Pocket Guide CVR october_Layout 1 4/10/12 3:54 PM Page C1

Why Quit Using ? We are here to help!

American Association for Respiratory Care Tobacco-Free Lifestyle Roundtable and American Respiratory Care Foundation Pocket Guide CVR october_Layout 1 4/10/12 3:54 PM Page C2 Pocket Guide Interior October_Layout 1 12/20/19 2:26 PM Page 1

PATIENT GUIDE TO CESSATION

Produced by members of the AARC Tobacco-Free Lifestyle Roundtable

Jonathan Waugh PhD, RRT, Roundtable Chair Gaylene Lee MEd, RRT, TTS, Coordinator Michael Anders PhD, RRT Robert Fluck Jr MS, RRT Alisa French MBA, RRT-NPS, AE-C Jody O'Farrell RRT, AE-C, TTS-C Jan Salo-Korby RRT, AE-C Karen Schell MHSc, RRT-NPS, CTTS Steven Schroeder MD Jay Taylor RRT, TTS Laura Van Heest RRT, NCTAS

Steven Nelson MS, RRT, AARC Liaison

Copyright ARCF, 2010

Printing and distribution provided by ARCF through a patient education grant from Pfizer

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TOP FIVE REASONS FOR QUI TTING 1. YOUR HEALTH • The two forms of COPD (Chronic Obstructive Pulmonary Disease), chronic bronchitis and emphysema, are high on the list of risks of smoking tobacco. These two diseases would diminish drastically if everyone stopped smoking. Smoking causes over 90% of all cases of COPD. • Smoking increases the risk of blood clots, which can lead to a heart attack or stroke. • Smoking makes it almost impossible to keep asthma under control. Each time a person lights up, it can trigger an asthma attack. • Smoking can lead to diseases of the blood vessels outside the heart and brain. Poor circulation can lead to the removal of toes, feet, and even parts of a leg. • Smoking decreases the amount of oxygen delivered to the body due to the presence of a gas called carbon monoxide (CO). Carbon monoxide is present in smoke from any source. People who die in a fire most often perish because of CO poisoning. When CO is in the blood, it takes the driver’s seat, and oxygen takes the back seat. As CO increases, oxygen decreases. As a result, people who smoke become increasingly short of breath. • If you have diabetes and use any form of tobacco, it may be very difficult to control your blood sugar. • If you use tobacco and have surgery, you may not heal as fast due to the and carbon monoxide in your body. • Burning tobacco produces more than 4,000 harmful chemicals, some 60 of which are known to cause cancer including, but not limited to, these organs: • Lung: Ninety percent (90%) of all lung cancer is due to smoking. – Lung cancer is the number one cancer killer for both men and women. • Mouth, larynx (voice box), pharynx, and esophagus (the tube that takes food from your mouth to your stomach) • Pancreas, kidney, stomach, and bladder • Heart contains more than 2000 harmful chemicals, 28 of which cause cancers including the following: • Lips, tongue, cheeks, gums, and the top and bottom of the mouth • Pancreas • Esophagus Other health problems associated with smokeless tobacco are: • Gum disease • Sores in the mouth • Tooth decay • Wearing down of teeth • Heart Attack • Possible diabetes and heart disease • Increase in Cholesterol

NOTE: People often get most upset about cancers found in the area of the mouth because surgery may cause many changes in how a person looks 2 Pocket Guide Interior October_Layout 1 12/20/19 2:26 PM Page 3

2. HEALTH OF FAMILY AND FRIENDS Secondhand smoke and thirdhand smoke are very dangerous and can kill. Secondhand smoke comes in two forms – sidestream and mainstream. comes from the burning end of a . Mainstream smoke is the smoke exhaled by a smoker. NOTE: There is no risk-free level of tobacco smoke. Until a person is Even brief exposure is unhealthy. ready to quit smoking, he or she Some of the health consequences resulting should at least from inhaling secondhand smoke are: make the home and car smoke free • Lung cancer for the health and • Asthma safety of family and friends. Using • Heart disease tobacco in any form around • Colds and flu children can • Ear infections in children increase their risk of taking up the • SIDS (Sudden Infant Syndrome) habit later in life. • Learning disabilities in children • Smaller birth-weight babies and increased risk of death Thirdhand smoke is what clings to a person's clothes, hair, furniture, drapes, and carpeting. Some particles are cancerous and even radioactive! Infants and children who are being held or who are on the floor or furniture may ingest these dangerous particles. A study on second hand smoke and its effects can be found at: www.jointogether.org/news/research/summaries/2009/ secondhand-smoke-a-killer.html Summary: The report, requested by the U.S. Centers for Disease Control and Prevention (CDC), said there is no safe level of exposure to secondhand smoke, and that people with heart conditions could risk heart attacks with less than an hour's exposure to environmental tobacco smoke, which restricts blood vessels and increases clotting.

