NICOTINE NICOTINE REPLACEMENT REPLACEMENT

THERAPYTHERAPYNRTNRT

Dr. Debbie Thompson; Dr. Jane DumontetDr. Debbie Thompson; Dr. Jane DumontetClinical Pharmacy Specialists for Fraser HealthClinical Pharmacy Specialists for Fraser Health

Feb 2008Feb 2008

ObjectivesObjectives

Understand the difference between Understand the difference between cessation and withdrawalcessation and withdrawal

Review the various Nicotine Review the various Nicotine Replacement Therapy optionsReplacement Therapy options

Contrast the symptoms of nicotine Contrast the symptoms of nicotine toxicity versus those of withdrawal, toxicity versus those of withdrawal, psychiatric symptoms, caffeine side psychiatric symptoms, caffeine side effectseffects

Nicotine WithdrawalNicotine Withdrawal

Patients without access to cigarettes Patients without access to cigarettes abruptly due to non-smoking policies abruptly due to non-smoking policies will experience withdrawal symptomswill experience withdrawal symptoms

Initial Goal/PriorityInitial Goal/Priority to make patients as comfortable as to make patients as comfortable as

possible by preventing withdrawal possible by preventing withdrawal symptomssymptoms

Thank-you for not smoking here!Thank-you for not smoking here!

Secondary Goal Secondary Goal Cessation Cessation

Physiological Physiological ConsiderationsConsiderations

WithdrawalWithdrawalNonspecific symptomsNonspecific symptoms

Vary in intensity and Vary in intensity and durationduration

Begin within hoursBegin within hours Peak in 2 to 3 daysPeak in 2 to 3 days Last weeks to monthsLast weeks to months

SymptomsSymptoms Irritability, frustration Irritability, frustration

or angeror anger Anxiety, restlessnessAnxiety, restlessness Dysphoria or Dysphoria or

depressed mooddepressed mood Difficulty Difficulty

concentratingconcentrating Increased appetite or Increased appetite or

weight gainweight gain InsomniaInsomnia Decreased heart rateDecreased heart rate

Nicotine WithdrawalNicotine Withdrawal

ImmediateImmediate Nicotine Replacement TherapyNicotine Replacement Therapy

Gum, Lozenge, (Inhaler)Gum, Lozenge, (Inhaler) PatchPatch

DelayedDelayed BupropionBupropion VareniclineVarenicline

Keep Nicotine Levels Close Keep Nicotine Levels Close to Comfort Zoneto Comfort Zone

http://www.esr.cri.nz/competencies/populationhealth/NRT.htm

Nicotine Levels/24 HoursNicotine Levels/24 HoursContinuous SmokingContinuous Smoking

http://images2.clinicaltools.com/images/tobaccofree/nicotine_levels.gif

Nicotine Levels/120 Nicotine Levels/120 MinutesMinutes

Single DoseSingle Dose

NicotineNicotine Cigarettes contain 6 to 11 mg of nicotineCigarettes contain 6 to 11 mg of nicotine

Smokers absorb between 1 to 3mg from Smokers absorb between 1 to 3mg from each cigarette i.e. average 2mgeach cigarette i.e. average 2mg

If a pack contains 20 cigarettesIf a pack contains 20 cigarettes 20 cigarettes x average 2mg each = 20 cigarettes x average 2mg each =

40mg/day40mg/day (1 PACK = 1 x 21 mg PATCH)(1 PACK = 1 x 21 mg PATCH)

1 Habitrol 21 patch is designed to provide 21 1 Habitrol 21 patch is designed to provide 21 mg over 24 hours of which only about 76% mg over 24 hours of which only about 76% reaches the bloodstream i.e. about 16mgreaches the bloodstream i.e. about 16mg

High Risk Smokers - High Risk Smokers - Mentally IllMentally Ill

More likely to smoke longer, be heavy More likely to smoke longer, be heavy users, smoke high tar brands with high users, smoke high tar brands with high nicotine contentsnicotine contents

And smoke that cigarette to the bitter And smoke that cigarette to the bitter endend

So likely getting more than 2mg out of each So likely getting more than 2mg out of each cigarettecigarette

Psych Services 1999. 50:1346-50

NRT FH ProtocolNRT FH Protocol

Nicotine patchNicotine patch 7 mg patch - low nicotine dependence7 mg patch - low nicotine dependence 14mg patch - moderate nicotine dependence 14mg patch - moderate nicotine dependence 21mg patch - high nicotine dependence21mg patch - high nicotine dependence

+ for moderate or high nicotine + for moderate or high nicotine dependence Nicotine 2 or dependence Nicotine 2 or 4 mg 4 mg gum or lozenge prn to a maximum of gum or lozenge prn to a maximum of 8/10 pieces respectively /24 hours8/10 pieces respectively /24 hours

DETAILED FAGERSTRŐM ASSESSMENT DETAILED FAGERSTRŐM ASSESSMENT 1. How soon after waking do you have your first cigarette?1. How soon after waking do you have your first cigarette?

