tobacco user currently is unwilling to make a quit attempt, clinicians should use the motivational treatments shown to be effective in increasing future quit attempts.

10. Tobacco dependence treatments are both clinically effective and highly cost-effective relative to interventions for other clinical disorders. Providing coverage for these treatments increases quit rates. Insurers and purchasers should ensure that all insurance plans include the counseling and medication identified as effective in this Guideline as covered benefits.

In addition to the 10 key recommendations, the Guideline also cites “The Five A’s” as a model for treating alcohol use and dependence. They are listed here:

The Five A’s model for Treating Tobacco Use and Dependence

1. Ask about tobacco use. Identify and document tobacco use status for every patient at every visit.

2. Advise to quit. In a clear, strong, and personalized manner, urge every tobacco user to quit.

3. Assess willingness to make a quit attempt. Is the tobacco user willing to make a quit attempt at this time?

4. Assist in quit attempt. For the patient willing to make a quit attempt, offer medication and provide or refer for counseling or additional treatment to help the patient quit. For patients unwilling to quit at the time, provide interventions designed to increase future quit attempts.

5. Arrange follow-up. For the patient willing to make a quit attempt, arrange for follow-up contacts, beginning within the first week after the quit date. For patients unwilling to make a quit attempt at the time, address tobacco dependence and willingness to quit at the next clinic visit.

Lisa’s comment:

I feel, after trying various processes to quit in the past, that it was having all my “forces” lined up behind me. In retrospect, I see that I had so many layers of support that mentally, I was thinking if one thing didn’t work, I had another thing to fall back on; there was one layer after another. I utilized every “tool” available to me: my doctor, a therapist, a cessation program, medication (Zyban, at that time), nicotine supplements (patch and gum), a self-hypnosis tape, a quiz to determine what kind of smoker I was, homework, acupressure, and a support group. I, who smoked two and a half packs a day for 30 years, have successfully lived my life entirely smoke-free now for 6 years. Before the combination of tools listed, I had only managed to struggle to 14 days before falling apart and smoking again.

 What are the qualifications of professionals who run smoking cessation groups?

Qualifications of those who run smoking cessation groups vary. People who run smoking cessation programs may be health professionals, health educators, or skilled volunteers.

Others have a background in substance abuse, are ex-smokers, and those who have witnessed the ill-effects of smoking, such as nurses and respiratory therapists. The American Cancer Society encourages people to make sure that the program leader has had training in smoking cessation counseling. Some people are interested in alternative therapies, such as acupuncture, laser acupuncture treatment, electro stimulation, and hypnotherapy. Studies have not shown that these alternative or complementary therapies are effective in the treatment of tobacco use. Additionally, an independent review of nine hypnotherapy trials by the Cochrane Group found insufficient evidence to support hypnosis as a treatment for smoking cessation. Credentialing of these professionals should be carefully investigated. Most accredited acupuncture schools require at least two years of undergraduate study prior to admission; others require students to complete a bachelor’s degree. Other training facilities do not require any prior education or experience. It is important to note that there are differences in success rates depending upon the type and number of clinicians utilized.

 What is my healthcare professional’s role in my smoking cessation?

The role of the healthcare professional is to assist you in selecting the quit assist method that is best for you, teach you tips on how to help yourself with the challenges of quitting, guide you through the steps to stop smoking, and support you during the withdrawal phase. If you are in a smoking cessation group, the counselor or professional will facilitate the group discussion and assist the group members to support each other.

Prior to your decision to quit smoking, your primary healthcare provider should have assessed your smoking history in order to make recommendations about the various resources that are available to help you to quit. Fifty to seventy percent of smokers see their primary healthcare provider each year. All clinicians, particularly primary healthcare providers, are uniquely poised to intervene with patients who use tobacco.

Smokers frequently cite a physician’s advice to quit as an important motivator for attempting to stop smoking. A physician’s advice to quit can increase the odds for success by 30%. A population-based survey found that less than 15% of smokers who saw a physician in the past year were offered assistance to stop smoking and only 3% had a follow-up appointment to address tobacco use. Health professionals should follow the Five A’s with every patient:

1. Ask about smoking.

2. Advise quitting.

3. Assess willingness to make a quit attempt.

4. Assist in a quit attempt.

5. Arrange a timely follow-up.

 A physician’s advice to quit can increase the odds for success by 30%.