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3. MONEY YOU WILL SAVE! All forms of tobacco are expensive. You will also have savings from damage caused by smoking – the burns in furniture, rugs, upholstery, and clothing. Add to that the money saved on cleaning bills for your clothing, house, and car. Use the example below to find out how much money you will save after you quit smoking.

AFTER SAVED 1 day ...... $5 Prices are based on an average of $5.00 per pack. 1 week ...... $35 The cost of a pack of 1 month ...... $150 may differ, 1 year ...... $1,820 depending on where 10 years ...... $18,200 you buy them. 20 years ...... $36,400

4. RETURN OF PLEASURE FROM EATING Smoking decreases the senses of taste and smell. For many people, this results in their adding more salt and sugar and in eating more fatty foods to improve the taste of the food.

5. LOOK BETTER AND SMELL BETTER Tobacco in any form stains teeth and results in bad breath. It also leaves the odor of smoke in clothing and hair.

List the reasons YOU want to quit using tobacco.

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______

______

______

______

______

______

______

______

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WHAT IS TOBACCO? Tobacco is the leaf of the tobacco plant (Nicotiana) that is harvested and dried but never cleaned. Tobacco comes in two forms, smokeless and smoking tobacco.Smokeless tobacco is available as chewing tobacco and snuff. Smoking tobacco is available as cigarettes (the most common form), cigars, pipes, bidis, , hookahs, and self-rolled cigarettes.

Tobacco and the additives in tobacco are the killers NOT the nicotine. Cigarette manufacturers closely guard the list of hundreds of additives, many of which are toxic, used in the manufacturing process.

WHAT IS NICOTINE? Nicotine is found in the tobacco leaf and can kill at high doses. In fact, nicotine has been used to kill insects on plants. The amount of nicotine in tobacco will not kill you, but it will enslave you by causing addiction. Some researchers believe nicotine is the most addictive drug, even more addictive than heroin, cocaine or alcohol. The two forms of nicotine are bound (pure) and free. In order for the body to use nicotine more quickly, the bound nicotine is freed by adding ammonia, a chemical used to clean a house! The amount of ammonia used is different for each type of tobacco.

WARNING: Although a toxic dose of nicotine in children has not been established, it is estimated that symptoms may start as low as 1 mg of nicotine, and death may occur at 1 mg/kg of nicotine.

WHAT IS NICOTINE ADDICTION AND DEPENDENCE? When the brain receives the free nicotine, the tobacco user gets a “kick.” You may have heard people say, “It is all in your head!” It really is in your head but not in the way people usually describe it. When people use tobacco, nicotine enters the blood stream and travels to the brain causing a release of chemicals that deliver the “kick.” It takes about 10 seconds for nicotine from cigarettes to reach the brain and deliver the “kick.” The amount of time varies with each form of tobacco. Nicotine causes changes in the brain that can lead to addiction and dependency. Changes can occur very quickly in some people, even after smoking the first cigarette. As nicotine levels decrease in the brain, withdrawal symptoms cause the brain to ‘scream for more nicotine.’ Unfortunately, because of the cycle of addiction, people feel like they have to smoke again to get rid of the symptoms. Over time, most people start needing more and more nicotine to get the same response. This results in more frequent use of tobacco or in changing to a stronger type of tobacco to feed the addiction. The addiction starts to rule the person’s life. Some people do not use tobacco daily, but still cannot quit. If a person is not able to quit using tobacco, he or she is ADDICTED !