Within 5 minutes (3 points) Within 5 minutes (3 points) 6- 30 mins (2 6- 30 mins (2 points) points) 31- 60 mins 31- 60 mins (1 point) (1 point) More than 1 More than 1 hour (0 points)hour (0 points)

2. Do you find it difficult to refrain from smoking in places 2. Do you find it difficult to refrain from smoking in places where it is forbidden?where it is forbidden? Yes (1 point) Yes (1 point) No (0 points) No (0 points)

3. Which cigarette would you be most unwilling to give up?3. Which cigarette would you be most unwilling to give up? First in morning (1 point) First in morning (1 point) Any others (0 points) Any others (0 points)

4. How many cigarettes, on average do you smoke per day?4. How many cigarettes, on average do you smoke per day? 31 or more 31 or more (3 points) (3 points) 21-30 (2 points) 21-30 (2 points) 11-20 11-20

(1 point) (1 point) 10 or less (0 points) 10 or less (0 points)5. Do you smoke more frequently during the first hours 5. Do you smoke more frequently during the first hours

after waking than during the rest of the day?after waking than during the rest of the day? Yes (1 Yes (1 point)point) No (0 points) No (0 points)

6. Do you smoke even if you are so ill that you are in bed 6. Do you smoke even if you are so ill that you are in bed most of the day?most of the day? Yes Yes (1 point) (1 point) No No (0 points) (0 points)

7. Assign Score: 7. Assign Score: SCORE = _________ SCORE = _________7-10 points = high 7-10 points = high nicotine dependence 4-6 points = moderate nicotine nicotine dependence 4-6 points = moderate nicotine dependencedependence

0-3 points = low nicotine dependence0-3 points = low nicotine dependence

8. Ask the patient if they feel they need assistance with 8. Ask the patient if they feel they need assistance with smoking abstinence in hospital (may not be needed if low smoking abstinence in hospital (may not be needed if low nicotine dependence).nicotine dependence). Yes Yes No No

Ottawa Heart ProtocolOttawa Heart Protocol

> 20 cigarettes/day = 21mg patch> 20 cigarettes/day = 21mg patch 10-20 cigarettes/day = 14mg patch10-20 cigarettes/day = 14mg patch < 10 cigarettes/day = 7mg patch< 10 cigarettes/day = 7mg patch

+ prn gum or inhaler+ prn gum or inhaler

Monitor for withdrawal Monitor for withdrawal symptomssymptoms

Within first day to see how they are doing, Within first day to see how they are doing, particularly if very heavy smokerparticularly if very heavy smoker

May have to increase dose of patch – doctor’s May have to increase dose of patch – doctor’s orderorder Increase by 7mg at a time and reassess Increase by 7mg at a time and reassess

Encourage use of prn gum, lozenge if not using Encourage use of prn gum, lozenge if not using and having cravings/withdrawal symptomsand having cravings/withdrawal symptoms

If smoking while on NRT it is likely the dose is If smoking while on NRT it is likely the dose is likely not high enough! likely not high enough! (or if behaviourally they have absolutely no intention (or if behaviourally they have absolutely no intention

of quitting and are accessing cigarrettes every of quitting and are accessing cigarrettes every chance they get – the patch may not be the chance they get – the patch may not be the withdrawal method of choice)withdrawal method of choice)

Nicotine Transdermal Nicotine Transdermal PatchPatch

Well absorbed Well absorbed through the skin through the skin

Onset 1-2 hoursOnset 1-2 hours Peak Peak

Habitrol® 5 to 6 Habitrol® 5 to 6 hourshours

Nicoderm® 4 hoursNicoderm® 4 hours Peak concentration: Peak concentration:

6-12 hrs6-12 hrs Plateau: 8-10 hrsPlateau: 8-10 hrs

http://www.quitsmoking.com/books/knowsmoking/chapter5.htmhttp://learn.genetics.utah.edu/units/addiction/drugs/delivery.cfm

