Tobacco Cigarettes

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Quick Facts

Tobacco is a plant grown for its leaves, which are dried and fermented before being put in tobacco products. Tobacco contains nicotine, the ingredient that can lead to addiction. People can smoke, chew, or sniff tobacco.
Nicotine acts in the brain by stimulating the adrenal glands to release the hormone epinephrine (adrenaline) and by increasing levels of the chemical messenger dopamine.
Tobacco smoking can lead to lung cancer, chronic bronchitis, and emphysema. It increases the risk of heart disease, which can lead to stroke or heart attack. Smoking has also been linked to other cancers, leukemia, cataracts, and pneumonia. Smokeless tobacco increases the risk of cancer, especially mouth cancers.
Secondhand smoke can lead to lung cancer and heart disease as well as other health effects in adults and children.
For many who use tobacco, brain changes brought on by continued nicotine exposure result in addiction.
Nicotine overdose is possible, though it usually occurs in young children who accidentally chew on nicotine gum or patches or swallow e-cigarette liquid. Anyone concerned that a child or adult might be experiencing a nicotine overdose should seek immediate medical help.

Treatment Considerations

The only reason why I’m mentioning cigarettes is due to the 99% of the substance abuse population smoking cigarettes or people in general. They try to cope, struggle to quit other habits, and it’s one of the hardest things to overcome. Some people say it’s easier to give up drugs compared to cigarettes so don’t press a person too hard.

Prepare for relapses. A patient may not even think it’s a problem or care, but we can still address it because we have to. There are a few precautions to take due to a person smoking and with medications. I’m going to discuss some considerations and options.

Tobacco is a CYP inducer: which means it can decrease certain Rx levels (see graphic below). Since medications are sometimes dosed with consideration that the patient is a smoker, it’s important to make appropriate dosage adjustments when trying to initiate smoking cessation measures. A specific CYP450 enzyme induced by smoking is CYP1A2. Common medications that are substrates of this enzyme include3: Duloxetine (Cymbalta), Caffeine, Clopidogrel (Plavix), Clozapine (Clozaril), Cyclobenzaprine (Flexeril), Diazepam (Valium), Haloperidol (Haldol), Mirtazapine (Remeron), Naproxen (Aleve), Nortriptyline (Pamelor), Olanzapine (Zyprexa), Ondansetron (Zofran), Propanolol (Inderal), Ropinirole (Requip), Theophylline (Theo-24)Since these medications are substrates of the enzyme being induced (CYP1A2), smoking will lower the drug concentration of the medication along with its efficacy in most cases. –Pharmacy Times
Don’t use olanzapine (in particular): when I inherit patients that have been on their medications, I try not to change things but when the person feels like the medication isn’t working or whatever, just get rid of it. With olanzapine, if your patient smokes, don’t even start it or get them off of it even if they’re mildly smoking. SGA’s have major side effects and increasing the dose (since the person smokes) may worsen the effects. If the dose is too low, it may not work so I would leave it alone.
Encourage bupropion: I have many patients taking bupropion and have at least cut back on smoking. Some patients even tell me that bupropion makes the cigarette taste weird and funny. I also tell people it reduces cravings so you may lose weight so sometimes the patient gets excited and quickly gets on board. Caution if the person has an SZ disorder, ETOH addictions, or prior poor response. Quick Side Note; if the patient regularly drinks (>2-3 drinks/day), I try to avoid this medication because patients usually tell me that it makes them sick but probably because the liver is getting beat up…
Target cravings: cravings and basically life, in general, will cause anxiety or a need to smoke so while targeting any addiction, give PRN options to decrease the anxiety and hopefully prevent other bad habits. Improve stress management.

Standard Treatments for Smoking Cessation

Nicotine Replacement Therapies (NRTs): the first medications the U.S. Food and Drug Administration (FDA) approved for use in smoking cessation therapy. Current FDA-approved NRT products include chewing gum, transdermal patch, nasal sprays, inhalers, and lozenges. NRTs deliver a controlled dose of nicotine to relieve withdrawal symptoms while the person tries to quit.
Other Medications: Bupropion (Zyban®) and varenicline (Chantix®) are two FDA-approved non-nicotine medications that have helped people quit smoking. They target nicotine receptors in the brain, easing withdrawal symptoms and blocking the effects of nicotine if people start smoking again.

–NIDA

More Personal Thoughts

Stahl’s and CARLAT both present smoking as an isolated issue but, of course, people are not in your office for “smoking cessation”. CARLAT at least has dosages but you can look that up online so here are some basic real-life applications:

Nicotine Gum/Patches: my patients have state insurance and it’s not covered. I don’t even talk about them… you can also put Zyban and varenicline (Chantix) in the same category. The generic, bupropion, is normally covered and cheaper.
Varenicline (Chantix): caution if your patient has a hx of being in the military, PTSD, SI, poor sleep, and night terrors. FDA took away the black box warning; an advisory panel voted 10-9 in support of removing the black-box warning from varenicline [in 2016]. It was originally added by the agency in 2009- NEJM. FYI that’s not a reassuring vote lol. A few of my patients had some bad psychological experiences with it. I would just avoid it to be on the safe side.
Lastly, keep targeting mood symptoms while avoiding certain medications. Make sure the patient is ready to QUIT and you’re not dealing with a brick wall and then try to PRN meds to deal with breakthrough cravings and anxiety/moods.