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CHEMICALS RELEASED BY NICOTINE AND THE EFFECT ON THE BODY Dopamine (dope-a-mean) Dopamine excites the reward center of the brain and causes feeling of pleasure and calm. It causes people to think, “I can make it through the night.” It also gives a person that “aaah” feeling. Dopamine is what brings you back for more because it makes you think, “If I use tobacco, I will get a reward!” Adrenalin (a-dren-a-lin) Adrenalin gives the “fight or flight” feeling known as the “adrenalin rush.” Another example of adrenalin rush is when you are scared or excited. Your heart rate, breathing, blood pressure, and sugar level quickly rise. In addition, your blood vessels constrict or become smaller.

NOTE: If you are a diabetic, you will have more difficulty controlling your blood sugar when using tobacco. The adrenaline rush causes a surge of sugar in your blood and decreases the release of insulin from the pancreas.

Serotonin (sarah-toe-nin) Serotonin calms you and helps you think, concentrate, and relax. Medications used to treat depression help maintain high levels of serotonin in the brain. Beta-Endorphins (in-door-fins) Beta-endorphins are naturally made opiates in the brain and body which reduce the feeling of pain, similar to the way morphine works. Like dopamine, these chemicals also give you the “I can make it through the night” response. Monoamine Oxidase (mono-a-mean ox-e-days) Monoamine oxidase (MAO) is a brain chemical that is involved in the breakdown of dopamine. Because smoking greatly decreases the level of MAO in the brain, this results in an even higher level of dopamine.

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HOW MUCH NICOTINE IS IN TOBACCO? The amount of nicotine delivered differs with each type of tobacco. The types of tobacco and approximate amount of nicotine delivered are: SMOKING TOBACCO Cigarettes Cigarettes are processed tobacco leaves wrapped in paper. Each cigarette delivers between 1 and 2 milligrams of nicotine into the bloodstream. Bidis (bee-dees) Bidis are small, flavored, hand-rolled tobacco cigarettes – not a tobacco-free herbal cigarette. Instead of being wrapped in paper, they are wrapped in tendu or temberni leaves. Each bidi delivers three times the amount of nicotine from one cigarette. Kreteks (cree-techs) Kreteks or clove cigarettes are made of tobacco, cloves, and other additives. One chemical released from cloves is eugenol, which delivers a numbing effect in the throat, thus decreasing the gag reflex. This can lead to the inhalation of food and stomach contents into the lungs. In addition, when eugenol is inhaled, it can be very toxic to the lungs. Each delivers the same amount of nicotine as two cigarettes. Hookahs Hookahs are water pipes that use . Although the inhaled smoke passes through water, this does not eliminate the risk of smoking. The suction required to breathe through the water allows the smoke to go deeper into the lungs. Each 45 – 60 minute hookah session delivers as much as 100 times the amount of as one cigarette! Additionally, the smoker can inhale the same amount of smoke in 100 cigarettes and up to 15 milligrams of nicotine.

WARNING: Hookah preparation and smoking methods can increase the risk of spreading infectious diseases and viruses like tuberculosis, hepatitis, and herpes.

Cigars Most people believe that smoke from a cigar is not inhaled. Although most of the nicotine is absorbed through the mouth, the truth is, when a person breathes in, the person inhales smoke. The amount of nicotine delivered from a cigar depends on its size, the tobacco used, and the length of time it is smoked. Cigars contain more ammonia than cigarettes; thus increasing the amount of freed nicotine. One cigar can deliver the same amount of nicotine as one or two packs of cigarettes! Pipes Nicotine from a pipe is absorbed primarily through the mouth. Like the cigar, the pipe contains more ammonia and increases the free nicotine. One pipe bowl can deliver the same amount of nicotine as seven cigarettes. 7 Pocket Guide Interior October_Layout 1 12/20/19 2:26 PM Page 8

SMOKELESS TOBACCO Smokeless tobacco provides more nicotine than cigarettes. The addition of more ammonia and salt produces more free-form nicotine for absorption. Chew Tobacco Chew tobacco comes in three forms: loose leaf, twist, or plug. Each time a person chews a plug of tobacco for 30 minutes, the amount of nicotine delivered equals that of four to five cigarettes. Snuff Snuff is ground tobacco that is sold in tins. It is available in three forms: dry, moist, and in pouches. Dry snuff is finely ground tobacco sniffed through the nose. Moist snuff is a pinch of tobacco placed between the lower lip and gum. Pouched snuff is a tea bag-like pouch placed between the lip and gums. Pouched snuff is both smokeless and spit-free. Two and a half (2.5) grams of snuff held in the mouth for 30 minutes provides the same amount of nicotine as three to four cigarettes.