Nicotine Transdermal Nicotine Transdermal PatchPatch

Plasma levels fall 1-2 hours after Plasma levels fall 1-2 hours after removing patchremoving patch

Duration of therapyDuration of therapy Habitrol – Taper dose by 7mg Q3-4 weeksHabitrol – Taper dose by 7mg Q3-4 weeks Nicoderm – 6,2,2Nicoderm – 6,2,2

Arbitrary stop date Arbitrary stop date NRT is much preferable and safer than NRT is much preferable and safer than

continued smokingcontinued smoking

Nicotine Transdermal PatchNicotine Transdermal Patch(Nicoderm(Nicoderm®, Nicotrol®, ®, Nicotrol®,

Habitrol®, Generics)Habitrol®, Generics) AdvantagesAdvantages

Easy to useEasy to use UnobtrusiveUnobtrusive Provides steady Provides steady

nicotine levelsnicotine levels Avoids gum side Avoids gum side

effectseffects Non-prescriptionNon-prescription

DisadvantagesDisadvantages Cannot adjust dose for Cannot adjust dose for

cravingscravings Nicotine released more Nicotine released more

slowly than other slowly than other productsproducts

Side effectsSide effects Mild skin irritation or Mild skin irritation or

sensitivitysensitivity Important to rotate sitesImportant to rotate sites Switch brands as neededSwitch brands as needed

Insomnia reportedInsomnia reported

Patch – choice of locationPatch – choice of location Choose an area on skin on upper body or the upper outer part of Choose an area on skin on upper body or the upper outer part of

arm. (UPPER & OUTER)arm. (UPPER & OUTER) To ensure that the patch will stick on well, make sure the skin is To ensure that the patch will stick on well, make sure the skin is

non-hairy, clean (not oily) dry and free of creams, lotions, oils or non-hairy, clean (not oily) dry and free of creams, lotions, oils or powder.powder.

Hair will interfere with the application of the patch and Hair will interfere with the application of the patch and should be clipped away.should be clipped away.

Do not shave the area as this may irritate the skin.Do not shave the area as this may irritate the skin. Do not put a patch on skin that is inflamed, burned, has broken out, Do not put a patch on skin that is inflamed, burned, has broken out,

or is irritated in any way, because these conditions may alter the or is irritated in any way, because these conditions may alter the amount of drug absorbed.amount of drug absorbed.

Women should not apply the patch to their breastsWomen should not apply the patch to their breasts.. Be sure to apply the patch to a different area each day. The same Be sure to apply the patch to a different area each day. The same

area should not be used again for at least one week area should not be used again for at least one week

Patch applicationPatch application Using scissors, carefully cut open the pouch along the edge.Using scissors, carefully cut open the pouch along the edge. Remove any old patches from skin, fold in half with the sticky Remove any old patches from skin, fold in half with the sticky

side inward and dispose of properly in the garbage.side inward and dispose of properly in the garbage. Remove the square shiny protective liner from the adhesive Remove the square shiny protective liner from the adhesive

side of the patch.side of the patch. Immediately apply the sticky side of the patch to the skin and Immediately apply the sticky side of the patch to the skin and

firmly press it on with the palm of your hand for 10 to 20 firmly press it on with the palm of your hand for 10 to 20 seconds.seconds.

Make sure that it is sticking well, especially around the edges.Make sure that it is sticking well, especially around the edges. It helps to clean that area of skin with alcohol wipe before It helps to clean that area of skin with alcohol wipe before

application.application. Medical adhesive tape may be used to help keep the patch on.Medical adhesive tape may be used to help keep the patch on. Wash hands with water only.Wash hands with water only. The patch should be worn for about 24 hours and be replaced The patch should be worn for about 24 hours and be replaced

everyday at about the same time. everyday at about the same time.

Patch TipsPatch Tips If insomnia or bad dreams occurIf insomnia or bad dreams occur

Take patch off at night or if on multiple patches, Take patch off at night or if on multiple patches, consider taking off one consider taking off one

Nicotine levels will drop overnight so encourage Nicotine levels will drop overnight so encourage use first thing of gum or lozenge until patch kicks inuse first thing of gum or lozenge until patch kicks in

Consider same procedure as with other Consider same procedure as with other patches i.e. extra line on MAR to indicate site patches i.e. extra line on MAR to indicate site and to document removal and to document removal

More nicotine will be released if exercising heavily More nicotine will be released if exercising heavily so suggest removal prior to exerciseso suggest removal prior to exercise

