Case Answers:
Case answers will be presented after review of the HPI.
Answer 1
What are your reasons for smoking? If you were to quit, what would be your
most important reasons? Have you ever thought about quitting? Have you ever tried to quit?
If you did quit, when did you quit? Why did you go back to smoking? What could you do the
next time to get rid of those urges to smoke? What are some of your concerns about
quitting? Do you think you're addicted to cigarettes?
Answer 2
Arch Int Med 1993;153, page 35.
Table 1. Health Consequences of Smoking* |
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Active Smoking/Addiction/Aging Acceleration |
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| Cancer | Respiratory Diseases | Cardiovascular Diseases | Pregnancy, Infant Health | Other Conditions |
| Lung | Emphysema | Coronary artery disease | Growth retardation | Peptic ulcer |
| Larynx | Bronchitis | Hypertension | Abortion | Osteoporosis |
| Mouth | Asthma | Aortic aneurysm | Fetal/neonatal death | Alzheimer’s disease |
| Pharynx | Bacterial pneumonia | Arterial thrombosis | Abruption placenta | --- |
| Esophagus | Tuberculosis pneumonia | Stroke | Bleeding | Wrinkling |
| Stomach | Asbestosis | Placenta previa | --- | |
| Liver | --- | --- | Premature/prolonged | --- |
| membrane rupture | ||||
| Pancreas | --- | --- | --- | --- |
| Bladder | --- | --- | Preterm labor | --- |
| Uterine cervix | --- | --- | Preeclampsia | --- |
| Breast | --- | --- | Sudden infant death syndrome | --- |
| Brain | --- | --- | Congenital malformation | --- |
*Redrawn with permission from Hirayama.
Answer 3
Arch Int Med 1993;153, page 43.
Table 12. Fagerstrom Test for Nicotine Dependence* |
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| Questions | Answers | Points | Score |
| How soon after you wake up do you smoke your first cigarette? | Within 5 min 6-30 min |
3 2 |
|
| Do you find it difficult to refrain from smoking in places where it is forbidden; e.g., in church, at the library, in cinemas? | Yes No |
1 0 |
|
| Which cigarette would you hate most to give up? | The first one in the morning Any others |
1 0 |
|
| How many cigarettes a day to you smoke? | 10 or less 11-20 21-30 31 or more |
0 1 2 3 |
|
| Do you smoke more frequently during the first hours after waking than during the rest of the day? | Yes No |
1 0 |
|
| Do you smoke even if you are so ill that you are in bed most of the day? | Yes No |
1 0 |
|
*With permission from Fagerstrom et al.
Answer 4
Pharmacologic therapy should be considered for all smokers and made available to
those who have no contraindication. All current therapies will about double quit rates,
i.e., from 4-8% to 10-15%, compared to placebo. Quit rates are even higher in those groups
who receive concomitant behavioral therapy.
Answer 5
Currently there are five different pharmacologic aids to smoking cessation. They
are: 1)nicotine gum (Nicorette), 2)nicotine patch(Nicoderm CQ, Nicotrol, Habitrol,
Prostep) 3)nicotine nasal spray (Nicotrol nasal spray) 4)nicotine inhaler (Nicotrol
Inhaler) and 5) bupropion (Zyban). At this time there are no head to head studies
comparing the different therapies available.
Answer 6
Nicotine gum was made OTC in 1995 in 2mg and 4mg doses. Initial guidelines
recommended that the gum be chewed on a prn basis, but (as the label now states) more
recent data suggest that patients should chew 1-2 pieces per hour. The 2mg dose is
recommended for those who smoke 25 or fewer cigarettes daily, while the 4mg dose is for
heavier smokers. See tables 10 and 11 below for instructions on gum use. It is of note
that pregnancy is not considered an absolute contraindication. (JAMA 28(1):72-6, Jan
6,1999).
