Up in Smoke

"You know, you're not as smart as you think you are!" The voice came from just beyond the prescription counter and directly in front of me, so I was sure it was directed at me.

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by Thomas A. Viola, RPH, CCP

"You know, you're not as smart as you think you are!"

The voice came from just beyond the prescription counter and directly in front of me, so I was sure it was directed at me. The fact that, in an instant, I was able to conjure up a list of 10 likely candidates who might make that comment was at once sad and comical to me. I didn't have high hopes for any conversation that began that way. Yet, I had a feeling that this encounter was not going to be as bad as it seemed. Since I had not yet had the chance to look up, I decided to add a little levity to the situation.

"Hi, Mom! Yes, I know, you've told me before. Hey, it's almost 3:00 p.m. Shouldn't you and Dad be having dinner right about now?" Laughter erupted. Everything was going to be all right.

I looked up to see the face of a patient that I had assisted several months earlier in her latest attempt to quit smoking.

"Well," she began, "I am proud to say that I have been smoke free for six months now and I owe a lot of the credit for my success so far to you."

"Please go on!" I said, completely tongue-in-cheek.

She chuckled and continued. "The combination of the nicotine patch and nicotine gum you recommended has worked better than I expected. And, you were the first to recommend behavior modification and counseling. It has really made a difference."

"That's great!" I exclaimed. "I'm so happy for you!"

"You were also the first to recommend that I see my dentist and hygienist for an oral examination, screenings, and follow-up," she said. "That visit was just the reinforcement I needed to swear off cigarettes forever."

"Thank you," I said, starting to feel a little uncomfortable with all of the accolades.

Then she leaned over the counter to get closer to me. Smiling broadly, she whispered, "You don't understand. For the first time since I was a teenager, I'm finally free!"

Pharmacological Therapy for Smokers

Cigarette smoking is the leading cause of preventable death in the United States. It is a major risk factor for cardiovascular disease and is the leading cause of lung disease, including chronic obstructive pulmonary disease and lung cancer. It is also linked to cancers of the stomach, colon, and bladder. Oral effects of smoking include squamous cell carcinoma, stomatitis, leukoplakia, and hairy tongue. A number of inactive components of tobacco smoke, such as carbon monoxide and hydrogen cyanide, contribute to smoking's adverse effects.

On average, smokers die 10 years earlier than nonsmokers. People who quit smoking live longer than those who continue to smoke. Unfortunately, success rates for smoking cessation attempts are low and quitting is associated with high rates of relapse. Nicotine has been compared to other drugs of abuse, such as alcohol, heroin, and cocaine, in terms of its potential for physical and psychological dependence. Cigarettes are very effective delivery devices for such a highly addictive drug, allowing nicotine to be absorbed both through inhalation (for a rapid effect) and through oral and nasal tissues (for a slower, more sustained effect).

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Other articles by Thomas Viola

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When associated with pleasurable activities, such as eating and socializing, or when tied to routine daily events, such as awakening and working, smoking becomes a learned behavior. This is further reinforced by the perceived positive psychological effects of nicotine, such as increased alertness, concentration, and memory, and decreased appetite. Like so many other addictive drugs, tolerance to the effects of nicotine develops over time, so it takes increasing doses to produce the same effect. Withdrawal symptoms include anxiety, difficulty concentrating, increased appetite, and repeated cravings. These symptoms are even more intense in the first few days of a smoking cessation attempt and can persist for months.

So, a successful smoking cessation program requires counseling and behavior modification, as well as pharmacological therapy for the suppression of symptoms of nicotine withdrawal. Nicotine replacement therapy (NRT) is considered first-line; the goal is to replace cigarettes with a source of nicotine which will maintain a baseline blood level to prevent withdrawal symptoms and reduce cravings. Without the harmful, inactive components of tobacco smoke, nicotine replacement products can be used for long periods as the patient's need for tobacco gradually tapers off.

NRT products that have been approved by the FDA for smoking cessation are available as transdermal patches, chewing gums, lozenges, inhalers, and nasal sprays. Selection of an NRT product is based upon patient preference and the patient's dependence on nicotine, as determined by the average number of cigarettes smoked in a day. In general, heavy smokers are more dependent on nicotine and require higher initial doses, and perhaps combination therapy (such as a long-acting patch combined with a short-acting gum or lozenge).