If smoking – likely dose not high enough, if If smoking – likely dose not high enough, if persistent in not choosing to quit (i.e. psychotic) persistent in not choosing to quit (i.e. psychotic) and continuing to smoke perhaps patch not best and continuing to smoke perhaps patch not best choicechoice

Nicotine Gum/Nicotine Nicotine Gum/Nicotine LozengeLozenge

http://www.quitsmoking.com/books/knowsmoking/chapter5.htmhttp://www.ennispharmacy.com/smokers.html

Buccal absorption, Buccal absorption, slowerslower 20 to 30 minutes of 20 to 30 minutes of

chewing releases 50 to chewing releases 50 to 90% of nicotine90% of nicotine

Peak plasma Peak plasma concentrationsconcentrations 15 to 30 minutes after 15 to 30 minutes after

starting chewingstarting chewing

Lozenges deliver 25 to Lozenges deliver 25 to 27% more nicotine than 27% more nicotine than gumgum

Nicotine Gum Nicotine Gum (Nicorette(Nicorette®)®)

AdvantagesAdvantages User controls doseUser controls dose Oral substituteOral substitute Non-prescriptionNon-prescription Sugar freeSugar free Delays weight gainDelays weight gain

Side effectsSide effects GastrointestinalGastrointestinal Oral disturbancesOral disturbances Jaw discomfortJaw discomfort HiccoughsHiccoughs

DisadvantagesDisadvantages Proper chewing Proper chewing

technique requiredtechnique required Cannot eat or drink Cannot eat or drink

while chewing gumwhile chewing gum Can damage dental Can damage dental

workwork Difficult for denture Difficult for denture

wearers to usewearers to use

How to use the gumHow to use the gum Place one piece of gum in mouth and chew very slowly Place one piece of gum in mouth and chew very slowly

once or twice.once or twice. Stop chewing and "Park it" between your cheek and Stop chewing and "Park it" between your cheek and

gums, and leave it there.gums, and leave it there. Wait a minute, and then repeat, "Parking" it again on the Wait a minute, and then repeat, "Parking" it again on the

opposite side of your mouth. BITE, BITE, PARK. BITE, opposite side of your mouth. BITE, BITE, PARK. BITE, BITE, PARK.BITE, PARK.

You may notice a peppery taste, or a slight tingling in You may notice a peppery taste, or a slight tingling in your mouth – this is nicotine being released and your mouth – this is nicotine being released and absorbed.absorbed.

Do not chew continuously or too quickly like ordinary Do not chew continuously or too quickly like ordinary chewing gum. Doing so may result in light-headedness, chewing gum. Doing so may result in light-headedness, nausea, hiccups or stomach upset because you are nausea, hiccups or stomach upset because you are swallowing the nicotineswallowing the nicotine

After about 30 minutes, all the nicotine will be released.After about 30 minutes, all the nicotine will be released. Discard the gum in the garbage.Discard the gum in the garbage.

Gum TipsGum Tips Slow down if you start feeling uncomfortableSlow down if you start feeling uncomfortable Do not chew more than one piece of gum at a Do not chew more than one piece of gum at a

timetime Do not use more than 20 pieces per day.Do not use more than 20 pieces per day. Avoid drinking acidic beverages such as Avoid drinking acidic beverages such as

coffee, tea, pop, alcohol or citrus fruit coffee, tea, pop, alcohol or citrus fruit juices before or during use of gum. Doing juices before or during use of gum. Doing so may affect nicotine absorptionso may affect nicotine absorption..

Consult your dentist or doctor if injury or Consult your dentist or doctor if injury or irritation to the mouth, teeth or dental work irritation to the mouth, teeth or dental work occurs. occurs.

Accidentally swallowing a piece of gum Accidentally swallowing a piece of gum shouldn't harm an adult. shouldn't harm an adult.

Nicotine lozengeNicotine lozenge Place one lozenge in mouth and allow it to Place one lozenge in mouth and allow it to

dissolve slowlydissolve slowly Do not chew or swallow – the lozenge Do not chew or swallow – the lozenge

contains a controlled amount of nicotine, contains a controlled amount of nicotine, which needs to be absorbed slowly and which needs to be absorbed slowly and gradually through the tissues in the gradually through the tissues in the mouthmouth

A tingling, or warm sensation may occurA tingling, or warm sensation may occur Occasionally move the lozenge from one Occasionally move the lozenge from one

side of the mouth to the otherside of the mouth to the other It takes about 20-30 minutes for the It takes about 20-30 minutes for the

lozenge to dissolve completelylozenge to dissolve completely

Lozenge TipsLozenge Tips

Do not eat or drink 15 minutes before Do not eat or drink 15 minutes before using, or while the lozenge is in your mouthusing, or while the lozenge is in your mouth

Do not use more than one lozenge at a time Do not use more than one lozenge at a time or continuously use one lozenge after or continuously use one lozenge after another. Doing so may cause hiccups, another. Doing so may cause hiccups, heartburn, nausea or other side effects.heartburn, nausea or other side effects.

