331.1 🎓 醫孞生版

331.1.0.1 📌 䞀頁重點

331.1.0.1.1 Epidemiology
331.1.0.1.1.1 Global Tobacco Use
  • ~ 1.3 billion smokers worldwide
  • ~ 8 million deaths/year
  • #1 preventable cause of death
  • Taiwan ~ 13% adult smoking prevalence (declining)
  • Higher in men, lower SES
331.1.0.1.1.2 Health Consequences

Pulmonary: - Lung cancer (80-85% of US cases) - COPD - Asthma exacerbation - Pneumonia susceptibility - ILD (some)

Cardiovascular: - CAD (top killer in smokers numerically) - Stroke - PAD - AAA - Atherosclerosis acceleration

Other Cancers: - Head + neck (oral, larynx, pharynx) - Esophageal - Bladder - Kidney - Pancreas - Cervical - AML, CML (some leukemias)

Pregnancy / Reproductive: - Infertility (both sexes) - Pregnancy complications - Low birth weight - SIDS - Childhood asthma

Other: - Dental disease, periodontitis - Cataracts, macular degeneration - Wound healing - Osteoporosis - Diabetes (worsens) - Depression - Decreased longevity (~ 10-15 years)

331.1.0.1.2 Nicotine Dependence
331.1.0.1.2.1 Pathophysiology
  • Nicotine binds nicotinic acetylcholine receptors (nAChR) in CNS
  • Activates ventral tegmental area → dopamine in nucleus accumbens → reward
  • Tolerance + dependence develop
  • Withdrawal: anxiety, irritability, depression, cravings, insomnia, weight gain
  • Genetic predisposition (CYP2A6 enzyme, others)
331.1.0.1.2.2 Severity Assessment

Fagerström Test for Nicotine Dependence (FTND): - 6-item questionnaire - Score 0-10 - Higher score = more dependent - Useful for treatment selection

Other Indicators: - Smoking within 30 min of waking - Cigarettes per day (≥ 20 highly dependent) - Cigarettes during illness - Difficulty refraining

331.1.0.1.3 Smoking Cessation — 5A’s Approach

331.1.1 Ask

  • All patients at every visit
  • Document
  • Quantify (pack-years, cigarettes/day)

331.1.2 Advise

  • Clear, strong, personalized
  • “Quitting smoking is the single most important thing you can do for your health”

331.1.3 Assess

  • Readiness to quit (Stages of Change)
  • Prochaska + DiClemente:
    • Precontemplation (not considering)
    • Contemplation (thinking about it)
    • Preparation (planning to quit in next month)
    • Action (within 6 months)
    • Maintenance (≥ 6 months)
    • Relapse

331.1.4 Assist

  • For ready patients
  • Set quit date
  • Pharmacotherapy + behavioral support
  • Follow-up

331.1.5 Arrange

  • Follow-up within 1-2 weeks of quit date
  • Phone, in-person, telehealth
  • Reassess progress
  • Adjust treatment
331.1.5.0.1 5R’s for Unwilling Patients
  • Relevance: connect to patient
  • Risks: discuss health
  • Rewards: discuss benefits
  • Roadblocks: address barriers
  • Repetition: continue to bring up
331.1.5.0.2 Pharmacotherapy

331.1.6 First-Line Agents

Varenicline (Chantix, Champix): - α4β2 nicotinic receptor partial agonist - Both blocks nicotine + reduces cravings - Most effective single agent - Dose: 0.5 mg × 3d → 1 mg BID for 12 weeks - Side effects: nausea (28%), insomnia, vivid dreams, neuropsychiatric (recent data show no excess risk) - May extend to 24 weeks - Quit before starting? Or after starting (Cytisine model) - Pre-quit reduction option

Nicotine Replacement Therapy (NRT): - Forms: - Patch (16 or 24 hour, varying dose) - Gum (2 or 4 mg) - Lozenge (2 or 4 mg) - Inhaler (rapid release) - Nasal spray (rapid, less popular) - Patch + short-acting (gum/lozenge) combination more effective - 8-12 weeks typically; can extend - Side effects: local irritation, vivid dreams (patch)

Bupropion (Wellbutrin, Zyban): - Norepinephrine + dopamine reuptake inhibitor (NDRI) - Dose: 150 mg daily × 3 d → 150 mg BID for 12 weeks - Quit date 7-14 days after starting - Side effects: insomnia, headache, seizure risk (esp eating disorders, brain injury) - Avoid if: seizure history, eating disorder, alcohol withdrawal - Useful for depression coexistence

331.1.7 Second-Line / Adjunctive

Cytisine: - α4β2 partial agonist (similar to varenicline) - Plant-derived - Cheaper alternative - Approved in Europe for years - FDA approval pending 2024-2025 in US - Effective + lower cost

