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freeCE Webcast
Beyond the Classroom:
Nicotine Cessation 1.0 HOUR CE

Mark Garofoli, PharmD, MBA, BCGP, CPE, CTTS

Brooke Fidler, PharmD
 Faculty Disclosure

Beyond the • Panelists for this educational activity have no relevant financial relationship(s) with
ineligible companies to disclose.
Classroom:
Nicotine Cessation
Mark Garofoli, PharmD, MBA, BCGP, CPE, • Advisory Board members and other individuals, not previously disclosed, who may
CTTS review, propose recommendations, and/or edit the content of PharmCon CE activities
Brooke Fidler, PharmD declare no existence of a financial interest in any amount related to the content of this
activity.

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Learning Objectives

At the conclusion of this activity, participants should be better able to:

– Compare and contrast the currently available OTC and
prescription options for nicotine cessation Recognize current social trends
– Recognize current social trends surrounding the use of nicotine,
surrounding the use of nicotine,
including demographics and delivery mechanism
– Identify the benefits of smoking and tobacco cessation including demographics and delivery
mechanism

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American Smoking Trends:

U.S. Tobacco Smoking and E-Cig Sales

U.S. % Tobacco Smoking

5 0%
44%
4 5%
4 0%

3 5%
3 0%
25%
2 5%
21%
2 0% 17%
1 5% 13%

1 0%
5%

0%
1 96 0 s' 1 99 0 s' 2 00 0 s' 2 01 0 s' 2 02 0 s'

• Fiore MC, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. HHS. Public Health Service.
• https://www.mordorintelligence.com/industry-reports/united-states-e-cigarettes-market

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 Secondhand Smoke

National Academy of Sciences Report (1986):

– Found that children of smokers were twice as likely to suffer from
respiratory infections, bronchitis, and pneumonia than children
whose parents did not smoke
– Transformed the idea of secondhand smoke from merely a social
annoyance to a health risk

– Surgeon General Koop recommended the establishment of

‘smoke free worksites’

https://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/index.htm Brandt, A. (2007). The Cigarette Century. New York, NY. Basic Books

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Secondhand Smoke I QUIT SMOKING!!!

“There is no risk-free level of “Every independent authoritative

secondhand smoke exposure; scientific body that has examined …. Now, I just vape!
even brief exposure can be the evidence has concluded that
harmful to health.” passive smoking causes many
diseases.”
– Centers for Disease Control and
Prevention
– World Health Organization

• http://www.who.int/tobacco/research/secondhand_smoke/about/en/
• https://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/general_facts/index.htm

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E-Cigarette Smoking Cessation?

E-Juice Components
JAMA and AHA
• Propylene glycol – to make the smoke (think fog machines)
• Vegetable glycines – to vaporize nicotine
• Nicotine – of course! Most vapes contain AHA Supports:
• FDA Regulation
• Benzoic acid – gives the sting to the back of the throat • Not Allowing in Smoke-Free Areas
• Limiting Marketing to Youth
• Flavorings – over 7,000 combos available • Taxation

• Diacetyl – a flavor enhancer *If a patient has failed initial NRT, has
been intolerant, or refused conventional
smoking cessation medication, and
wishes to use e-cigarettes to aid quitting,
it is reasonable to support the attempt.

~American Heart Association

Bhatnagar A., et al., AHA Policy Statement: Electronic Cigarettes. Circulation. 2014;130:1418-1436.

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 Smoking Cessation:
E-Cigarettes vs NRT

Juul Pods
have 150%
to 200%
nicotine of
e-cigs in this
Identify the benefits of smoking
and tobacco cessation
study

Only
for
ONE
year

Hajek P, et. al. A Randomized Trial of E-Cigarettes versus Nicotine-Replacement Therapy. N Engl J Med 2019;380:629-37.