 

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What is the Single Best Thing You Can Do to Quit Smoking?

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How much does a smoking cessation program cost?

The cost of smoking cessation programs varies from almost nothing to hundreds of dollars. Many health plans and worksites provide free quit-smoking programs, and some health plans cover the cost of medications to help smokers quit. We recommend that you check with your insurance carrier or employer for information. But before investing your time or money in a program, ask yourself the following questions:

• Is there a cost to me? If so, how much?

• Is the program convenient for me?

• Is the staff well trained and professional?

• Does the program meet my needs?

• What is the success rate of this program?

• What are the program leader’s credentials? Does insurance pay for any of the smoking cessation programs or products?

The United States Department of Health and Human Services (DHHS) published recommendations for insurers and managed care organizations to cover tobacco dependence treatments, both counseling and pharmacotherapy, for their subscribers or members of health insurance packages. If you have questions about your insurance coverage, contact your insurance provider and ask them for information. Even if there is no coverage for a smoking cessation program, you should check into payment or partial payment for smoking cessation products.

Medicare covers people who are on Medicare and are diagnosed with a smoking-related illness or are taking medications that may be affected by tobacco. Medicare will cover up to eight face-to-face visits during a twelve-month period. These visits must be ordered by a physician and provided by a Medicare-recognized practitioner. Medicare will pay 20% of the approved amount after you meet the yearly Part B deductible.

What are the benefits of enrolling in a smoking cessation program, and what is the average length of stay of a smoking cessation program?

The success rate increases to 32.5% when a person is enrolled in a more intensive smoking cessation program while also taking anti-smoking addiction medications. The benefits of a smoking cessation program include support, education, and guidance to deal with the psychological and behavioral aspects of nicotine withdrawal. The medications take care of the physiological symptoms of withdrawal. The American Cancer Society states that there is a strong link between the intensity of an anti-smoking program and success rates. Generally, the more intense the program is, the greater the chance for success. Intensity may include more time in treatment, more or longer sessions, or an increased number of weeks of participation. When considering a program, look for one that has the following:

• The length of each session should be at least 20 to 30 minutes.

• The number of sessions should be at least four to seven.

• The program should last at least two weeks.

Quit-smoking programs that involve more than 90 minutes and up to 300 minutes can increase the success rate of quitting up to 28%, regardless of the method of quitting, and programs that involve eight or more sessions can increase the quit rates up to 24.7%.

Inpatient programs can be found in various parts of the country. Inpatient programs are considered the most intense of all smoking cessation programs. One inpatient smoking cessation program is an eight-day program at the Mayo Clinic in Rochester, Minnesota. This residential program helps severely addicted smokers stop smoking. In a clinical study, it was found that inpatient treatment was more effective for participants who were moderately to severely addicted smokers. Another inpatient program is run by The Seventh Day Adventists, who have a smoking cessation program at the St. Helena Health Center and Hospital, Napa Valley, California. This residential program is over 30 years old. Each stop smoking session lasts a week. During admission, a physical assessment is conducted on each smoker to include lung capacity. Blood and urine tests are done to monitor the adequacy of the dose for those participants using nicotine replacement medications to eliminate withdrawal symptoms. The treatment program is holistic, which includes fluids (namely fruit juices), many fresh fruits and vegetables, and no red meat, chicken, or fish. Massage is combined with exercise in a gym and/or swimming pool, and long walks every morning. An exercise therapist assists participants to increase their endurance, and a nutritionist is available to help participants control the potential weight gain. Group work includes health education and group counseling. There is the option to receive individual counseling, if requested. Both programs are examples of intense smoking cessations programs, which have had a high degree of success.

Joseph’s comment:

I find a class like “smoking cessations” a very beneficial way to quit smoking because of the group environment. This allows you to work on the problem with others. Our classes were one hour long, which I felt was a good amount of time to give everyone a chance to share how they were doing and share their tools with other members of the group. Tools included hearing slogans like “You’re one away from a pack day” to calling the facilitator if I was having a tough day.

 How successful are people who quit on their own?