NOTE: On June 22, 2009, President Barack Obama signed into law the Family Smoking and Act. This law gives the Food and Drug Administration (FDA) the power to regulate tobacco products. The law will prohibit the manufacture of cigarettes with any artificial or natural flavor (other than tobacco or menthol) or any herb or spice (including strawberry, grape, orange, cloves, cinnamon, or vanilla) that characterizes the flavor of the tobacco product or tobacco smoke. The law will also ban cigarette labels such as “light” and “low tar.” Additionally, the FDA will examine whether nicotine levels will need to be decreased.

ALTERNATE FORMS OF SMOKELESS AND SPIT-FREE TOBACCO Alternate forms of smokeless and spit-free tobacco are not considered quit aids or reduced-risk products. The health risks are the same. New FDA regulatory law might make these forms unavailable. Some of the alternate forms include dissolvable smokeless tobacco and nicotine tablets, strips, and sticks. These forms contain between 0.6 milligrams and 4.0 milligrams of nicotine.

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NICOTINE WITHDRAWAL SYMPTOMS Nicotine withdrawal occurs when nicotine levels in the brain drop. Most often, a person will have to use tobacco again just to relieve the symptoms. Check all the nicotine withdrawal symptoms you have experienced. n Anxiety n Intense craving n Chest tightness n Irritability n Constipation n Post-nasal drip n Depression n Problems thinking n Dizziness n Sadness n Fatigue n Trouble thinking n Headache TRIGGERS A trigger is a situation, emotion, or thought that increases the desire or urge to use tobacco. For example, a person may smoke after a meal or with coffee. Another person may use smokeless tobacco while watching television. Still another person may use tobacco after exercise. (Activities that increase metabolism also decrease chemicals in the brain, resulting in an urge for more of the chemical.) One may ask, “Why does stress, anger, or sadness increase my craving for tobacco?” People get used to reaching for tobacco to help them cope with certain emotions, and when faced with these emotions, they automatically reach for tobacco. The brain remembers the “reward,” the “I can make through the night,” and the “aaah” response. Check the triggers that make you want to use tobacco. n After eating n Watching TV n Talking on the phone n Driving the car n Working on the computer n Anger n Boredom n During the holidays n Stress n After sex or exercise n Breaks at work n When you are sad n With coffee n When you are happy n Drinking alcohol

Quitting is tough, but YOU can do it! It may take several tries, so don’t give up. STAY COMMITTED !

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Strategies to help you identify your triggers Consider keeping a journal about your tobacco use patterns. Include the following information: When (the date and time) ______What (what you were doing) ______Why (what triggered the use) ______Need (how badly you needed the tobacco) ______BECOMING TOBACCO FREE FOR LIFE Quitting tobacco is not easy, but is the most important thing you can do for your health.Most people try many times before they can quit successfully. Slips are common. Even a relapse can make a person stronger for the next quit attempt. Quitting tobacco involves withdrawal from a highly addictive drug as well as lifestyle change. The first step is to commit to quitting. Get help from your physician or a tobacco treatment specialist, and take it one step at a time so you will be able to transition to a tobacco-free lifestyle. Which of the following describes you? n Unwilling – no desire or perceived need to change – “I don’t want to quit.” n Willing – intention to change soon – “I want to quit.” n Recently Quit – the first 6 months after quitting –“I am in the process of quitting.” n Sustained Quit – sustaining change that begins at 6 months after quitting and lasts until the 5-year tobacco free anniversary – “I have quit.” If you are unwilling to quit, write down your reasons. ______

If you are afraid or have tried to quit before and failed, you are not alone. Most people have fears and concerns about facing the unknown or about failing. But there is no failure in trying. Just take one step forward to being tobacco free for life.

