smoking out tobacco use: tobacco cessation treatment ......health risks tobacco use is the leading...
TRANSCRIPT
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Smoking Out Tobacco Use:
Tobacco Cessation
Treatment
Updates
Roxane Took, PharmD
Assistant Professor, Pharmacy Practice Department
St. Louis College of Pharmacy
Golden L. Peters, PharmD, BCPS
Associate Professor, Pharmacy Practice Department
St. Louis College of Pharmacy
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Drs. Took and Peters declare no conflicts of interest, real or apparent, and no
financial interests in any company, product, or service mentioned in this
program, including grants, employment, gifts, stock holdings and honoraria.
Disclosures and Conflict of Interest
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At the conclusion of the program, the pharmacists will be able to:
1. Discuss over-the-counter (OTC) and prescription treatment options for
tobacco cessation
2. Describe the role of combination therapy for tobacco cessation
3. Explain recommendations and precautions for using electronic cigarettes
Pharmacist Objectives
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At the conclusion of the program, the pharmacy technician will be able to:
1. Discuss over-the-counter (OTC) and prescription treatment options for
tobacco cessation
2. Describe the role of combination therapy for tobacco cessation
3. Explain recommendations and precautions for using electronic cigarettes
Technician Objectives
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A customer is at your pharmacy and would like help choosing the right OTC
product for smoking cessation. She smokes ½ pack per day (ppd) with her first
cigarette when she wakes up each morning (about 15 minutes after waking).
Which is the best produce and initial dose for this patient?
a. Nicotine lozenge 4 mg (Nicorette)
b. Nicotine lozenge 2 mg (Nicorette)
c. Nicotine patch 21 mg (Nicoderm CQ)
d. Nicotine patch 7 mg (Nicoderm CQ)
Pre-Test Questions
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What is an advantage of the nicotine patch (Nicoderm CQ) over the nicotine gum
when used for combination therapy?
a. Has flexible dosing based on cravings
b. Is readily accessible since it is OTC
c. Has more consistent and faster delivery of nicotine
d. May help reduce morning cravings for a cigarette
Pre-Test Questions
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Which of the following is a contraindication for use with bupropion SR (Zyban)?
a. History of myocardial infarction
b. History of seizures
c. Uncontrolled depression
d. Concurrent use of SSRI (selective serotonin reuptake inhibitors within 14 days)
Pre-Test Questions
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True/False: Specific brands of e-cigarettes are recommended by the FDA for
smoking cessation.
Pre-Test Questions
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Background
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Epidemiology
1.3 billion smokers worldwide
Estimated that 38 million American adults smoke
Male: 17.5%
Female: 13.5%
Smoking has declined in the United States
1965: 42.5% of adults smoked
2010: 19.3% of adults smoked
2016: 15.5% of adults smoked
CDC. Smoking & tobacco use. 2018.
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Health Risks
Tobacco use is the leading cause of preventable morbidity and
mortality in the United States
Smoking leads to ~480,000 deaths/year in the United States
1 in 5 deaths/year in the United States
Nearly 6 million deaths worldwide
Roughly half of smokers will die from a tobacco-related illness
On average, smokers die 10 years earlier than nonsmokers
CDC. Smoking & tobacco use. 2018.
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Background
Economic Impact
Cigarette smoking causes $300 billion in health care cost
Direct medical expenses – $170 billion
Indirect costs – $156 billion
Tobacco companies spent $8.9 billion in marketing
CDC. Smoking & tobacco use. 2018.
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Benefits of Smoking Cessation
Smokers who quit around age of 30 gain approximately 10 years of life
expectancy
Smokers who quit after age 40 also gain life expectancy
Smokers who quit after age 80 also reduces mortality
CDC. Smoking & tobacco use. 2018.
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Benefits of Smoking Cessation
Smoking cessation is associated with substantial reduction in:
Myocardial infarction
Sudden cardiac death
Stroke
Improved coagulation parameters
Reversal of endothelial dysfunction
Slowing or reversal of atherosclerosis
Progression of peripheral artery disease
CDC. Smoking & tobacco use. 2018.
