Page 814 - Cardiac Nursing

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790 PA R T V / Health Promotion and Disease Prevention
Question Answers Points
1. How soon after you wake up do you smoke your first cigarette? Within 5 minutes 3
6–30 minutes 2
31–60 minutes 1
After 60 minutes 0
2. Do you find it difficult to refrain from smoking in places where it Yes 1
is forbidden (e.g., in church, at the library, in the cinema, etc.)? No 0
3. Which cigarette would you hate most to give up? The first on in the morning 1
All others 0
4. How many cigarettes/day do you smoke? 10 or less 0
11–20 1
21–30 2
31 or more 3
5. Do you smoke more frequently during the first hours after waking Yes 1
than during the rest of the day? No 0
6. Do you smoke if you are so ill that you are in bed most of the day? Yes 1
No 0
Total score ranges from 0 to 10.
Total score of greater than 7 indicates nicotine dependence.
■ Figure 34-2 The Fagerstrom tolerance test. (Reprinted with permission from Heatherton, T., Kozlowski, L.,
Frecker, R., et al. [1991]. The Fagerstrom Test for Nicotine Dependence: A revision of the Fagerstrom Toler-
ance Questionnaire. British Journal of Addiction, 86, 1119–1127.)6 6
nonsmoker, because alcohol consumption is an independent predic- partial nicotine receptor agonist and antagonist effect. Vareni-
tor of relapse to smoking. 75 Alcohol consumption and its relation- cline is available by prescription only. The abstinence rates for
ship to smoking cessation are further discussed later. varenicline are three times greater than for placebo, and vareni-
cline is about one and a half times more effective than nicotine
Pharmacologic Therapy patch.
The most important development since the last guideline has Like bupropion, smokers need to take varenicline 1 week be-
been the additional option of varenicline (Chantix), a nicotine fore the quit date. Varenicline is well tolerated for periods up to 1
76
receptor antagonist. The guidelines 61,62 recommend that all pa- year. Unlike bupropion, varenicline is not recommended for use
tients expressing the desire to quit smoking receive both counsel- in combination with NRT because of its nicotine antagonist
ing and pharmacotherapy, except when medication use is con- properties. Varenicline is relatively well tolerated in most patients.
traindicated or with specific populations in which medication use However, recent studies reported incidents of exacerbations of
has not been shown to be effective such as pregnant or breast- preexisting psychiatric illness, schizophrenia, and bipolar illness,
feeding women, adolescents, smokeless tobacco users, light in patients who took varenicline. 77,78 Therefore, it is important
smokers (those smoking fewer than 10 cigarettes per day), and that patients are carefully monitored while taking varenicline and
those with medical contraindications such as recent MI or wors- this includes that patients be advised to tell their health care
ening angina. Through meta-analysis, seven first-line pharma- provider about any history of psychiatric illness prior to starting
cotherapies were determined to be safe and efficacious, leading to this medication. Clinicians need to monitor patients for any
cessation rates approximately double those of placebo. These are changes in mood and behavior when prescribing this medication.
nicotine patch, nicotine gum, nicotine inhaler, nicotine nasal In February 2008, the FDA warned that depressed mood, agita-
spray, nicotine lozenge, sustained-release (SR) bupropion and tion, changes in behavior, suicidal ideation, and suicide have been
varenicline. Each of these first-line agents has received the U.S. reported in patients attempting to quit smoking while using
Food and Drug Administration (FDA) The 2008 Guideline in- varenicline. In addition, varenicline should be used with caution
terestingly reported the different effectiveness among these in patients with severe renal dysfunction (creatinine clearance
agents. Comparing placebo as a reference group, combination 30 mL/min), since varenicline is eliminated almost entirely un-
therapy of nicotine patch and ad libitum nicotine replacement changed in the urine.
therapy (NRT) (gum or spray) presented highest abstinence rate Bupropion. Another alternative to NRT is SR bupropion
followed by varenicline. However, other agents did not show sta- (Zyban SR; GlaxoSmithKline, Research Triangle Park, North
tistically significant difference (Table 34-1). The nicotine patch, Carolina), an oral medication that comes in tablet form. This
gum, and lozenge are available over the counter. The other forms pharmacologic aid for smoking cessation has been used for many
of NRT are available by prescription only. The first-line agents years to treat depression. The exact mechanism that promotes
are discussed below.
smoking cessation is unknown. Bupropion is, however, a weak
Varenicline. Varenicline (Chantix) is newly approved as a inhibitor of neuronal uptake of dopamine, serotonin, and norep-
non-nicotine medication by the U.S. FDA for smoking cessa- inephrine. 79 It is believed to affect the mesolimbic dopaminergic
tion (Table 34-2). 62 Its mechanism of action is assumed to be a system and, therefore, mediates reward for nicotine use. 80 Like