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TEN STEPS TO BECOMING TOBACCO FREE

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STEP 1. COMMIT TO QUIT Quitting tobacco is a major lifestyle change, so commit yourself to being successful and making this your last quit! Quitting may be tough, but YOU can do it!

TAKE CONTROL! 1-800- QUIT-NOW STEP 2. SEEK HELP Contact your healthcare provider about medications and join a tobacco cessation program. This will triple your chances of quitting successfully. Most programs will offer one-to-one counseling or group support to help you break the bondage of tobacco addiction. If you are not able or do not desire to attend a cessation program, call your state’s Quitline. (1-800-784-8669) If you are under the care of a psychiatrist, a psychologist, or other mental health professional, be sure to involve her or him in the process.

NOTE: If you are presently taking medication, your healthcare provider may need to alter the dosage of the medication after you quit tobacco. Keep you healthcare provider informed about your progress.

Where To Go For Help When you are ready to quit, get help as soon as possible. Quitting is difficult, but there are many resources to assist you. • Your state Quitline • Self-help materials • Interactive websites: www.smokefree.gov – The site provides live online support so you can chat with experts in tobacco cessation. You may also order free printed booklets from this website. www.becomeanex.org – Become an Ex smoker www.quitnet.com – The Quit Net www.ffsonline.org – Freedom from Smoking Online www.nicotine-anonymous.org – A 12-step approach to quitting. If you are interested in attending a tobacco cessation program, the programs can vary considerably. Use the following resource to gather information about different programs:

Program ______

Contact ______

How Long Established ______

Trained Staff ______

Structure of Program ______12 Pocket Guide Interior October_Layout 1 12/20/19 2:26 PM Page 13

STEP 3. OBTAIN MEDICATION Check with your physician to find out if you can use medications to help you quit. Research has shown that people who use medications have an easier time quitting and staying quit. The FDA has approved seven first-line medications for use with quitting smoking. Five of these medications are considered nicotine replacement therapy (gum, inhaler, lozenge, nasal spray, and patch). Two medications do not contain nicotine (Bupropion SR and Varenicline) NOTE: If you are pregnant or breast-feeding and haven’t been able to quit smoking completely, talk to your physician. Your physician might recommend medications to help you quit, such as “short-bursts” of nicotine replacement therapies (NRT) like or lozenges.

MEDICATIONS TO HELP YOU QUIT Nicotine Replacement Therapy Nicotine replacement therapy (NRT) helps individuals quit smoking by reducing the craving sensations associated with withdrawal from the nicotine in tobacco. NRT products provide controlled amounts of nicotine. Individuals reduce their use of NRT products over time, allowing their bodies to gradually adjust to increasingly lower nicotine levels. • Nicotine Patch • Nicotine Gum • Nicotine Inhaler • Nicotine Lozenge • Nicotine Nasal Spray

Nicotine Patch The nicotine patch is placed on the skin and supplies a small and steady amount of nicotine into the body. Nicotine patches contain varied concentrations of nicotine (21mg, 14mg, or 7mg, for example) and the user reduces the dose over time.

Product Information: • 21 mg, 14 mg, 7 mg strengths • 24-hour release • May wear for 16 hours if patient experiences sleep disturbances

Dosing: If you smoke less than 10 cigarettes per day use: • 14 mg/d x 6 weeks • 7 mg/d x 2 weeks If you smoke greater than 10 cigarettes per day use: • 21 mg/d x 6 weeks • 14 mg/d x 2 weeks • 7 mg/d x 2 weeks 13 Pocket Guide Interior October_Layout 1 12/20/19 2:26 PM Page 14

Contraindications/Precautions: • Recent (<2 weeks) MI • Serious underlying arrhythmias • Serious or worsening angina pectoris • Pregnancy category: not applicable for OTC formulations

Nicotine Gum Nicotine gum is chewed to release nicotine that is absorbed through tissue inside the mouth. The user chews the gum until it produces a tingling feeling, then the gum is placed (parked) between the cheek and gum tissue. Nicotine gums have varied concentrations of nicotine (typically 2mg or 4mg) to allow the user to reduce the amount of nicotine in his or her system Product Information: 2 mg, 4 mg Dosing: • If you smoke less than 25 cigarettes per day, use the 2 mg gum. • If you smoke greater than 25 cigarettes per day, use the 4 mg gum • Maximum: 24 pieces per day

