Nicotine AddictionNicotine Addiction

Pharmacy Practice IIPharmacy Practice II

Winter 2005Winter 2005

Tobacco Use InterviewTobacco Use Interview

When did you start?When did you start? Why?Why? How much, how often?How much, how often? What do you like?What do you like? What don’t you like?What don’t you like? Health risks?Health risks? Quitting experience?Quitting experience? What would it take to What would it take to

quit?quit?

Pharmacist’s RolePharmacist’s Role

AskAsk AdviseAdvise AssessAssess AssistAssist ArrangeArrange

Stages of ChangeStages of Change

PrecontemplationPrecontemplation ContemplationContemplation PreparationPreparation ActionAction MaintenanceMaintenance

PrecontemplationPrecontemplation

Unaware, unwilling, too discouragedUnaware, unwilling, too discouraged Won’t change in the next six monthsWon’t change in the next six months Listen, empathy, identify barriersListen, empathy, identify barriers Focus on benefits of changeFocus on benefits of change Interview questionsInterview questions

ContemplationContemplation

Open to information, thinking about Open to information, thinking about quitting in next 6 monthsquitting in next 6 months

Provide information, emotional supportProvide information, emotional support EncouragementEncouragement ResourcesResources Information about optionsInformation about options What it will take, who is availableWhat it will take, who is available

PreparationPreparation

Getting ready o try new behavior Getting ready o try new behavior within 30 dayswithin 30 days

Goal setting, praise readiness, enlist Goal setting, praise readiness, enlist support of otherssupport of others

GoalsGoals ResourcesResources OptionsOptions Who can helpWho can help

ActionAction Taking steps, needing willpowerTaking steps, needing willpower Habituating behaviorsHabituating behaviors Stimulus control, reinforce + Stimulus control, reinforce +

behaviors, continuing emotional behaviors, continuing emotional supportsupport

Action plansAction plans Other supportOther support Product informationProduct information Positive effectsPositive effects

MaintenanceMaintenance

Engaged for at least six monthsEngaged for at least six months Continue emotional supportContinue emotional support Relapse preventionRelapse prevention Reinforce benefitsReinforce benefits Relapse – encouragement, Relapse – encouragement,

persistencepersistence

Treatment optionsTreatment options

Behavior Behavior modificationmodification

Nicotine lozengesNicotine lozenges Nicotine gumNicotine gum Nicotine patchesNicotine patches Nicotine inhalerNicotine inhaler Nicotine nasal sprayNicotine nasal spray Bupropion SRBupropion SR

Treatment optionsTreatment optionsNicotine polacrilex lozengesNicotine polacrilex lozenges

2 mg (12 mg (1stst cig > 30 min after waking) cig > 30 min after waking) 4 mg (14 mg (1stst cig < 30 min after waking) cig < 30 min after waking) Allow to slowly dissolve (20-30 min)Allow to slowly dissolve (20-30 min) Do not chew, eat, or drinkDo not chew, eat, or drink < 20 lozenges/d< 20 lozenges/d CI: pregnancy, CVD, PUDCI: pregnancy, CVD, PUD SE: hiccups, sore mouth, sore throat, nauseaSE: hiccups, sore mouth, sore throat, nausea 12 weeks12 weeks

Treatment optionsTreatment optionsNicotine polacrilex gumNicotine polacrilex gum

2 mg (<24 cigs/d), 4 mg (>24 cigs/d)2 mg (<24 cigs/d), 4 mg (>24 cigs/d) Bite and parkBite and park Avoid eating, drinking while chewingAvoid eating, drinking while chewing Acid decreases releaseAcid decreases release SE: hiccups, nausea, sore throat, sore SE: hiccups, nausea, sore throat, sore

mouthmouth CI: pregnancy, CVD, esophagitis, PUDCI: pregnancy, CVD, esophagitis, PUD 12 weeks12 weeks

Treatment OptionsTreatment OptionsTransdermal nicotineTransdermal nicotine

7, 14, 21 mg, 24-hour7, 14, 21 mg, 24-hour 5, 10, 15 mg, 16-hour5, 10, 15 mg, 16-hour Usage guidelines p.1166Usage guidelines p.1166 SE: local skin reaction, insomniaSE: local skin reaction, insomnia CI: pregnancy, CVD, derm. problemsCI: pregnancy, CVD, derm. problems 8 weeks8 weeks Must not use tobaccoMust not use tobacco

Rx Nicotine replacementRx Nicotine replacement

Nicotine InhalerNicotine Inhaler SE: local irritation of mouth & throatSE: local irritation of mouth & throat Up to 6 monthsUp to 6 months

Nicotine Nasal SprayNicotine Nasal Spray SE: nasal irritationSE: nasal irritation Up to 6 monthsUp to 6 months

Bupropion SRBupropion SR

Wellbutrin, ZybanWellbutrin, Zyban Antidepressant, dopamine reuptake inhibitorAntidepressant, dopamine reuptake inhibitor Start 1 week before quittingStart 1 week before quitting 150 mg q am x 3 d, then increase to bid 150 mg q am x 3 d, then increase to bid

(may take second dose mid afternoon)(may take second dose mid afternoon) CI: History of seizure, eating disordersCI: History of seizure, eating disorders SE: insomnia, dry mouthSE: insomnia, dry mouth Can use with nicotine replacementCan use with nicotine replacement

What’s new? What’s new?

Rimonabant (Acomplia)Rimonabant (Acomplia) Cannabanoid Receptor AntagonistCannabanoid Receptor Antagonist Weight loss, tobacco cessationWeight loss, tobacco cessation Phase III clinical trialsPhase III clinical trials

Other considerationsOther considerations

CostsCosts IrritabilityIrritability Weight gainWeight gain Proper disposal of productsProper disposal of products Abstinence ratesAbstinence rates

14-30% vs 8-20% placebo14-30% vs 8-20% placebo

ReferencesReferences

See Blackboard linksSee Blackboard links Treating Tobacco Use and Treating Tobacco Use and

Dependence, Dependence, www.cme.wisc.edu/online/ctri/index.www.cme.wisc.edu/online/ctri/index.htm University of Wisconsin Medical htm University of Wisconsin Medical School and center for Tobacco School and center for Tobacco Research and InterventionResearch and Intervention