Do not use more than five lozenges in six Do not use more than five lozenges in six hours, or more than 15 lozenges total per hours, or more than 15 lozenges total per day.day.

NRT Side Effects NRT Side Effects

Relatively few side effectsRelatively few side effects Minor side effects mild headache, Minor side effects mild headache,

appetite stimulation, constipation, appetite stimulation, constipation, diarrhea, dizziness, dysmenorrhea, diarrhea, dizziness, dysmenorrhea, flushing, insomnia irritabilityflushing, insomnia irritability

Others include hiccups, jaw ache, sore Others include hiccups, jaw ache, sore throatthroat

Of Note!Of Note! Remember – there is a lot of nicotine left Remember – there is a lot of nicotine left

in a patch (a Habitrol patch that releases in a patch (a Habitrol patch that releases 21 mg actually contains 51 mg total)21 mg actually contains 51 mg total) A 21 mg patch of Nicoderm has 114mg total A 21 mg patch of Nicoderm has 114mg total

2 mg of a 4mg piece of gum 2 mg of a 4mg piece of gum 4mg of a 10mg inhaler cartridge 4mg of a 10mg inhaler cartridge DISPOSE OF SAFELY IN GARBAGEDISPOSE OF SAFELY IN GARBAGE

Very toxic to nicotine naïve – children, animalsVery toxic to nicotine naïve – children, animals WARN parents that this is not innocuousWARN parents that this is not innocuous

Supply and ChartingSupply and Charting

Ensure ready access to gum and patch Ensure ready access to gum and patch on wardon ward Consider initial wardstock supply of bothConsider initial wardstock supply of both

If large anticipated # patients on a ward, If large anticipated # patients on a ward, consider wardstock for prn versus patient consider wardstock for prn versus patient specific specific

Consider providing a few gum or lozenges Consider providing a few gum or lozenges at a time depending upon the compliance at a time depending upon the compliance and understanding of the patientand understanding of the patient How will this be charted? How will this be charted?

Access to the inhaler?Access to the inhaler? Patients with patch allergy?Patients with patch allergy?

ConsiderationsConsiderations

Withdrawal versus toxicityWithdrawal versus toxicity DepressionDepression Drug interactions with smoking Drug interactions with smoking

cessation and resumptioncessation and resumption Cardiac risksCardiac risks Discharge planningDischarge planning

Withdrawal vs. NRT Withdrawal vs. NRT ExcessExcess

Nicotine Intoxication:Nicotine Intoxication: Pallor, diaphoresisPallor, diaphoresis Tremor, headache, Tremor, headache, dizzinessdizziness ConfusionConfusion Tachycardia, PalpitationsTachycardia, Palpitations N/VN/V//D, abdominal painD, abdominal pain HypersalivationHypersalivation

Treatment????Treatment????

Withdrawal vs. Caffeine Withdrawal vs. Caffeine toxicitytoxicity

Sudden cessation of tobacco smoking may Sudden cessation of tobacco smoking may result in reduced caffeine clearance (~ 40%)result in reduced caffeine clearance (~ 40%)

Caffeine-related side effects may occur if use Caffeine-related side effects may occur if use remains the same or increase if drink more remains the same or increase if drink more coffee for something to occupy themcoffee for something to occupy them Nausea, nervousness, irritability, Nausea, nervousness, irritability,

tremors, insomniatremors, insomniaDifferentiate between withdrawal Differentiate between withdrawal symptoms of smoking cessation and symptoms of smoking cessation and excess caffeine!excess caffeine!