Contraindications/Precautions: • Recent (<2 weeks) MI • Serious underlying arrhythmias • Serious or worsening angina pectoris • Temporomandibular joint disease • Pregnancy category: not applicable for OTC formulation

Special Instructions – “Chew and Park” method: We recommend the “Chew and Park” method. Chew the gum until a “peppery” or “flavored” taste emerges, then park it between your cheek and gum to let the nicotine absorb. When you no longer taste the peppery or flavored taste, start chewing again. Continue the “chew and park” method until the taste leaves, which is about 30 minutes.

The newer form of nicotine gum is softer and tastes much better than the older forms.

Chew and Park Method for Nicotine Gum

Chew slowly

Chew again when tingling Stop at sign fades of peppery taste Park gum between cheek and gum 14 Pocket Guide Interior October_Layout 1 12/20/19 2:26 PM Page 15

Nicotine Inhaler The nicotine inhaler consists of a cartridge attached to a mouthpiece. Inhaling through the mouthpiece delivers a specific amount of nicotine to the user.

Product Information: • 10 mg cartridge • Delivers 4 mg inhaled nicotine vapor

Dosing: • 6 – 16 cartridges per day • Individualized dosing: initially use 1 cartridge every 1 – 2 hours

Contraindications/Precautions: • Recent (<2 weeks) MI • Serious underlying arrhythmias • Serious or worsening angina pectoris • Bronchospastic disease • Pregnancy category D

Nicotine Lozenges Nicotine lozenges look like hard candy and are placed in your mouth to dissolve slowly. The nicotine lozenge (typically 2mg or 4mg dose of nicotine) releases nicotine as it slowly dissolves in the mouth. A faster dissolving mini-lozenge is also available.

Product Information: 2 mg, 4 mg

Dosing: • If you smoke greater than 30 minutes after waking, use the 2 mg lozenge. • If you smoke less than 30 minutes after waking, use the 4 mg lozenge. • Maximum: 20 lozenges/day

Contraindications/Precautions • Recent (<2 weeks) MI • Serious underlying arrhythmias • Serious or worsening angina pectoris • Pregnancy category: not applicable for OTC formulations

Nicotine Nasal Spray Nicotine nasal spray is a pump bottle containing nicotine that is inserted into the nose and sprayed. Nicotine nasal spray can be used for fast craving control, especially for heavy smokers.

Product Information: Metered spray – Each spray delivers 0.5 mg of nicotine to the nasal mucosa

Dosing: • 1-2 doses per hour • One dose = 2 sprays (one in each nostril) • Maximum: 5 doses per hour or 40 doses per day 15 Pocket Guide Interior October_Layout 1 12/20/19 2:26 PM Page 16

Contraindications/Precautions: • Recent (<2 weeks) MI • Serious underlying arrhythmias • Serious or worsening angina pectoris • Underlying chronic nasal disorders (rhinitis, nasal polyps, sinusitis) • Severe reactive airway disease • Pregnancy category D

Non-Nicotine Medications These medications do NOT contain nicotine. They help with withdrawal symptoms and lessen the urge to smoke. • Bupropion SR (Zyban, Wellbutrin SR) • Varenicline (Chantix)

WARNING: The U.S. Food and Drug Administration is requiring manufacturers to put a Boxed Warning on the prescribing information for the drugs Chantix (varenicline) and Zyban (bupropion). The warning will highlight the risk of serious mental health events including changes in behavior, depressed mood, hostility, and suicidal thoughts when taking these drugs. The warning will also extend to Wellbutrin SR and Bupropion SR.

Bupropion SR (Zyban, Wellbutrin SR) Buproprion for smoking cessation, also known as Zyban or Wellbutrin SR, helps to reduce nicotine withdrawal symptoms and the urge to smoke. Bupropion can be used safely with nicotine replacement products.