Nicotine is subject to first-pass metabolism in the liver, which would limit the efficacy of an oral tablet. As a result, oral NRT products are designed to deliver nicotine through the oral mucosa. Nicotine patches deliver nicotine more slowly than any other NRT product and are ideal for establishing and maintaining prolonged baseline blood levels. Nicotine nasal spray delivers nicotine more rapidly than any other NRT products and is ideal for providing fast relief of nicotine withdrawal symptoms.

Nicotine gum and lozenges may cause flatulence, indigestion, and nausea due to swallowed nicotine. Nicotine nasal sprays and oral inhalers may cause burning and stinging of the nasal mucosa and throat irritation. Nicotine patches may cause application site reactions and sleep disturbances, unless the patient removes the patch at bedtime.

Interestingly, unlike tobacco smoke, nicotine replacement products do not alter the metabolism of other drugs. However, when the patient stops smoking, doses of many medications often need to be adjusted. These include benzodiazepines, such as Ativan (lorazepam) and Xanax (alprazolam); hypnotics, such as Ambien (zolpidem); psychotherapeutic medications, such as Zyprexa (olanzapine) and clozapine (Clozaril); antidepressants and related agents, such as Remeron (mirtazapine) and Cymbalta (duloxetine); beta-blockers, such as Inderal (propranolol); anticoagulants, such as Coumadin (warfarin); and even insulin.

In addition to NRT products, two non-NRT products are widely used as smoking cessation agents. Bupropion is an atypical antidepressant which acts on dopamine-norepinephrine pathways that are also involved in nicotine addiction. It is available as a slow-release formulation (bupropion SR) and was previously marketed under the brand name Zyban. Bupropion SR is effective when used alone or in combination with an NRT product. Typically, patients start with 150 mg each morning for three days, then increase to 150 mg twice daily. Bupropion should be started seven to 14 days before the expected "quit date."

Bupropion SR is well tolerated and not associated with any major adverse events. The most common adverse effects are insomnia, headache, and dry mouth. It is contraindicated in patients with seizure disorders, or in those who may be prone to seizures, and in patients who are taking other drugs that lower seizure threshold. The FDA requires a warning about suicide for bupropion similar to that required with other antidepressants. Since it is extensively metabolized in the liver, bupropion may interact with inducers of hepatic enzymes, such as rifampin, carbamazepine phenytoin, or phenobarbital, as well as inhibitors of hepatic enzymes, such as cimetidine. Bupropion itself inhibits liver enzymes and may interact with many other antidepressants, antipsychotics, and beta-blockers.

Chantix (varenicline) is the second non-NRT product used for treating tobacco dependence. Varenicline is a partial nicotinic acetylcholine receptor agonist which relieves cravings and withdrawal symptoms. However, since it binds to those receptors more tightly than nicotine itself, varenicline also acts as an antagonist to nicotine delivered by smoking, reducing the pleasure derived from smoking, and thereby encouraging abstinence. Typically, patients start with 0.5 mg once daily for three days, increasing to 0.5 mg twice daily for days four to seven, and then increasing to the maintenance dose of 1 mg twice daily for the remaining course of therapy (normally 12 weeks). Varenicline should be started at least seven days before the expected quit date.

In general, varenicline is well tolerated. The most common side effects include nausea, sleep problems, and changes in mood or behavior. Unlike bupropion SR and most nicotine drugs, varenicline cannot be used in conjunction with other smoking cessation drug products. In addition, the FDA has warned that agitation, changes in behavior, and suicidal ideation have occurred in patients who took varenicline. Varenicline is not metabolized in the liver and has no clinically significant drug interactions.

Not so smart

"So, I'm confused," I said to my patient as she was preparing to leave.

"Confused? About what?" she asked.

"Everything seems to be going well for you in your quest to quit smoking," I replied. "And you said that I deserve a lot of the credit for that success."

"Yes," she replied. "That's true, but you're still not as smart as you think you are."

"Why is that?" I asked.

"You also told me if I stopped smoking, I would save a bunch of money!" she replied.

"Yes," I said, "That's true."

"Wrong!" she exclaimed. "Now that I have quit smoking, I'm constantly shopping for new clothes to replace my old smelly ones. So, one way or the other, my budget still goes…"

"Up in smoke!" we shouted in unison. RDH

THOMAS A. VIOLA, RPH, CCP, In addition to his daily practice of the profession of pharmacy, Thomas A. Viola, RPh, CCP, also serves the professions of dentistry, dental hygiene, and dental assisting as an educator, published writer, and professional speaker. As an educator, Viola is a member of the faculty of seven dental hygiene and dental assisting programs, as well as several national board exam review courses. Visit Viola's website: www.tomviola.com.

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