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Benefits of Smoking Cessation
After smoking cessation for…
24hrs 48hrs 2-12 wks 1 yr 5 yrs 10 yrs 15 yrs
BP
drops
Carbon
monoxide
level
in blood
returns to
normal
Circulation
and lung
function
improves
Risk of CHD is
half that of a
smoker’s
Risk of
cardiac death
is decreased
significantly
Risk of lung
cancer is half
that of a
smoker’s
Risk of CHD
and stroke is
same as
nonsmoker’s
CDC. Smoking & tobacco use. 2018.
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Therapeutic Options for
Tobacco Cessation
Source: https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm
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Behavioral counseling
Nicotine replacement therapies (NRT)
Over-the-counter products
Nicotine gum
Nicotine patch
Nicotine lozenge
Prescription products
Varenicline
Bupropion SR
Nicotine inhaler
Nicotine nasal spray
Tobacco Cessation Therapies
Treating Tobacco Use and Dependence: 2008 Update.
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Pharmacotherapy is recommended for all those trying to quit
EXCEPT for:
Pregnant/breastfeeding
Children/adolescents (restricted to > 18 years old)
Minors require a prescription
Medical contraindications
Smoking <10 cigarettes/day
Except for nicotine patch, FDA approval for light smokers, < 10
cigarettes/day
Smokeless tobacco and cigar users
No FDA indication
Tobacco Cessation Therapies
Treating Tobacco Use and Dependence: 2008 Update.
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Nicotine gum
Dosing based on time to first cigarette (TTFC)
First cigarette is within 30 minutes of waking
Nicotine 4 mg
First cigarette is greater than 30 minutes of waking
Nicotine 2 mg
Special considerations
Avoid with significant dental problems
“Chew and Park”
Smoking Cessation TherapiesTobacco Cessation Therapies
Lexicomp Online, Wolters Kluwer Clinical Drug Information, Inc.:2013; Accessed May 8, 2018.
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Nicotine lozenge
Dosing based on time to first cigarette
First cigarette is within 30 minutes of waking
Nicotine 4 mg
First cigarette is greater than 30 minutes of waking
Nicotine 2 mg
Special considerations
Do not chew or swallow, allow to dissolve
Smoking Cessation TherapiesTobacco Cessation Therapies
Lexicomp Online, Wolters Kluwer Clinical Drug Information, Inc.:2013; Accessed May 8, 2018.
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Nicotine patch
Dosing based on number of cigarettes/day
> 10 cigarettes/day
Start with 21 mg patch
< 10 cigarettes/day
Start with 14 mg patch
Special considerations
Precautions/CI – skin disease (e.g. psoriasis, eczema, atopic dermatitis)
ADRs – skin irritation, insomnia, abnormal dreams
Vivid dreams
Smoking Cessation TherapiesTobacco Cessation Therapies
Lexicomp Online, Wolters Kluwer Clinical Drug Information, Inc.:2013; Accessed May 8, 2018.
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Nicotine inhaler
Precautions/CI
Reactive airway disease
Special considerations
Hand-to-mouth action
Nicotine nasal spray
Precautions/CI
Chronic nasal disorders
Severe reactive airway
disease
Special considerations
Fastest nicotine delivery
system
Most addictive NRT
Passive administration
Smoking Cessation TherapiesTobacco Cessation Therapies
Lexicomp Online, Wolters Kluwer Clinical Drug Information, Inc.:2013; Accessed May 8, 2018.
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Bupropion SR
Precautions
Boxed warning – serious neuropsychiatric events
Contraindications
Seizure disorder
Bulimia/anorexia
History of head trauma
Dosing
150 mg daily x 3 days; then 150 mg BID x 7 – 12 weeks
Special considerations
Initiate 1 week prior to quit date
Smoking Cessation TherapiesTobacco Cessation Therapies
Lexicomp Online, Wolters Kluwer Clinical Drug Information, Inc.:2013; Accessed May 8, 2018.
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Varenicline
Precautions
Renal impairment – CrCl < 30mL/min
Boxed warning – serious neuropsychiatric events REMOVED!!!