 Quitting on one’s own may be hard, but it can be done. Many factors contribute to success. First, you must be very motivated to quit. Then you must have made a commitment to quit. To give up cigarettes “cold turkey” means to choose not to use any quit aids that help decrease withdrawal symptoms. Until recently, this was the only option for smokers. The advantage of this method is that the majority of nicotine is out of the body within a few days. Yes, the discomforts can be intense, but the length of time for withdrawal is short. Some smokers think that they do not need to use pharmacotherapy aids and they should just be able to quit by using willpower alone. Other smokers think cold turkey is too extreme. They want the medications to help them through the most difficult time. They choose to avoid the discomfort from the withdrawal symptoms. Studies have demonstrated that quitting on one’s own without the benefits of any therapy results in a success rate of about 4% to 7%. The success rate can be increased to 10% by using over-the-counter (OTC) nicotine replacement therapies. The success rate after a year, using the cold turkey method of quitting is about 4%. At the end of the year, the people who used medications had a success rate equal to the ex-smokers who quit using the cold turkey method.

 

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What is the Single Best Thing You Can Do to Quit Smoking?

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Can smoking cessation be done “one-on one” with a counselor or health educator, or must it be in a group?

Many find that they are not “group” people and don’t enjoy belonging to a group nor participate in any group interactions. For these people, an option is a one-on-one counselor who has a background of a healthcare provider, healthcare educator, or someone who is skilled in conducting smoking cessation classes. The positive aspect of individual counseling is that individual concerns can be immediately addressed. The negative aspect of one-on-one counseling is that there is no added benefit from the support of a group, whose members is going through a similar ordeal and has many of the same thoughts and feelings. During group counseling sessions, people bounce their thoughts and feelings off each other. For many, the added knowledge of not thinking that he or she is “the only one in the world” going through the withdrawal symptoms is valuable.

Lisa’s comment:

The group setting was invaluable for me. I felt that nobody else but my fellow program members really knew what I was going through. Each session, I looked forward to seeing at least one other person still succeeding, as this built up my courage that I, too, could continue to cease smoking.

Joseph’s comment:

For me, I learned a tremendous amount from working with the group. I replaced, “I myself will” with “we will” work with others towards a common goal of quitting.

What are some of the medication aids, notably the nicotine replacement therapies (NRTs), to smoking cessation?

Nicotine replacement therapies (NRTs) are smoking cessation medicines that release small amounts of nicotine into the bloodstream to help counter cravings and reduce other physical withdrawal symptoms. NRTs are used to slowly wean the smoker off of nicotine. The NRT products contain nicotine, which is equally addictive, but the NRT medications deliver smaller amounts of nicotine than cigarettes and without many of the other harmful effects of tar and carbon monoxide found in cigarettes. Follow the package directions carefully. It is important to first check with your doctor or pharmacist about the interactions of NRT drugs with other drugs you may be taking. Also, check with them about any medical condition that one may have that may restrict the use of an NRT, such as severe cardiovascular disease.

There are currently five forms of nicotine replacement therapies available in the United States: (1) nicotine gum, (2) nicotine patch, (3) nicotine nasal spray, (4) nicotine inhaler, and (5) nicotine lozenge.

1. Nicotine Gum

A physician’s prescription used to be required to obtain the gum, but in 1996 the gum became an over-the-counter (OTC) medication. Nicorette is the brand name but there are generic forms of the gum. The manufacturer states that Nicorette allows smokers to self-titrate (up to 24 pieces a day) and it is currently available in six different flavors. The gum allows the nicotine to be absorbed through the mucus membranes of the mouth between the cheek and the gums. It comes in a 4 milligram (mg) dose for those patients who smoke more than 25 cigarettes a day, and a 2 mg dose for those who smoke less than 25 cigarettes a day.

Directions: It is very important you follow the directions on your prescription label carefully and exactly as directed. One piece of nicotine gum is chewed every one to two hours at first, or it may be chewed when you have the urge to smoke. Chew slowly until you can taste the nicotine or feel a slight tingling in your mouth. Then stop chewing and place (park) the gum between your cheek and gum. When the tingling sensation is almost gone (about 1 minute), start chewing again. Repeat this procedure for about 30 minutes. Do not chew more than one piece of gum at a time, and do not chew one piece after another. Gradually reduce the amount of nicotine gum after two to three months. Reducing the use of nicotine gum over time will help prevent withdrawal symptoms.