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Benefits of Smoking Cessation

At EVERY Encounter
• Within 1 year of quitting, the risk of coronary
“ALL health care professionals should artery disease is half that of a continuing
discuss at EVERY encounter diet, smoker!
exercise, and smoking cessation. No • Within 2-5 years, the risks of cancers are cut in
matter if you are a physical therapist, half!
optometrist, or pharmacist, we need • Within 2-5 years, the risk of stroke becomes
to offer our skills to these patients!” that of a non-smoker
– Dr. Boris Lushniak, • Within 10 years, the risk of dying of lung
cancer is half that of a person who is still
Former US Surgeon General
smoking
• Within 15 years, the risk of coronary artery
disease is that of a non-smoker
https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/tobacco_related_mortality/index.htm

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Help Us! The Five As of Tobacco Cessation

• About 70% of smokers want to quit Ask

smoking
– About half try to quit each year Advise
– Less than 10% succeed • In a clear, strong, and personalized manner, urge every tobacco user to quit
• In 2010, less than half of smokers Assess
(48.3%) who saw a health
• Willingness to quit now? Barriers to remaining abstinent?
professional in the past year reported
receiving advice to quit Assist
• 50-75% of smokers who try to quit do
not use any evidence-based cessation Arrange
counseling or medications • Follow-up contact should begin soon after the quit date, preferably during the first week. A
second follow-up contact is recommended within the first month. Schedule further follow-up
contacts as indicated.

https://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/clinicians/references/quickref/index.html

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 Compare and contrast the
currently available OTC and
prescription options for nicotine
cessation

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Nicotine: Mechanisms of Action Nicotine Replacement Therapy: The Patch

10-WEEK PROTOCOL 8-WEEK PROTOCOL
• Teratogen promoting tumor growth (IF SMOKING MORE THAN 10 CIGARETTES/DAY) (IF SMOKING LESS THAN 10 CIGARETTES/DAY)
• Nicotine stimulates the release of:
– Dopamine (euphoria)
21 mg
• Use for 6 weeks • Use for 6
– Glutamate (memory)
– GABA (reduces anxiety)
14 mg weeks
– Serotonin (improves mood)
14 mg
• Use for 2 weeks
– Norepinephrine (arousal)
– Beta-endorphin (reduce anxiety)
• Use for 2
– ACETYLCHOLINE (AROUSAL) • Use for 2 weeks 7 mg weeks
• Nicotine ultimately increases NE, which increases HR/BP/RR
7 mg
• Heart needs more oxygen to increase workload, yet not received
Aapted from: Clinical Pharmacology Online Database

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Nicotine Replacement Therapy: Gum Nicotine Replacement Therapy: Lozenge

Nicotine Polacrilex Gum • Patients who use tobacco within 30 Weeks 1-6
• Use 1 lozenge
• First cigarette ≤30 minutes after minutes of awakening should use a every 1-2 hours
• C hew one
waking: 4 mg
Weeks 1-6 piece every
1-2 hours 4 mg lozenge
• First cigarette >30 minutes after
waking: 2 mg • Patients who use tobacco 30
Weeks 7-9
Weeks 7-9
• C hew one
piece every
2-4 hours
minutes or later after awakening • Use 1 lozenge
every 2-4 hours
• Use a minimum of 9 pieces/day for should use a 2 mg lozenge
the first 6 weeks
Weeks 10- • C hew one

12
piece every
4-8 hours
• Do not exceed 24 pieces/day
Weeks 10-12
• Do not use for more than 12 weeks
• Use 1 lozenge
every 4-8 hours

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 Smoking Cessation:
Nicotine Replacement Therapy: Nasal Spray
Rx Medications

• 1-2 doses per hour for 3 months First-Line Second-Line

– One dose: 2 sprays OR 1 spray in each nostril (1 mg nicotine) FDA-Approved Off-Label
– Do not use more than 5 doses per hour
– Do not use more than 40 doses per day Varenicline Clonidine

Bupropion SR 150 mg Nortriptyline

There are no FDA-approved smokeless tobacco cessation products,

yet many are utilized off-label

https://dailymed.nlm.nih.gov/dailymed/archives/fdaDrugInfo.cfm?archiveid=14335 Clinical Pharmacology Online Database

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Bupropion SR: Bupropion:

Dosage Smoking Cessation Utilization

Initiation Day 1 to day 3 150 mg QD Consider Avoid

• Still smoking
• Pregnancy and lactation
• Can begin 1 to 2 weeks
prior to cessation Day 4 to day 7 150 mg BID • Hepatic impairment
• Looking to utilize medication(s) and
• Psychological conditions including bipolar, significant
nicotine patches anxiety, and seizure disorder
Days 8 and onward 150 mg BID • Concomitant bupropion therapy
Continuation 7 weeks Reassess
• History of depression and/or • Current or prior diagnosis of bulimia or anorexia nervosa
(Not smoking) cardiovascular disease • Simultaneous abrupt discontinuation of alcohol or
sedatives/benzodiazepines
12 weeks Reassess • Aiming to delay weight gain typically • MAO inhibitors in preceding 14 days; concurrent use of
reversible MAO inhibitors
seen with smoking cessation
• Allow at least 8 hours between doses Black Box Warning for suicidal thoughts and behaviors
• Avoid bedtime dosing to minimize insomnia (Removed in 2016)

• Max daily dose: 300 mg

Clinical Pharmacology Online Database Clinical Pharmacology Online Database

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Varenicline: Varenicline:
Mechanism, ADEs, and Risks Dosage
• Mechanism Day 1 to day 3 0.5 mg QD
– Nicotinic receptor partial agonist Initiation
• Blocks pleasurable effects of smoking (Still smoking) Day 4 to day 7 0.5 mg BID
• Common Adverse Effects
Days 8 and onward 1 mg BID
– Vivid dreams, insomnia, headache, taste alteration, N/V, constipation,
flatulence, and skin reactions Continuation 12 weeks Reassess
• Mental Health Risk (Not smoking)

– Black Box Warning for adverse psychiatric events removed in 2016 Round 2 ???
• Cardiovascular Risk
• Starter pack (53 tablets) is available
– Patients with CV disease may be at increased CV risk; however, smoking
itself poses major risk • Renal dosing
– Severe renal impairment (CrCl </= 30 mL/min): 0.5 mg QD titrated to 0.5 mg BID
Ø Should NOT be used by pilots, air traffic controllers, truckers, or bus drivers – ESRD (dialysis): Maximum dose of 0.5 mg QD

Clinical Pharmacology Online Database Clinical Pharmacology Online Database

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 Varenicline: Second-Line Rx Options:
Patient Education Not FDA Approved
• Set a QUIT DATE. Start varenicline (starter pack) one week prior. Clonidine Nortriptyline
• Take after a meal with a full 8 oz glass of water (minimizes GI upset)
• Do NOT drive until patient sees how the drug affects them • Blocks reuptake of norepinephrine with a
• Decrease alcohol intake until cognition assessed • Stimulates alpha-2-adrenoceptors to lesser effect on serotonin

• Average Cost: ~$1,200 (12-week duration) reduce sympathetic (NE) outflow • Similar efficacy to bupropion/NRT, but
side effects limit utilization

• Clinical Pharmacology Online Database

• Chantix Package Insert Clinical Pharmacology Online Database

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Be an Advocate! NCI’s Smoking Quit Line

Things you can do to help:

• Express things in terms of your own concern about the smoker’s 1-877-44U-QUIT (1-877-448-7848)
health (“I’m worried about…”)
• Acknowledge that the smoker may get something out of smoking and • NCI’s Smokefree.gov offers science-driven tools, information, and
may find it difficult to quit support that has helped smokers quit. You will find state and national
• Be encouraging and express your confidence that the smoker can resources, free materials, and quitting advice from NCI.
quit for good
• For clinicians: U.S. Department of Health & Human Services ‘Quick
– Note that one-half of all people who have ever smoked have now quit
Reference Guide for Clinicians’
• Suggest a specific action, such as calling a smoking quit line, for help
in quitting smoking
• Ask the smoker for ways in which you can provide support

https://www.cancer.gov/about-cancer/causes-prevention/risk/tobacco/help-quitting-fact-sheet

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Test Questions Pharmacist, Pharmacy Technician, Nurse
To receive CE credit, access the webcast and take the test online at freeCE.com