Table 10. Recommended Exclusion Criteria for Nicotine Gum |
Table 11. Information for Patients About Nicotine Gum and Instructions on Its use* |
| Postmyocardial infarction Peripheral vascular disease Serious cardiac arrhythmias Systemic hypertension Vasospastic disease Active peptic ulcer disease Active esophagitis Oral or pharyngeal inflammation Pheochromocytoma Hyperthyroidism Insulin-dependent diabetes mellitus Pregnancy Breast feeding Active temporomandibular joint disease Extensive dental work |
The gum is not a magic cure; personal commitment and
effort are still necessary for success. Its use should be started after quitting cigarettes. The gum contains nicotine that is released as it is chewed and absorbed through the lining of the mouth; it takes approximately 15 chews to release the nicotine at which time a tingling sensation will be felt in the mouth; when the tingling begins, the gum should be parked between the cheek and gums; when the tingling is almost gone, chewing should begin again. Absorption of nicotine is slower than from cigarettes; therefore, the gum does not give the positive pleasure from smoking. The gum does not stop the smoker from smoking, but it does make it easier to cope without cigarettes after stopping. The gum makes the withdrawal symptoms from not smoking less severe; the craving for a cigarette may not be relieved by the gum and if not, needs to be handled without smoking. Each piece should be chewed for 20 to 30 minutes to allow all the nicotine to be released. The gum should not be chewed during or immediately after drinking coffee or carbonated drinks, which may decrease the absorption of the nicotine. The gum should be chewed gently, with frequent pauses. Too vigorous chewing causes excessive salivation and nicotine swallowed with the saliva is destroyed and wasted and may cause indigestion. A piece of gum should be chewed whenever the urge to smoke is very strong. The gum may taste unpleasant at first and irritate the throat; most people adapt to it after persistent use for 1 day or 2, but it may take up to 1 week to get used to it. The gum should be used for up to 3 months before attempting to discontinue its use. Even then it is a good idea to carry a few pieces in case of "emergencies". |
* Adapted with permission from Russeli and Jarvis.
Answer 7
Transdermal nicotine is available today in several different delivery systems,
depending upon the maunfacturer, designed to provide nicotine over 16-24 hours. Nicotine
is released directly through the skin and through a membrane system. Side effects are
minimal which include mild to moderate sleep disturbances, dyspepsia, various myalgias and
poorly defined body aches and increased cough. The most common complaint, however, has
been an allergic reaction which includes transient itching or burning and erythema during
the trials. The patch should not be placed over hairy skin which will decrease absorption.
Answer 8
The nicotine inhaler is a plastic rod with a nicotine plug which provides a
nicotine vapor when puffed. In actuality, the nicotine is inhaled via the buccal mucosa
and not in the lungs. Consequently, the absorption rate of nicotine from this delivery
system is similar to that of gum (peak plasma levels seen in 15-30 minutes). Side effects
are mild, including throat irritation and cough, in addition to the systemic effect of
nicotine itself.
Nicotine nasal spray is designed to give the most rapid onset of plasma levels of nicotine (about ten minutes) and thereby simulate the effect of an actual cigarette. (The peak serum nicotine level is only about 2/3 that of a cigarette.) Side effects occur frequently in the majority of users, though tolerance occurs to these in the first week. Side effects include: cough, sneezing, throat irritation, rhinitis and watery eyes.
Bupropion was initially developed as an atypical antidepressant, and was later found to be helpful as a smoking cessation aid. Like nicotine replacement, bupropion consistently doubles quit rates, regardless of any problems with depression. The dose is 300mg/day in two divided doses. Adverse effects include dry mouth and insomnia. Also, there probably is a slight increased risk of seizure at this low dose (comparable to the increased risk seen with other antidepressants) and so patients with a history of seizures, anorexia, heavy alcohol use, or head trauma should use a different medication.
Answer 9
To assess if the patient is ready to quit, one must ask him is he interested in
stopping to smoke which include the following: Do I want to quit smoking for myself? Is
quitting smoking a number one priority in my life? Have I tried to quit smoking before? Do
I believe smoking is dangerous to my health? Am I committed to trying to quit even though
it may be tough at first? Are my family, friends, and co-workers willing to help me quit
smoking? Beside health reasons, do I have other personal reasons for quitting smoking? Do
I know how to handle my urges? If smokers answer "yes" to four or more, they are
probably ready to quit.