Dosing
Days 1 – 3: 0.5 mg daily
Days 4 – 7: 0.5 mg BID
Days 8 – on: 1 mg BID
Duration of treatment = 12 weeks
Special considerations
Initiate 1 week prior to quit date
Smoking Cessation TherapiesTobacco Cessation Therapies
Lexicomp Online, Wolters Kluwer Clinical Drug Information, Inc.:2013; Accessed May 8, 2018.
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Second-line treatment options
Clonidine
Drowsiness, dry mouth, dizziness, sedation
Lower BP due to antihypertensive effect
Rebound hypertension with abrupt discontinuation
Nortriptyline
Dry mouth, light headedness, blurry vision, sedation, urinary retention
Complementary or alternative
Hypnosis
Acupuncture
Auriculotherapy
Smoking Cessation TherapiesTobacco Cessation Therapies
Lexicomp Online, Wolters Kluwer Clinical Drug Information, Inc.:2013; Accessed May 8, 2018.
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Combination therapy for
tobacco cessation
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Nicotine patch + PRN NRT (nicotine gum, lozenge, or nasal spray)
NRT + bupropion *FDA approved
Alternatives:
Varenicline + bupropion
Varenicline + NRT
Varenicline+ nortriptyline
Combination therapy options for tobacco
cessation
REFERENCES: Clinical Guidelines for Prescribing Pharmacotherapy for Smoking Cessation. Content last reviewed December 2012. Agency for Healthcare Research and Quality,
Rockville, MD. http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/prescrib.html
U.S. Public Health Service. Treating Tobacco Use and Dependence. Clinical Practice Guideline. U.S. Department of Health and Human Services. 2008. Available at
www.ncbi.nlm.nih.gov/books/NBK63952/. Accessed May 4, 2018.
The Journal of Family Practice. Smoking Cessation: What Should You Recommend? https://www.mdedge.com/jfponline/article/105467/addiction-medicine/smoking-cessation-what-
should-you-recommend/page/0/2 2016. Available at: Accessed May 11, 2018.
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Better for highly dependent smokers or those with history of severe
withdrawal
Long-acting products provide constant level of nicotine replacement, while
short-acting products provide breakthrough relief from cravings and prevents
severe withdrawal symptoms
Benefits of combination therapy for
tobacco cessation
Source: https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm
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Evidence for combination therapy for
tobacco cessation
Source: Report of the Surgeon General. The Health Consequences of Smoking – 50 Years of Progress. Available at
www.surgeongeneral.gov/library/ reports/50-years-of-progress/exec-summary.pdf. 2014. Accessed May 11, 2018.
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Evidence for combination therapy for
tobacco cessation
Source: Veterans Health Administration Pharmacy Benefits Management Services, Medical Advisory Panel, Tobacco Use Cessation
Technical Advisory Group, and Public Health Strategic Healthcare Group. Recommendations for Use of Combination Therapy in
Tobacco Use Cessation. April 2009. https://www.healthquality.va.gov/guidelines/CD/mtu/tuc_combination_therapy.pdf. Accessed
April 6, 2018.
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A 56-year old African American male presents to clinic asking for help in his first
quit attempt.
Social history: smoked ~15 cigarettes per day x 36 years (no previous attempts to
quit smoking); smokes first cigarette after breakfast (~1 hour after waking up)
Past Medical History (PMH): type 2 diabetes, hypertension, dyslipidemia,
glaucoma
Current med list: metformin 1000 mg po BID, lisinopril 10 my po daily,
fenofibrate 145 mg po daily, latanoprost 0.005% 1 drop in OS QHS
Allergies: none, intolerant to statins
What is/are the most appropriate therapy for him?
Patient Case
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• Behavioral counseling
• Nicotine replacement therapy
• Nicotine patches 21 mg x 4-6 wks, 14 mg patch/day x 2 wks, then 7 mg
patch/day x 2 wks OR
• Nicotine lozenges 2 mg: 1 lozenge every 1-2 hrs in wks 1-6; 1 every 2-4 hrs
in wks 7-9 and; 1 every 4-8 hrs in wks 10-12)
• Varenicline 0.5mg daily (days 1-3), 0.5mg BID (days 4-7) and 1 mg BID for the
remainder of 12 wks (started 1 week prior to quit date)
• Bupropion 150mg daily x 3 days; then 150mg BID x 7 – 12 weeks (started 1
week prior to quit date)
• Combination therapy, nortriptyline, clonidine
• E-cigarettes???