Tips to help reduce the use of nicotine gum gradually include:

• Decrease the total number of pieces used per day by about one piece every four to seven days.

• Decrease the chewing time with each piece from the normal 30 minutes to 10 to 15 minutes for 4 to 7 days. Then gradually decrease the total number of pieces per day.

• Substitute pieces of nicotine gum with one or more pieces of sugarless gum for an equal number. Every four to seven days, increase the number of sugarless gum pieces as substitutes for nicotine gum.

• Replace the 4-mg gum with the 2-mg gum and apply the previous steps.

• Consider stopping use of nicotine gum when your craving for nicotine is satisfied by one or two pieces of gum per day.

2. The Nicotine Patch

The patch comes in four main brands: Nicotrol, Nicoderm, Prostep, and Habitrol. All four patches transmit low doses of nicotine to the body throughout the day. Other smoking cessation programs or materials should be used while using the patch.

Directions: It is very important you follow the directions on your prescription label carefully and exactly as directed The Nicoderm patch offers a three-step program that can be used for 16 to 24 hours each day. One patch contains 21 mg of nicotine and is recommended for patients who smoke more than 10 cigarettes per day. Another patch contains 14 mg of nicotine and is recommended for patients who smoke less than 10 cigarettes per day. Apply the patch directly to the skin once a day, usually at the same time of day. Apply the patch to a clean, dry, hairless area of skin on the upper chest, upper arm, or hip, as specified by the package directions. Remove the patch from the package, peel off the protected strip, and immediately apply the patch to your skin. The sticky side should touch the skin. Press the patch to the skin by placing the palm of your hand over it for about 10 seconds. Be sure the patch is held firmly in place, especially around the edges. Wash your hands with water only after applying the patch. If the patch falls off or loosens, replace it with a new one. Wear the patch continuously for 16 to 24 hours. The patch may be worn even while showering or bathing. Remove the patch carefully, and dispose of it by folding it in half with the sticky sides touching. After removing the patch, apply the next patch to a different skin area to prevent skin irritation.

Nicotine patches may be used from 6 to 20 weeks. A switch to a lower strength patch may be considered after the first two weeks. A gradual reduction to a lower dosage of the patch is recommended so that the amount of nicotine in the system is reduced and consequently, the nicotine withdrawal symptoms will be reduced.

3. Nicotine Nasal Spray

Nicotine nasal spray comes as a liquid to spray into the nose. It should be used along with a smoking cessation program, which may include a support group, counseling, or specific cognitive or behavioral techniques. It allows smokers to cut back on their intake of nicotine gradually. Nicotine is absorbed rapidly through the nasal membranes.

Directions: It is very important you follow the directions on your prescription label carefully and exactly as directed to use the nasal spray, follow these steps:

1. Wash your hands.

2. Gently blow your nose to clear your nasal passages.

3. Remove the cap of the nasal spray by pressing in the circles on the side of the bottle.

4. To prime the pump before the first use, hold the bottle in front of a tissue or paper towel.

5. Pump the spray bottle six to eight times until a fine spray appears. Throw away the tissue or towel.

6. Tilt your head back slightly.

7. Insert the tip of the bottle as far as you comfortably can into one nostril, pointing the tip toward the back of your nose. Breathe through your mouth.

8. Pump the spray firmly and quickly one time. Do not sniff, swallow, or inhale while spraying. If your nose runs, gently sniff to keep the nasal spray in your nose. Wait two or three minutes before blowing your nose.

9. Repeat steps six to eight for the second nostril. Replace the cover on the spray bottle.

If you have not stopped smoking at the end of four weeks, talk with your doctor. Your doctor can try to help you understand why you were not able to stop smoking and make plans to try again. Ask your pharmacist or doctor for a copy of the manufacturer’s information for the patient. Stay in touch with your doctor. He or she may need to change the doses of your medications once you stop smoking completely. If you continue smoking while using the nicotine nasal spray, you may have some adverse effects. Remember a nicotine overdose can be lethal.

