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Doctors' Answers to "Frequently Asked Questions" - Smoking

These comments are made for the purpose of discussion and should NOT be used as recommendations for or against therapies or other treatments. An individual patient is always advised to consult their own physician.

[posted 08/5/2000]
Question: I am interested in quitting smoking. With Zyban I had many bad side effects: crying, insomnia etc... I am very interested in some new drugs I have recently read about:clonidine and mecamylamine. Could I get some info and how hard will it be for my doc to presicbe these for me? I am an otherwise healthy 34 year old woman. Thank you in advance for your reply.

Answer: Clonidine is an central alpha blocker first used intreating hypertension. Subsequently, it became clear of it's advantages in blocking symptoms of different kinds of drug withdrawals. First used in narcotic addiction, it is often used with different drug withdrawals to block the symptoms. It will not particularly affect the craving like Zyban can. But, can be helpful. Side effects are sedation, constipation, dry mouth. Start with 0.1 mg at bedtime. If that works it does come in a patch which lasts a week, and some start with the patch increasing it as you can tolerate the side effects. I have not been impressed with mecamylamine(Inversine) but worth a try if clonidine is not helpful.

[posted 03/30/2000]
Question: Dear Doctor !
I have a friend who is 26, and been smoking ever since he turned 12.

These days he happend to find out that he is unable to imprgnate his wife due to sterility.

I happend to hear a conversation mentioning that there is apossability of a connection between smoking & sterility.

I would like to know if there is, It might couse him to quit.

Thank you.
Gadi K.

Answer: No connection that I am aware of.

[posted 11/13/1999]
Question: Hi. I am a 24 year old female who would like to quit smoking. I went on Wellburtin for one month, only to find out that I am allergic to it and had to be taken off. I subsequently was put on Paxil, but due to my hypersensitive system, experienced bad nausea, vomitting, diarrhea, etc. and took myself off of it. I am extremely concerned about weight gain and know that many anti-depressant medications cause weight gain. I was wondering if you could recommend an ant-depressant to help me quit smoking that had the most minimal side effects and minimal weight gain/weight loss in the majority of its patients. If there exists no such thing, what do you think the best method is for me to quit smoking? I have tried to do it on my own since going off the Paxil (now, one month) and it is not working at all.

Answer: I assume you have tried to replace the nicotine while you stop? You can do this with the patch, gum etc. There are two parts of smoking addiction. One is the social aspect(I always smoke when I drink or with coffee, office break etc.) The other is nicotine. Try breaking one at a time. That is use nicotine to break the social aspect and then go for the nicotine. Clonidine a blood pressure pill is sometimes helpful in withdrawal and won't cause weight gain, (drowsiness is it's problem). Focus on your emotional needs and keep at it.

Smoking Tree Leaves [posted 1/6/99]
Question: My friend from school smokes leafs from trees and says it tastes good. Is this harmful? Is it more or less harmful than cigarettes? I know this sounds strange, but please tell me if he is harming himself?

Answer: It always amazes me that people will voluntarily put things into their bodies from a recreational perspective that they would sue any polluter or drug manufacturer that did it. Every inhaled smoke damages lung function. However, the exact risk depends on the type of tree.

Nicotine & Haldol [posted 11/5/98]
Question: I have been told that nicotine causes the liver to use up the Haldol in the body there by leaving the patient with none in the system to help them. We have been told to give a small amount (.25 mm in my sons case) after each cigerette to put some back in his system. How much time should we wait after the cigerette before we give it to him?

Answer: It does change the metabolism;but not necessary to change the dosing a great deal with each cigarette. This is micromanaging.

Nicotine Patch Doses [posted 11/4/98]
Question: I have a client who smokes " roll your own " cigarettes.He is not sure how many a day. Does he start on nicotine patches 21 mg/day as with cigarette smokers with a 20/day habit.I 'm not sure how the nicotine levels of these 2 types of cigarette compare?

Answer: Usually higher;but, I'd start with the 21 mg and see the result.