Combination NRT: - Patch + gum/lozenge - More effective than either alone - Higher cessation rate - Recommended for heavy smokers

Combination Varenicline + NRT: - Some evidence of synergy - Increased side effects - Selected use

331.1.8 Third-Line

Nortriptyline: - TCA - Effective but side effects - For when others fail

Clonidine: - α2-agonist - Limited evidence

331.1.8.0.1 Behavioral Support

331.1.9 Counseling Approaches

Brief Advice: 1-3 minutes by clinician

Brief Behavioral Intervention: 5-15 minutes

Intensive Behavioral Intervention: ≥ 4 sessions × ≥ 10 minutes each

331.1.10 Methods

  • Cognitive Behavioral Therapy (CBT)
  • Motivational Interviewing (MI)
  • Telephone quitlines (state, national)
  • Text messaging programs
  • Mobile apps (variable evidence)
  • Group counseling
  • Individual counseling

331.1.11 Combination Therapy

  • Pharmacotherapy + behavioral = best results
  • Each alone less effective
  • Synergistic

331.1.12 Tobacco Treatment Specialists

  • Certified providers
  • Multidisciplinary clinics
  • Integrated care
331.1.12.0.1 E-Cigarettes (Vapes)

331.1.13 Controversy

  • Harm reduction tool: less toxic than combustible cigarettes
  • Gateway concern: youth uptake
  • Long-term effects: unknown
  • EVALI (e-cigarette/vaping product use-associated lung injury): vitamin E acetate

331.1.14 Evidence

  • 2019 NEJM RCT: e-cigarettes more effective than NRT for cessation (UK trial)
  • 2024 Cochrane: e-cigarettes likely effective for cessation in some
  • Other studies: variable

331.1.15 Position Statements

  • WHO: not first-line; concerns
  • FDA: regulation evolving
  • UK NHS: harm reduction approach
  • US AHA, ACS: cautious

331.1.16 Use in Practice

  • Not first-line cessation tool
  • Consider for refractory smokers as harm reduction
  • Discuss risks + benefits
  • Avoid in adolescents / never-smokers
331.1.16.0.1 Withdrawal Management
331.1.16.0.1.1 Symptoms
  • Anxiety, irritability, restlessness
  • Cravings
  • Depression
  • Insomnia
  • Fatigue
  • Increased appetite + weight gain
  • Decreased heart rate
  • Difficulty concentrating
331.1.16.0.1.2 Duration
  • Peak 2-4 weeks
  • Most resolve in 4-6 weeks
  • Cravings persist longer (months)
331.1.16.0.1.3 Management
  • NRT helps significantly
  • Varenicline reduces cravings
  • Behavioral techniques
  • Reassurance about timeline
331.1.16.0.2 Special Populations

331.1.17 Pregnancy

  • Smoking cessation during pregnancy critical
  • NRT (lowest effective dose) may be considered (FDA pregnancy category D, but less than smoking)
  • Varenicline: limited data; not first-line
  • Bupropion: not recommended
  • Behavioral support emphasized

331.1.18 Cardiovascular Disease

  • Strong indication to quit
  • NRT safe (vs continued smoking)
  • Varenicline neutral CV effects (CATS, EAGLES)
  • Bupropion OK

331.1.19 Mental Health Conditions

  • Smoking 2-3x more prevalent
  • More difficult to quit
  • Varenicline: post-EAGLES no excess neuropsychiatric risk
  • Combine pharmacotherapy + behavioral
  • Integrated treatment

331.1.20 Adolescents

  • Counseling primarily
  • NRT/varenicline limited evidence
  • E-cigarette prevention important
  • Cessation programs

331.1.21 Hospitalized Patients

  • Opportunity to assist
  • Initiate pharmacotherapy
  • Connect to outpatient

331.1.22 Cancer Survivors

  • Critical to quit (5-year survival ↑ 30-50%)
  • Multimodal approach
  • Specialty consultation

331.1.23 Surgery Pre-Op

  • ≥ 4-8 weeks cessation before surgery
  • Reduces complications
  • NRT acceptable

331.1.23.1 🩺 床邊速查

  • 5A’s: Ask, Advise, Assess, Assist, Arrange
  • 5R’s for unwilling: Relevance, Risks, Rewards, Roadblocks, Repetition
  • Varenicline: most effective single agent
  • NRT combination (patch + gum/lozenge): more effective than single
  • Bupropion: ↑ seizure risk (avoid if seizure, eating disorder)
  • Cytisine: cheaper alternative; FDA pending 2024-2025
  • Pharmacotherapy + behavioral support = best results
  • Cessation in cancer survivors improves survival 30-50%
  • EVALI: vitamin E acetate in THC vapes
  • Pregnancy: NRT considered (less than smoking risk)