Other Instructions:

• Handle the bottle with care. If the bottle drops, it may break. If this happens, wear rubber gloves and clean up the spill immediately with a cloth or paper towel. Avoid touching the liquid. Throw away the used cloth or paper towel in the trash. Pick up the broken glass carefully using a broom. Wash the area of the spill a few times

• If even a small amount of nicotine solution comes in contact with the skin, lips, mouth, eyes, or ears, these areas should be immediately rinsed with water.

4. Nicotine Inhaler

The inhaler should be used with a smoking cessation program, which may include support groups, counseling, or specific cognitive and behavioral therapies. Nicotine oral inhalation comes as a cartridge to inhale by mouth using a special inhaler.

Directions: It is very important you follow the directions on your prescription label carefully and exactly as directed. Your doctor may increase or decrease your dose depending on your urge to smoke. The inhaler has a plastic mouthpiece with a nicotine plug to deliver the nicotine to the mucous membranes of the mouth. The nicotine in the cartridges is released by frequent puffing over 20 minutes. You may use up a cartridge all at once or puff on it for a few minutes at a time until the nicotine is finished. Try different schedules to see what works best for you.

Read the directions for how to use the inhaler and ask your doctor or pharmacist to show you the proper technique. Practice using the inhaler while in his or her presence. If you continue smoking while using nicotine inhalation, you may experience adverse side effects. Remember: an overdose of nicotine kills. You should know that even though you are using nicotine inhalation, you may have some withdrawal symptoms.

5. Nicotine Lozenge

This is a more recent addition to the growing number of tools to combat nicotine withdrawal symptoms. Slowly allow the lozenge to melt in your mouth.

Directions: For weeks one to six of treatment, you should use one lozenge every one to two hours. Use at least nine lozenges per day to increase your chances of quitting. During weeks seven to nine you should use one lozenge every two to four hours. Weeks 10 to 12, you should use one lozenge every four to eight hours. Do not use more than five lozenges in six hours or more than 20 lozenges per day. Do not use more than one lozenge at a time or use one lozenge right after another. Using too many lozenges at a time or one after another can cause side effects such as hiccups, heartburn, and nausea. Do not eat while the lozenge is in your mouth. Stop using the nicotine lozenges after 12 weeks. After 12 weeks if you still feel the need to use nicotine lozenges, talk to your doctor.

 

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Motivation to Quit Smoking

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What are the recommendations for when you should take medication in order to quit smoking?

The general recommendation is that all smokers trying to quit should be offered medication. There is compelling evidence that medication aids in abstinence. The evidence is even stronger that medication and counseling are more effective than either alone. For that reason, medication is strongly encouraged. All seven of the FDA-approved medications for treating tobacco use are recommended, including bupropion SR, nicotine gum, nicotine inhaler, nicotine lozenge, nicotine nasal spray, nicotine patch, and varenicline. Additionally, the use of these medications for up to six months does not present a known health risk, and developing dependence on these medications is rare. The higher-dose preparations have been shown to be effective in highly dependent smokers.

NRT combinations are especially helpful for highly dependent smokers or those with a history of severe withdrawal. Combining the nicotine patch long-term with nicotine gum, nicotine nasal spray, nicotine inhaler, or bupropion SR, also increases long-term abstinence rates relative to placebo treatments.

However, combining varenicline with NRT agents has been associated with higher rates of side effects (such as nausea and headaches). Unfortunately, there are no well-accepted

algorithms to guide optimal selection among the first-line medications. Data show that bupropion SR and nicotine replacement therapies, in particular the 4-mg nicotine gum and 4-mg nicotine lozenge, bupropion SR, and nortriptyline appear to be especially effective in treating tobacco-dependent patients diagnosed with depression, but nicotine replacement medications also appear to help individuals with a past history of depression.

That being said, there are some exceptions to that general recommendation.

These exceptions are:

1. Women: Evidence is mixed as to whether NRT is less effective in women than men. The clinician should consider the use of another type of medication with women, such as bupropion or varenicline.

2. Pregnant women: These smokers should be encouraged to quit without medication. The studies of medication use are far too small. Bupropion has not been found to be effective at all in pregnant smokers. That being said, one may still recommend medication to this group if, in the clinician’s opinion, the benefits outweigh the risks.