Is Zyban Suggested for One Pack per Day Smoker [posted 10/28/98]
Question: For a one-pack a day smoker, what is your best quit-therapy Zyban alone or Zyban plus nicotine-patch and for how long.

Answer: Start with the Zyban, if you fail try the combo.

Zyban [posted 10/9/98]
Question: I am a 25+ year smoker with as many failures in traditional smoking cession programs. I decided to try again an my GP recommended Zyban with a Nicotine transdermal patch. My concer is siezure potential and drug interaction. I have had only two siezures (cause undetermined) since 1982, the last 8 years ago. I still take the Dilantin as a "insurance" as one siezure ocurred when serum level was 3.2 ug/dl (it is now 18.6 ug/dl). My GP does not consider Zyban to be an elevated risk, my neurologist does not recommend Zyban for anyone how has ever had a siezure. Does my situation appear to present significant risk compared to the definite risk of smoking? Can the risk be minimize by anything other then adhering to the dosage schedule? Can Zyban and Dilantin interact?

Answer: Zyban does have increased risk of seizure and is relatively contraindicated in patients with a seizure disorder. I know of no reaction between Zyban and Dilantin,but, you need to watch your dilantin levels closely when starting an additional drug. However, I would not recommend Zyban for you.

Wellbutrin and Prozac [posted 7/30/98]
Question: I was on Prozac, 40 mg per day , since it first came on the market and have done very well with it. My GP recently took me off of Prozac and put me on Wellbutrin to help in smoking cessation. He had me wait three days after stopping the Prozac to begin the Wellbutrin. The problem is that the Wellbutrin has seemed to have been giving me a lot of blotchy looking skin and a lot of itching. I need to know how long I should wait before going back on my Prozac. I have only been on the Wellbutrin for about 4 weeks and I have been crying every day and itching all over on a daily basis.

Answer: About one week should be sufficient.

Smoking Cessation Medication [posted 7/27/98]
Question: I was thinking about asking my doctor for Zyban or of course Welbutrin for smoking cessation. I am concerned about the withdrawal effects. I was given another antidepressant for headaches - Paxil, and had a very bad time coming off of it. I had dizziness, I felt like I was being shocked all of the time, every time I moved my eyes I had a rushing sound in my ears, my hands were going numb, etc. Anyway, before I ask for this medication, I want to be certain that this will not happen again, as it was very distressing and my doctor did nothing to alleviate the problem except tell me to keep taking the Paxil, which I did not agree with so I weaned myself off of this. Since my doctor does not seem to want to answer my questions or have time for my questions I am asking you for any information you may have.

Answer: Completely different class of drug, so it is hard to know if you would have troubles stopping it. Usually, you can use somewhat lower doses with nicotine stoppage than in depression.

Smoking Cessation Medication [posted 7/24/98]
Question: My wife is currently taking Zyban to help quit smoking, but also heard of a drug called Rebea. Any information on this would be greatly appreciated.

Answer: Must be an OTC, as I’m not aware of it. Do you have a generic name?

Nicotine replacement
Question: I'm looking for recent information about use of nicotine replacement during pregnancy.

Answer: That study has been done with cigarettes as the source of the nicotine. The nicotine patch or nicotine gum may have slightly less effects, but probably similar. The addition of nicotine will decrease the placental size and oxygen carrying capacity of the blood. Consequently, the babies of smokers are about 1/2 to 1 pound lighter and tend to have earlier onset of labor by two weeks or so on average. The birth scores of nicotine babies are slightly less than non-nicotine babies. One does not apparently see the developmental problems that alcohol causes, but further research is in progress.

Smoking Cessation
Question: Now that Nicoderm patches have gone OTC, how do you know when to suggest to a patient to consider nicotine replacement therapy?

Answer: Whether to use a drug has little with its availability. The cessation rate for stopping smoking is about 10-15%. This rises about 5% or so with the use of nicotine patches. This is particularly true of those patients who are truly nicotine addicted versus socially addicted. That is, some patients smoke at predictable times dictated by social parameters.(Breaks, parties, first cup of coffee, etc.). Others are “climbing the walls” with any cessation of nicotine intake. This is the best group to use patches, although both groups will benefit.