Withdrawal vs. Psychiatry Withdrawal vs. Psychiatry SymptomsSymptoms

Very important to differentiate as Very important to differentiate as many symptoms overlap many symptoms overlap AnxietyAnxiety RestlessnessRestlessness IrritabilityIrritability Mood changesMood changes

DepressionDepression

Current and past depression more Current and past depression more common in smokerscommon in smokers

Experience more depressive symptoms Experience more depressive symptoms during withdrawalduring withdrawal

Increased risk of recurrent depression Increased risk of recurrent depression after stoppingafter stopping

JAMA 1990. 264:1546-9

Smoking Cessation and Smoking Cessation and Drug InteractionsDrug Interactions

Hydrocarbons in tobacco induce Hydrocarbons in tobacco induce drug-metabolizing enzymes (not the drug-metabolizing enzymes (not the nicotine) particularly CYP 1A2nicotine) particularly CYP 1A2 Can take several weeks to get to Can take several weeks to get to

maximum inhibition as well as to return maximum inhibition as well as to return to baseline following discontinuationto baseline following discontinuation

Pharmacotherapy, 1998;18(1):84-112, Psychiatric times, 2005;22(6)

Psychiatric Medications Psychiatric Medications AffectedAffected

Extent of interaction highly variable Extent of interaction highly variable

Examples include;Examples include; CaffeineCaffeine AntidepressantsAntidepressants

Imipramine, clomipramine, Imipramine, clomipramine, fluvoxaminefluvoxamine, , trazodonetrazodone

Variable effect on Amitriptyline and NortriptylineVariable effect on Amitriptyline and Nortriptyline AntipsychoticsAntipsychotics

Fluphenazine, haloperidol, Fluphenazine, haloperidol, olanzapineolanzapine, , chlorpromazine, chlorpromazine, clozapineclozapine

BenzodiazepinesBenzodiazepines Alprazolam, lorazepam, oxazepam, diazepam Alprazolam, lorazepam, oxazepam, diazepam

Desai HD et al. CNS Drugs 2001. 15(6):469-94

Clozapine and Clozapine and OlanzapineOlanzapine

Individual cases of large increases in Individual cases of large increases in serum levels with smoking cessationserum levels with smoking cessation

Consider baseline serum levels Consider baseline serum levels particularly of clozapineparticularly of clozapine

Monitor for increased adverse Monitor for increased adverse effects for the first few weeks after effects for the first few weeks after smoking cessation smoking cessation i.e.i.e. Sedation, increased drooling, Sedation, increased drooling,

dizzinessdizziness

Nicotine, Smoking and Nicotine, Smoking and DiabetesDiabetes

Tobacco smoking is known to aggravate Tobacco smoking is known to aggravate insulin resistance; Insulin absorption is slowed insulin resistance; Insulin absorption is slowed from injection sites.from injection sites.

Cessation of NRT or tobacco smoking may Cessation of NRT or tobacco smoking may decrease blood glucosedecrease blood glucose Stopping smoking will increase subcutaneous Stopping smoking will increase subcutaneous

absorption of insulinabsorption of insulin Recommend monitoring blood glucose Recommend monitoring blood glucose

concentrations when nicotine intake or smoking concentrations when nicotine intake or smoking status changesstatus changes

Dosage adjustments in antidiabetic agents may be Dosage adjustments in antidiabetic agents may be requiredrequired

Nicotine CV riskNicotine CV risk

The use of NRT is not associated with any The use of NRT is not associated with any increase in the risk of MI, stroke or deathincrease in the risk of MI, stroke or death

(N = 33,247 Hubbard 2005)(N = 33,247 Hubbard 2005) Much more rapid absorption of nicotine Much more rapid absorption of nicotine

when smokingwhen smoking Smoking produces higher nicotine peaks Smoking produces higher nicotine peaks

than NRTthan NRT Any patient who is at risk of smoking is Any patient who is at risk of smoking is

safer on NRT than continuing to smokesafer on NRT than continuing to smokehttp://www/quitsmoking.com/books/knowsmoking/chapter6.htm

At DischargeAt Discharge

If an individual resumes smoking at dischargeIf an individual resumes smoking at discharge Levels of medication (particularly clozapine and Levels of medication (particularly clozapine and

olanzapine) are likely to fall potentially resulting in olanzapine) are likely to fall potentially resulting in relapserelapse

PlanPlan Baseline serum levels of clozapine, (olanzapine)Baseline serum levels of clozapine, (olanzapine) Provide information to discharge treatment team of Provide information to discharge treatment team of

smoking statussmoking status Provide education/information to patient of Provide education/information to patient of

potential impact of changes in smoking habits and potential impact of changes in smoking habits and that they should inform their treatment team if they that they should inform their treatment team if they resume or quit smokingresume or quit smoking

Go Green

Use Clean Nicotine

GUM

PATCH

LOZENGES