In pregnant women, for example, the risks of nicotine alone on the mother and the fetus must be weighed against the risks of nicotine, tar and carbon monoxide should the pregnant woman be unable to stop smoking without the benefit of an NRT.

3. Cardiac patients: NRT should be used with caution among particular cardiovascular patient groups: those who have had a heart attack within two weeks, those with serious arrhythmias, and those with unstable angina pectoris.

4. Light smokers, smokeless tobacco users, and adolescents: Few studies have been done on these populations to conclude any significant benefit, nor suggest any potential risk. Again, the clinician should weigh the risks against the benefits when considering medications in these populations.

Terms:

Arrhythmias - Abnormal heart rhythm.

Angina Pectoris (Also known as angina.) – Severe chest pain due to a blockage of blood flow in the arteries of the heart. It is a symptom of an impending heart attack.

There is compelling evidence that medication aids in abstinence

What are the success rates of the five nicotine replacement therapies alone and in combination with other forms?

Recent studies have examined the combination of some of the nicotine replacement products and the smoking cessation aids. The FDA has not approved these medications incombination because of the limited number of efficacy and safety studies. Nevertheless, it is frequently done in practice. Using the patch alone, there is an estimated abstinence rate of 17.4%. By combining the nicotine gum or nicotine lozenge with the patch, the abstinence rate can increase to 28.6%. Therefore, combining the patch with other self-titrating nicotine replacement therapies may be more effective than just using the nicotine patch alone. There is less evidence to support doubling the nicotine patch. In fact, there are warnings against doing so. Combining medications is one of the recommended treatments for those heavy smokers who have difficulty quitting with just the patch and who are being closely monitored by a physician.

Can I become addicted to any of the drugs used to assist a person to quit smoking?

It is estimated that 1.5 to 2 million Americans try the nicotine gum each year. Thanks to the gum, many people have successfully kicked the cigarette habit. However, some ex-smokers have weaned themselves from one nicotine habit only to pick up a new addiction, but a less risky one. GlaxoSmithKline, manufacturers of Nicorette gum, advises people to stop using the nicotine gum at the end of 12 weeks, and to talk to a doctor if you need to continue to use the gum. But these guidelines haven’t stopped some people from using the gum for many months and even years.

In a recent report evaluating data collected by A.C. Nielsen, researchers concluded that 5% to 9% of nicotine gum users relied on nicotine gum longer than the recommended three months. About half of the people in the study used it for six months or longer. In published studies at the Mayo Clinic Nicotine Dependence Center, people have used nicotine gum up to five years without heart or vascular problems. By chewing the gum, the nicotine is delivered slowly through the mucous membranes in the mouth, at much lower levels than the quick-hit surge of nicotine when puffing on cigarettes.

At the same time, the gum does not contain any of the cancer-causing substances present in cigarettes. The cancers and vascular diseases associated with smoking develop from the carcinogens, tars, and the carbon monoxide in cigarettes.

What is Bupropion SR?

Bupropion is also known as Zyban or Wellbutrin. Zyban is the trade name for the medication when it is prescribed for smoking cessation and Wellbutrin is the trade name for the medication when it is prescribed for depression. It is therefore classified as an antidepressant. Bupropion works by blocking the dopamine transporter pump preventing the transport of dopamine back into the neuron, and thereby increasing the amount of dopamine in the synaptic cleft. Dopamine is a neurotransmitter found in the brain that is involved in attention, decision making, motor activity, mood, and the generation of psychoses. It is also the major reward chemical thought to be involved in all forms of addiction. Bupropion comes in two forms of tablets to be taken by mouth: a regular tablet and a sustained-release or extended-release (long-acting) tablet. The regular tablet (Wellbutrin) is usually taken three or four times a day, with doses at least six hours apart. The sustained-release tablet (Wellbutrin SR or Zyban) is usually taken once or twice daily in the morning and afternoon.

Directions:

• Your doctor will probably start you on a low dose of bupropion and gradually increase the dose over time.

• It may take four weeks or longer before you feel the full benefit of bupropion.

• Continue to take bupropion even if you feel well. Do not stop taking bupropion without talking to your doctor.

• Your doctor will probably decrease the dose gradually over a period of two weeks prior to stopping the medication.

• If you forget, skip, or miss a dose, then continue your regular dosing schedule. Do not take a double dose to make up for a missed dose.

