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Tobacco cessation fall 2011 Instructor (1)_ For use in lecture (3)

Post marketing surveillance data indicate potential

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Post-marketing surveillance  data indicate potential for  neuropsychiatric symptoms. ADVANTAGES Easy to use oral  formulation. Twice daily dosing might  reduce compliance  problems. Offers a new mechanism of  action for persons who  have failed other agents.
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LONG-TERM ( 6 month) QUIT RATES  for AVAILABLE CESSATION  MEDICATIONS 0 5 10 15 20 25 30 Nicotine gum Nicotine patch Nicotine lozenge Nicotine nasal spray Nicotine inhaler Bupropion Varenicline Active drug Placebo Data adapted from Cahill et al. (2008). Cochrane Database Syst Rev; Stead et al. (2008). Cochrane Database Syst Rev; Hughes et al. (2007). Cochrane Database Syst Rev Percent quit 18.0 15.8 11.3 9.9 16.1 8.1 23.9 11.8 17.1 9.1 19.0 10.3 11.2 20.2
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COMBINATION  PHARMACOTHERAPY Combination NRT Long-acting formulation  (patch) Produces relatively constant levels of nicotine PLUS Short-acting formulation  (gum, inhaler, nasal spray) Allows for acute dose titration as needed for nicotine  withdrawal symptoms Bupropion SR + Nicotine Patch Regimens with enough evidence to be ‘recommended’ first-line
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COMPLIANCE IS KEY to  QUITTING Promote compliance with prescribed regimens. Use according to dosing schedule, NOT as  needed. Consider telling the patient: “When you use a cessation product it is important to read all  the directions thoroughly before using the product. The  products work best in alleviating withdrawal symptoms when  used correctly, and according to the recommended dosing  schedule.”
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$0 $1 $2 $3 $4 $5 $6 $7 $8 Trade $6.58 $5.26 $3.89 $5.29 $3.72 $7.40 $4.75 Generic $3.28 $3.66 $1.90 - - $3.62 - Gum Lozenge Patch Inhaler Nasal spray Bupropion SR Varenicline COMPARATIVE DAILY COSTS  of PHARMACOTHERAPY $/day Average $/pack of cigarettes, $4.32
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SUMMARY To maximize success, interventions should include counseling  and one or more medications Clinicians should encourage the use of effective medications  by all patients attempting to quit smoking Exceptions include medical contraindications or use in specific  populations for which there is insufficient evidence of effectiveness First-line medications that reliably increase long-term smoking  cessation rates include: Bupropion SR Nicotine replacement therapy  (gum, inhaler, lozenge, patch, nasal spray) Varenicline Use of effective combinations of medications should be  considered
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COUNSELING a PATIENT who is NOT  READY TO QUIT: A Demonstration CASE SCENARIO:   MS. STEWART You are a clinician providing care to   Ms. Stewart, a 55-year-old patient  with emphysema. She uses two different inhalers for  her emphysema.
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Ask about tobacco use Link inquiry to knowledge of disease  Assess readiness to quit Aware of need to quit; not ready yet Advise to quit Discuss implications for disease progression “I will help you, when you are ready” NOT READY to QUIT: Case Scenario Synopsis
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