1. Nicotine transdermal patches are typically worn for 8. A patient who smokes around 15 cigarettes per day
_____. would like to begin nicotine replacement therapy using
a. 4-6 hours the transdermal patch. This patient should be advised
b. 6-8 hours to use the ____mg patch for the first 6 weeks.
c. 16-24 hours a. 7
d. 7 days b. 14
c. 21
2. When using a nicotine nasal spray, do not exceed ____ d. 32
doses per hour.
a. 3 9. What was the most impactful and important omission
b. 5 from the published results of a 2019 NEJM study of E-
c. 25 Cigarettes showing a more successful 5-year abstinence
d. 40 rate compared to NRT?
a. Nicotine Content of E-Cigarettes in the study
3. When taking bupropion SR for tobacco cessation, being much less than what’s available in
patients should be advised to: society
a. Take two tablets once daily b. Nicotine Content of E-Cigarettes in the study
b. Take one tablet twice daily, separating doses being much more than what’s available in
by at least 8 hours society
c. Take the second dose at bedtime c. E-cigarette utilizers died more during the study
d. Quit smoking on the first day that the drug is d. E-cigarette utilized had more hospital
started admissions during the study

4. The recommended dosage of varenicline on the first day 10. Which of the following statement(s) best summarize
of treatment is: trends among high school users of nicotine:
a. 0.5mg once daily a. Cigarette smoking remains the dominant
b. 0.5mg twice daily dosing mechanism for nicotine abuse among
c. 1mg once daily high school students
d. 1mg twice daily b. Cigarette smoking has sharply trended upward
over the past 10 years among high school
5. The maintenance dose (i.e. after day 7) of varenicline is: students
a. 0.5mg once daily c. E-cigarettes have surpassed the popularity of
b. 0.5mg twice daily cigarettes among high school students
c. 1mg once daily d. Smokeless tobacco products are more
d. 1mg twice daily common among high school students than e-
cigarettes or regular cigarettes combined
6. Patient counseling tips for the use of nicotine lozenges
include:
a. Chew the lozenge thoroughly before
swallowing
b. The lozenge should be taken along with a
glass of milk or a light snack
c. Do not exceed 9 lozenges per day
d. All of the above are correct
e. None of the above are correct

7. The 5 As of Smoking Cessation are:

a. Ask, advise, assess, assist, arrange
b. Act, acknowledge, accuse, abuse, actualize
c. Abandon, abide, acquit, affirm, archive
d. Articulate, aromatize, assign, ambush,
asphyxiate
PHARMACIST LEARNING OBJECTIVES
1. Compare and contrast the currently available OTC and prescription options for nicotine cessation
2. Recognize current social trends surrounding the use of nicotine, including demographics and delivery mechanism
3. Identify the benefits of smoking and tobacco cessation

PHARMACY TECHNICIAN LEARNING OBJECTIVES

1. Compare and contrast the currently available OTC and prescription options for nicotine cessation
2. Recognize current social trends surrounding the use of nicotine, including demographics and delivery mechanism
3. Identify the benefits of smoking and tobacco cessation

NURSE LEARNING OBJECTIVES

1. Compare and contrast the currently available OTC and prescription options for nicotine cessation
2. Recognize current social trends surrounding the use of nicotine, including demographics and delivery mechanism
3. Identify the benefits of smoking and tobacco cessation

OVERVIEW
Former US Surgeon General Dr. Boris Lushniak once challenged all health care professionals to discuss at EVERY encounter the topic of smoking cessation. 50-75% of smokers
who try to quit will not use any evidence-based cessation counseling or medications. This represents a huge opportunity, then, in helping patients understand the resources that
are available, both pharmacologic and non-pharmacologic. This unique panel discussion hosts multiple cessation specialists to discuss perhaps one of the most significant health
interventions that we can assist patients in making. As with all ‘Beyond the Classroom’ discussions, participants will be able to interact directly with the panelists in real time.

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TARGET AUDIENCE AUTHOR DISCLOSURE

Pharmacist, Pharmacy Technician, Nurse Panelists report no financial relationship with the manufacturer(s) or provider(s) of any
commercial interest(s) or service(s) that appear in this program.

ACPE UNIVERSAL ACTIVITY NUMBER

PHARMACIST: 0798-0000-24-032-H01-P ACTIVITY TYPE: Knowledge-based
PHARMACY TECHNICIAN: 0798-0000-24-032-H01-P RELEASE DATE: 02/07/2024
CE BROKER ID NUMBER: 20-1170648 EXPIRATION DATE: 07/31/2026

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