• Always allow the full scheduled amount of time to pass between doses of bupropion.

Your doctor may need to change the doses of your medications or monitor you carefully for any pre-existing conditions.

There are a number of conditions for which you should not be taking this medication, including if you have a seizure disorder.

If you have anorexia or if you have liver disease you should let your doctor know, as these are general contraindications to taking this medication If you experience a serious side effect, you or your doctor should send a report to the Food and Drug Administration’s (FDA) Med watch Adverse Event Reporting program online (at http://www.fda.gov/MedWatch/report.htm).

If you are taking the sustained or extended-release tablet, you may notice something that looks like a tablet in your stool. This is just the empty tablet casing and does not mean that you did not get your complete dose of medication.

Term:

Contraindications - A condition or factor that increases the risk of an adverse event when taking a particular medication or receiving a particular treatment.

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 Tobacco - World Health Organization

Chantix - It Does work. Here is my story

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What is Chantix?

 Varenicline, known by its trade name Chantix, is the most recent medication that is FDA approved to treat smoking addiction. It is available by prescription only. Currently there is no generic form. Varenicline is a partial agonist to a subtype of the nicotinic acetylcholine receptor. A partial agonist is a compound that both stimulates and inhibits the receptor to a mild degree, thereby eliminating any withdrawal effects associated with smoking cessation, but also eliminating the possibility of deriving any additional pleasure from smoking.

It therefore acts like a thermostat, stimulating the receptor when nicotine levels are low and blocking the receptor when nicotine levels are high.

Varenicline was developed by Pfizer through modifying the structure of cytisine, a chemical found in a variety of plants that is known to be a nicotine receptor agonist and has been used as a smoking cessation aid in its own right in Eastern Europe for at least 40 years. Varenicline was fast tracked by the U.S. Food and Drug Administration in February 2006, shortening its approval from 10 to 6 months because of its demonstrated effectiveness in clinical trials and perceived lack of safety issues. The FDA approved varenicline on May 11, 2006, which became available in the U.S. public August 1, 2006 and in the European Union September 29, 2006.

Varenicline comes as a tablet to be taken by mouth. It is usually taken once or twice daily with a full glass of water after eating.

Group support programs or individual counseling are strongly recommended as an adjunct to the medication regime. Directions:

• Your doctor will probably start you on a low dose of varenicline and gradually increase the dose over the first week of treatment.

• Set a quit date to stop smoking, and start taking varenicline one week before that date. You may continue to smoke during this first week, but stop smoking on the quit date. It may take several weeks for you to feel the full benefit of varenicline.

• You may slip and smoke during your treatment. If this happens, you will still be able to stop smoking.

• Continue to take varenicline for 12 weeks.

• If you have completely stopped smoking at the end of the 12 weeks, your doctor may tell you to take varenicline for another 12 weeks. Continuing to take varenicline may ensure that you will not start to smoke again.

• Once you have stopped smoking, your doctor may need to change the doses of some of your other medications.

• If you have not stopped smoking at the end of 12 weeks, tell your doctor so he or she can help you to understand why you were not able to stop smoking and make plans for you to try to quit again. Do not use varenicline with other smoking cessation products.

• Varenicline may make you drowsy. Do not drive a car or operate machinery.

• If you forget a dose: Take the missed dose as soon as you remember it. However, if it is almost time for the next dose, skip the missed dose and continue your regular dosing schedule. Do not take a double dose to make up for the missed one.

• Do NOT drink alcohol while taking this medication.(However, instructions on the package may not specify if you can drink any alcohol while taking this prescription.)

Call your doctor if you experience any of the following side effects: thinking about harming or killing yourself, planning or trying to do so, or thinking about harming someone else; changes in your usual thoughts, mood, or behavior. Call your doctor immediately and report it to: The Food and Drug Administration’s (FDA) Medwatch Adverse Event Reporting program online (at http://www.fda.gov/MedWatch/report.htm).

What is the suicide risk associated with the anti-smoking drug Chantix?

In November 2007, a year and three months after varenicline became available to the American public, the FDA announced it had received reports that patients using it for smoking cessation had experienced several serious psychological symptoms, including suicidal ideation and occasional suicidal and agitated behavior. On February 1, 2008, the FDA issued an alert, noting that “it appears increasingly likely that there is an association between varenicline and serious neuropsychiatric symptoms.”