Patient Case
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Electronic Cigarettes
https://www.fda.gov/tobaccoproducts/labeling/productsingredientscomponents/ucm456610.htm
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First introduced in the United States in 2007
Electronic cigarettes
E-cig
E-cigarette
ENDS (electronic nicotine delivery system)
E-hookahs
Vape pens
Tank systems
Background
PL Detail-Document. Pharmacist’s Letter. 2014.
e-cigarettes.surgeongeneral.gov/
Wynn WP III, et al. J Pharm Pract. 2012;25(6):591-9.
Drew AM, et al. Am Fam Phys. 2014.
smokefree.gov/quitting-smoking/e-cigs-menthol-dip-more/what-we-know-about-e-cigarettes
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There are more than 250 e-cigarette brands available
Major tobacco companies have entered into the e-cigarette market
Using an e-cigarette is sometimes called “vaping”
E-cigarettes can be used to deliver marijuana and other drugs
Background
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Estimated 2.5 million e-cigs users
E-cigarette sales
2011 – $250 million
2012 – $500 million
2013 – $1 billion
2014 – $1.5 billion
2015 – $1.9 billion
2016 - $2.35 billion
2017 – $2.9 billion
2018 estimated $3.6 billion
Background
Palazzolo DL. Front Public Health. 2013;1(56):1-20.
Wynn WP III, et al. J Pharm Pract. 2012;25(6):591-9
https://www.statista.com/statistics/285143/us-e-cigarettes-dollar-sales/
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Many smokers use e-cigarettes for smoking cessation
E-cigarettes are gaining popularity
Novel approach to smoking cessation
Data is currently lacking regarding safety and efficacy
E-cigarettes lack FDA approval for smoking cessation aids
Background
Bullen C, et al. Lancet. 2013;382(9905):1629-37.
Drew AM, et al. Am Fam Phys. 2014.
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Epidemiology
MMWR Morb Mortal Wkly Rep 2017;66:597–603.
CDC. MMWR. 2013;62(35):729-30.
https://www.drugabuse.gov/publications/drugfacts/electronic-cigarettes-e-cigarettes
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E-cigarettes are still fairly new
Long-term health effects is undetermined
While e-cigarettes may be less harmful than regular cigarettes, this does not
mean that they are harmless
Early evidence suggests that e-cigarette use may serve as an introductory
product for preteens and teens who then go on to use other tobacco products
E-cigarette use exposes the lungs to a variety of chemicals, including those
added to e-liquids, and other chemicals produced during the
heating/vaporizing process
Precautions
smokefree.gov/quitting-smoking/e-cigs-menthol-dip-more/what-we-know-about-e-cigarettes
https://www.drugabuse.gov/publications/drugfacts/electronic-cigarettes-e-cigarettes
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Studies have shown:
Some e-cigarette products contain
Carcinogens
Toxins
Toxic metals
Nickel
Chromium
Cadmium
Precautions
smokefree.gov/quitting-smoking/e-cigs-menthol-dip-more/what-we-know-about-e-cigarettes
https://www.drugabuse.gov/publications/drugfacts/electronic-cigarettes-e-cigarettes
https://www.cdc.gov/tobacco/basic_information/e-cigarettes/index.htm
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Poison Control Center
E-cigarette Device and Liquid Nicotine Reported Exposures to Poison Centers
Most frequent calls – related to persons 0 to 5 years old
Background
PL Detail-Document. Pharmacist’s Letter. 2014.
http://www.aapcc.org/alerts/e-cigarettes/
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E-cigarette Components
Common components of e-cigarettes
Battery
Cartridge containing solution
Atomizer (heating element, creates vapor)
Source: http://www.icig.ca/
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E-cigarette Mechanism
Air is drawn through the device
Activating the airflow sensor
Heating element is activated in the atomizer
Solution is heated to create water vapor
Small light is at the end of some devices to simulate a flame
Source: http://starfocal.com/category/electronic-cigarette/
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E-cigarette Design
There are 4 common styles of e-cigarettes
Disposable e-cigarette
Rechargeable e-cigarette
Pen-style, medium sized rechargeable e-cigarette
Tank-style, large sized rechargeable e-cigarette
Grana R, et al. Circulation. 2014:129:1972-86.