Nicotine In Blood
Question: How long does nicotine remain in your system(if you are trying to quit) how long after you quit would it not show up in blood or urine?

Answer: Nicotine will be out of your system in 48 hours or so. It is usually detectable in urine for 3-4 days depending on the sensitivity of the test.

Second Hand Smoke
Question: How bad can smoke effect someone who doesn’t smoke when they’re in a well vented room with a smoker.

Answer: A lot of debate here. There are two potential effects. The first is the immediate effect. It is clear that children exposed to smoking parents will have higher rates of respiratory illness. Also, the susceptibility of the non-smoker to asthma in particular will vary widely. Some patients will have severe asthma triggered by minimal smoking -others with no trigger with heavy smokers. Long term there appears to be a higher risk of lung cancer and heart disease in spouses of smokers; but, there is heavy debate here.

Quit Smoking
Question: How can I stop smoking?

Answer: I recommend to patients to follow certain steps. First, decide if you really want to stop. This should be an emotional decision not an intellectual one. Second, find something in your emotional inventory that you prefer/fear more than smoking. For example, losing control of your life with a stroke or seeing your children suffer after your death. Then use the emotional focus to help the decision to stop. Set a date known only to yourself-make it an emotional memory that is important to you. Finally, try to break the habits associated with smoking in the six weeks leading to the stop date. For example, if you habitually smoke with coffee-don't smoke for one week with coffee to break the associative habit. Finally, when you stop throw the cigarettes away-if you need nicotine supplements use them they help 20% or so of patients. Finally, reward yourself with something you would not do with the proceeds of not smoking. That is save it in a jar with a picture of Hawaii or whatever on the jar where you can see it. Focus on the emotions of your life that are stronger than your need to smoke. They will break the habit with you.

Drug Combinations
Question: What durgs are avalable that take the cravings away in combination with the patch?

Answer: Smoking cessation can be one the most difficult tasks you will ever choose to undertake. However, should you succeed, the rewards are many. Improved cardiovascular function, improved energy level, as well as a lower risk of heart and lung disease, cancer, stroke, are all amongst the benefits obtained down the road, in those who quit smoking tobacco. Quitting is not easy, and the majority of those who do quit successfully require more than one attempt. As a physician, I am pleased to see that you have taken the first and most important step- to decide to quit. The next important step is to find an ally- a friend, spouse, co-worker, or any person in your life that you can count on to be there when the cravings hit, when you start to think about smoking again, and to keep you away from tobacco when things get difficult. Your physician should not only be involved in this process, but if you choose, can be depended on to serve as your “coach” or ally, until you break the habit. There are many different options available to aid in smoking cessation. Each has its advantages and drawbacks, and the final option you choose should be the result of a discussion with your physician, so that the regimen is tailored to your specific needs, and will maximize the possibility of success. The first thing I tell my patients to do is to first get rid of the tobacco - from the house, the car, the workplace- all of it. I encourage them to put the daily cash that would have gone towards tobacco purchases, into a jar in the kitchen, so they can find some motivation from the fact that this money can be put towards something they may really want. The first and oldest quitting technique is the so called “cold turkey” approach, in which you just simply stop entirely- no weaning or slow reductions in the amount you smoke. In people who are well motivated this technique has a surprisingly high rate of success, but relies heavily on outside support. The medication options currently available include nicotine patches or gum (both of which simply replace nicotine, and then require slow weaning of these agents) as well as non-nicotine pills. These pills are designed to do what you asked about- they take away the craving, or that “rush”, or intense need for smoking. These are fairly new medications and the long term success studies are not as numerous, but early data suggests some success. You should know that all of these drugs, like all medications, have side effects, which can be serious depending on whether you have any other medical problems. These pills are available through your physician (one of them goes by the generic name “bupropion”, and is also used in different doses to treat depression), who can discuss a plan for quitting with you, and provide you with additional information to help you make the right medication choice. Good luck!

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