As of February 2008, 491 cases of suicidal thinking or behavior were reported, including 420 in the United States. Thirty-nine of the 491 cases resulted in suicide, including 34 in the United States. More than 6 million people have been prescribed the pill since it was launched. When considering the number of prescriptions, the risks of serious psychological symptoms are extremely low, and the risk that those symptoms will result in death is even lower. When weighing such risks against the risks of continued smoking, varenicline actually ends up being safer than continued tobacco use.

Sorting out the cases individually in order to determine what role, if any, varenicline has in contributing to or even causing these symptoms remains a daunting task. One of the more celebrated cases, the case of Carter Albrecht who was shot by his neighbor after striking his girlfriend and entering his neighbor’s house, was probably due to mixing the drug with large amounts of alcohol. Suicidal thinking is a complex behavior with multiple contributing factors, including personality, mood, environment, history, and other substance or prescription medication use. But the end result is often extremely tragic and traumatic, prompting public outcry and a large amount of press. It is important to keep these issues in mind when considering the risks of using this medication against the risks of continuing to smoke.

 What other non-NRT medication therapies are available, if any?

A number of other medications have been studied, but only two are currently recommended as second-line therapies, should individuals either fail the first-line therapies or experience side effects that contraindicate future use. It is important to remember when selecting medications that prior failure with a medication does not predict future failure. Thus, second-line therapies are generally used when first-line therapies are contraindicated or some other compelling clinical reason suggests their trial over a first-line therapy. An example would be for those who have migraines in addition to tobacco dependence, where the clinician would suggest trying nortriptyline as a first-line therapy because it is commonly used to treat migraine headaches. Additionally, there is some evidence demonstrating that women tend to have poor response rates to NRTs and therefore non-NRT medications should be considered, such as bupropion, varenicline, nortriptyline, and clonidine.

The other medications that have been extensively studied, which have not been found to be successful include selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine, paroxetine, citalopram, etc., and naltrexone (ReVia). Tobacco dependence is a common problem with depression, and treating the depression can assist the patient in following through with a smoking cessation program. While SSRIs can be used in conjunction with the other smoking cessation medications to treat depression, their use as standalone agents is not effective.

Naltrexone has been found to be effective in treating alcoholism in order to assist in abstinence and decrease craving. Naltrexone acts by blocking opiate receptors, but it is not helpful in decreasing craving for cigarettes. Other medications that have not been found to be helpful include benzodiazepines, beta-blockers, silver acetate, and mecamylamine. Mecamylamine is a nicotine antagonist that may prove useful in boosting the effectiveness of antidepressants, but it is too early to tell if this medication will actually pan out.

Two medications that have proven to be effective as second-line therapies include the tricyclic antidepressant, nortriptyline (trade name, Pamelor), and the antihypertensive, clonidine. Nortriptyline blocks the transporter pump and prevents the reuptake of norepinephrine, thus increasing levels of this neurotransmitter in the brain. Norepinephrine release is stimulated by nicotine, so that nortriptyline may aid as an indirect replacement therapy through this action. Clonidine is a more complicated medication. It generally reduces what is called sympathetic tone-that is, it reduces the “fight or flight response” by reducing the release of norepinephrine. Clonidine is used not only to reduce blood pressure, but also to treat neuropsychiatric conditions such as Tourette’s disorder and ADHD (attention deficit hyperactivity disorder). It is also used to reduce the effects of opiate withdrawal in opiate-dependent patients. Clonidine, in a sense, does the exact opposite of nortriptyline, demonstrating the underlying complexity of nicotine addiction and how oversimplified our current theories are about this drug and its effects on the brain and body.

Term:

Partial agonist-A chemical (such as a drug) that can both block and stimulate a receptor depending upon the relative amount of neurotransmitter present in the synaptic cleft. If the amount of neurotransmitter is large, the chemical acts as an antagonist and if the amount of neurotransmitter is low, the chemical acts as an agonist.

When considering the number of prescriptions, the risks of serious psychological symptoms are extremely low, and the risk that those symptoms will result in death is even lower.

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