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E-cigarette Design
Disposable e-cigarette
Cigarette shaped devices
Not rechargeable or refillable
Discarded after solution runs out
Brand names
NJOY, OneJoy, FlavorVapes
Grana R, et al. Circulation. 2014:129:1972-86.
Source: http://www.cia-on-campus.org/disposables/flavor-vapes/
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E-cigarette Design
Rechargeable e-cigarettes
Cigarette shaped device
Rechargeable
Refillable
Regulator for puff duration and frequency
Brand names
Blu, GreenSmoke, EonSmoke
Grana R, et al. Circulation. 2014:129:1972-86.
Source: http://store.blucigs.com/rechargeables/
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E-cigarette Design
Pen-style, medium-sized rechargeable e-cigarette
Larger than a cigarette
Higher capacity battery
Prefilled or refillable cartridge
Regulator for length and frequency of puffs
Brand names
VaporKing, Storm, Wicked, Tornado
Grana R, et al. Circulation. 2014:129:1972-86.
Source: http://www.bestecig.com/product_view.asp?id=2
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E-cigarette Design
Tank-style, large sized rechargeable e-cigarettes
Much larger than a cigarette
High capacity battery
Large, refillable cartridge (tank)
Regulator for length and frequency of puffs
Easily modified/customized
Brand names
Volcano, LavaTube
Grana R, et al. Circulation. 2014:129:1972-86.
Source: http://www.volcano-ecigs.dk/
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Juuling = vaping
Juul is a manufacturer of an e-cigarette
Makes up ~33% of the e-cigarette market
Don’t look like traditional e-cigarettes
Difficult for parents and teachers to identify
1Juul cartridge = nicotine in 1 pack of cigarettes
Intended for adults per Juul CEO
Statement from FDA Commissioner (April 24, 2018):
New enforcement actions and a Youth Tobacco Prevention Plan to stop
youth use of, and access to, JUUL and other e-cigarettes
Electronic Cigarettes
Juul ®
https://www.fda.gov/newsevents/newsroom/pressannouncements/ucm605432.htm
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Source:
www.juul.com
https://www.drugabuse.gov/publications/drugfacts/electronic-cigarettes-e-cigarettes
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E-cigarette Components
E-cigarette solution (e-juice)
Concentrations can vary
Toxins
Nicotine
Nicotine-free
E-cigarettes can contain:
Flavors
Chocolate, caramel,
strawberry, bubble gum,
menthol, tobacco, coffee, cola,
Belgian waffle
Nicotine
Additives
Nicotine free
Herbal extracts
Vitamin supplements
Benowitz NL, et al. JAMA. 2013;310(7):685-6.
Drew AM, et al. Am Fam Phys. 2014.
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FDA Tobacco Regulations
FDA now regulating:
Electronic cigarettes
Hookah
Cigars
Pipe tobacco
New requirements:
Must be > 18 y.o.
No free samples
No vending machine sales (except in adult only locations)
www.fda.gov/downloads/TobaccoProducts/AboutCTP/UCM580536.pdf
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FDA Tobacco Regulations
Specific requirements for manufacturers:
Register establishment and list of products manufactured
Report ingredients
Place warning statements on packages and advertisements
No modified risk claims
i.e. “light”, “low”, or “mild”
Future Regulations (2019):
Premarket application and review for all new tobacco products
Report quantities of harmful or potentially harmful contents
https://www.fda.gov/TobaccoProducts/GuidanceComplianceRegulatoryInformation/Manufacturing/default.htm
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E-cigarettes
www.cdc.gov/tobacco/basic_information/e-cigarettes/index.htm
Grana R, et al. WHO. 2013.
who.int/fctc/cop/cop7/FCTC_COP_7_11_EN.pdf
WHO Tobacco Free Initiative Statement. Accessed 7/14/14.
Bhatnagar A, et al. Circulation. 2014 Aug 24. [Epub ahead of print]
heart.org/idc/groups/heart-public/@wcm/@global/documents
lung.org/e-cigarettes. May 10, 2018.
Organization Position
CDC • E-cigarettes have the potential to benefit adult smokers that
substitute use of cigarettes
WHO • “Until deemed safe, effective and of acceptable quality by a
regulatory body, “consumers should be strongly advised not to
use… electronic cigarettes.”
AHA • Clinicians should recommend proven smoking cessation therapies
first line; if patients fails, rejects or is intolerant to conventional
therapy consider using.
• Must set quit date for e-cigarettes
ALA • E-cigarettes are tobacco products
• Patients that want to quit should use proven safe and effective
methods, not electronic cigarettes
ALL:
• More research is needed regarding: characteristics of e-cigarettes, environmental
health, public health, safety and efficacy.
• Concerned about the impact on public health in youth
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Place in Therapy
Patients seeking advice on e-cigarettes
Sign of patient’s readiness to quit
Provide support for the quit attempt
Advice should not undermine their motivation
Encourage evidence-based treatments
Smoking cessation counseling
Approved prescription products
Approved NRT
Grana R, et al. Circulation. 2014;129:e490-2.
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Place in Therapy
Patients using e-cigarettes for smoking cessation
Support the quit attempt
Encourage patient to quit all tobacco products
Inform patient about e-cigarettes
Not FDA-approved for smoking cessation
Insufficient safety and efficacy data
No conclusive scientific evidence on the effectiveness of e-cigarettes for
long-term smoking cessation
Not enough data exists on the safety of e-cigarettes
Grana R, et al. Circulation. 2014;129:e490-2.
www.drugabuse.gov/publications/drugfacts/electronic-cigarettes-e-cigarettes
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A 56-year old African American male presents to clinic asking for help in his first
quit attempt.
Social history: smoked ~15 cigarettes per day x 36 years (no previous attempts to
quit smoking); smokes first cigarette after breakfast (~1 hour after waking up)
PMH: type 2 diabetes, hypertension, dyslipidemia, glaucoma
Current med list: metformin 1000 mg po BID, lisinopril 10 mg po daily,
fenofibrate 145 mg po daily, latanoprost 0.005% 1 drop in OS QHS
Allergies: none, intolerant to statins
Can we recommend e-cigarettes?
Patient Case
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Questions??
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A customer is at your pharmacy and would like help choosing the right OTC
product for smoking cessation. She smokes ½ ppd with her first cigarette when
she wakes up each morning (about 15 minutes after waking). Which is the best
produce and initial dose for this patient?
a. Nicotine lozenge 4 mg (Nicorette)
b. Nicotine lozenge 2 mg (Nicorette)
c. Nicotine patch 21 mg (Nicoderm CQ)
d. Nicotine patch 7 mg (Nicoderm CQ)
Pre-Test Questions
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What is an advantage of the nicotine patch (Nicoderm CQ) over the nicotine gum
when used for combination therapy?
a. It has flexible dosing based on cravings
b. It is readily accessible since it is OTC
c. It has more consistent and faster delivery of nicotine
d. May help reduce morning cravings for a cigarette
Pre-Test Questions
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Which of the following is a contraindication for use with bupropion SR (Zyban)?
a. History of myocardial infarction
b. History of seizures
c. Uncontrolled depression
d. Concurrent use of SSRI (selective serotonin reuptake inhibitors within 14 days)
Pre-Test Questions
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True/False: Specific brands of e-cigarettes are recommended by the FDA for
smoking cessation.
Pre-Test Questions
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NRT should not be used in the following scenarios:
o Pregnant patients
o < 18 years old
o Medical contraindications
o < 10/cigs per day (except nicotine patch)
o Smokeless tobacco or cigar users
OTC NRT products:
o Nicotine gum – dosed based on TTFC
o Nicotine lozenge – dosed based on TTFC
o Nicotine patch – number of cigs/day
Prescription products:
o Bupropion and varenicline
TAKE HOME POINTS
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Combination therapy options
o Patch + nicotine gum or lozenge or spray
o NRT + Bupropion
Electronic cigarettes
o Long term effects have not been established
The FDA now regulates electronic cigarettes
Statements regarding electronic cigarettes have been made by
numerous organizations (CDC, WHO, AHA, and ALA) with the consensus that
not enough data is available regarding e-cigarette use for tobacco cessation
TAKE HOME POINTS
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CDC. Smoking & tobacco use. 2018.
https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm
Treating Tobacco Use and Dependence: 2008 Update.
Lexicomp Online, Wolters Kluwer Clinical Drug Information, Inc.:2013; Accessed May 8, 2018.
Clinical Guidelines for Prescribing Pharmacotherapy for Smoking Cessation. Content last reviewed December 2012.
Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/clinicians-
providers/guidelines-recommendations/tobacco/prescrib.html
U.S. Public Health Service. Treating Tobacco Use and Dependence. Clinical Practice Guideline. U.S. Department of
Health and Human Services. 2008. Available at www.ncbi.nlm.nih.gov/books/NBK63952/. Accessed May 4, 2018.
The Journal of Family Practice. Smoking Cessation: What You Should You Recommend?
https://www.mdedge.com/jfponline/article/105467/addiction-medicine/smoking-cessation-what-should-you-
recommend/page/0/2 2016. Available at: Accessed May 11, 2018.
Report of the Surgeon General. The Health Consequences of Smoking – 50 Years of Progress. Available at
www.surgeongeneral.gov/library/ reports/50-years-of-progress/exec-summary.pdf. 2014. Accessed May 11, 2018.
Resources & References
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Veterans Health Administration Pharmacy Benefits Management Services, Medical Advisory Panel, Tobacco Use
Cessation Technical Advisory Group, and Public Health Strategic Healthcare Group. Recommendations for Use of
Combination Therapy in Tobacco Use Cessation. April 2009.
https://www.healthquality.va.gov/guidelines/CD/mtu/tuc_combination_therapy.pdf. Accessed April 6, 2018.
PL Detail-Document. Pharmacist’s Letter. 2014.
https://e-cigarettes.surgeongeneral.gov/
Palazzolo DL. Front Public Health. 2013;1(56):1-20.
Wynn WP III, et al. J Pharm Pract. 2012;25(6):591-9
Bullen C, et al. Lancet. 2013;382(9905):1629-37.
Drew AM, et al. Am Fam Phys. 2014.
WHO Tobacco Free Initiative Statement. Accessed 7/14/14.
Bhatnagar A, et al. Circulation. 2014 Aug 24. [Epub ahead of print]
heart.org/idc/groups/heart-public/@wcm/@global/documents
http://www.lung.org/stop-smoking/smoking-facts/e-cigarettes-and-lung-health.html. Accessed May 10, 2018.
Resources & References
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MMWR Morb Mortal Wkly Rep 2017;66:597–603.
CDC. MMWR. 2013;62(35):729-30.
https://www.drugabuse.gov/publications/drugfacts/electronic-cigarettes-e-cigarettes
https://smokefree.gov/quitting-smoking/e-cigs-menthol-dip-more/what-we-know-about-e-cigarettes
https://www.cdc.gov/tobacco/basic_information/e-cigarettes/index.htm
PL Detail-Document. Pharmacist’s Letter. 2014.
http://www.aapcc.org/alerts/e-cigarettes/
Wynn WP III, et al. J Pharm Pract. 2012;25(6):591-9.
Drew AM, et al. Am Fam Phys. 2014.
Grana R, et al. Circulation. 2014:129:1972-86.
Benowitz NL, et al. JAMA. 2013;310(7):685-6.
www.fda.gov/downloads/TobaccoProducts/AboutCTP/UCM580536.pdf
Resources & References
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Speaker Contact InformationRoxane Took, PharmD
Golden Peters, PharmD, BCPS