Product Information: • 150 mg sustained-release tablet

Dosing: • 150 mg in the morning for 3 days, then increase to 150 mg twice a day for 4 days

Contraindications/Precautions: • Seizure disorder • Concomitant Bupropion (e.g. Wellbutrin) therapy • Current or prior diagnosis of bulimia or anorexia nervosa • Simultaneous abrupt discontinuation of alcohol or sedatives (including benzodiazepines) • MAO inhibitor therapy in previous 14 days

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Varenicline (Chantix) Varenicline, also known as Chantix, is a prescription medication that eases nicotine withdrawal symptoms and blocks the effects of nicotine from cigarettes if the user resumes smoking.

Product Information: • 0.5 mg, 1 mg tablet

Dosing: • Days 1–3: Take a 0.5 mg tablet every morning • Days 4–7: Take a 0.5 mg tablet twice each day • Weeks 2–12: Take a 1 mg tablet twice each day

Contraindications/Precautions: •Severe renal impairment (dosage adjustment is necessary) • Neuropsychiatric symptoms (behavior changes, agitation, depressed mood, suicidal ideation or behavior) • Pregnancy category C

Combination Therapy Combinations of medications have been shown to be effective smoking cessation treatments. Talk with your healthcare provider about using any of the following combinations if you are willing to quit smoking. • Long-term (> 14 weeks nicotine patch + other NRT (gum and spray) • The nicotine patch + the nicotine inhaler • The nicotine patch + Bupropion SR

Source: USPHS Clinical Practice Guideline 2008 Update, Treating Tobacco Use and Dependence

Be sure to obtain the medication before your quit date.

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MEDICATION ASSISTANCE FOR PEOPLE WITHOUT INSURANCE If you do not have health insurance with drug coverage, there is help. The following resources are available to assist you:

MEDICATIONS PROGRAMS WEBSITE TELEPHONE About half of 1-800-QUITNOW the states’ (1-800-784-8669) quitlines offer free or discounted medications. Federally- funded www.findahealthcenterhrsa.gov health centers Chantix 1-866-706-2400 Nicotrol Connection to Care Nasal www.pfizerhelpfulanswers.com Spray Pfizer Nicotrol Friends Inhaler Bridges to Zyban Access www.bridgestoaccess.com 1-888-788-7921)

Chantix Nicotrol Nasal Spray Together Rx Access www.togetherrxaccess.com 1-800-444-4106 Nicotrol Inhaler Zyban

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ALTERNATIVE QUIT SMOKING METHODS (NOT FDA-APPROVED FOR USE)

Hypnosis – Acupuncture – Laser Stimulation While these treatments have been around for a long time, there is no evidence that they are effective. The people selling hypnosis and other alternative methods will often say they are 100% guaranteed. Be careful with what you believe and where you put your money.

E-Cigarette – – E-Cig. Don’t be tricked into thinking this product is safe or a way to quit smoking! Here are some facts about this product: • These products are considered a drug-device combination • They do NOT contain tobacco leaf or stem material. • They are designed to look like conventional cigarette and to produce a mist or vapor upon each inhalation.. • They are considered "new drugs" by the FDA and must be tested for premarket approval. • The marketing of the "electronic" cigarettes is illegal and subject to enforcement action. • The FDA has detained and refused several importations of various brands of the "electronic" cigarettes, cigars AND their components.

NOTE: A detailed discussion of the new drug application (NDA) process is available on FDA’s Internet Web site at: http://www.fda.gov/cder/regulatory/applications/default.htm. The sections of the Act referenced above are also available on FDA's Internet web site at www.fda.gov.

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STEP 4. SET A QUIT DATE Set a quit date and write it on your calendar. Give yourself plenty of time to develop your quit plan and prepare for quitting.

STEP 5. TELL OTHERS Be sure to tell your family, friends, and coworkers that you plan to quit . Tell them how they can help you. Quitting is easier with the support of others.

STEP 6. PREPARE FOR QUIT DAY Keep track of your triggers and get ready to experience the freedom from tobacco use. If you are taking Bupropion or Chantix, set your quit date according to the schedule you were advised to use. Before your quit date, make your home and car smoke-free. Remove anything that makes you want to smoke, like ashtrays, cigarettes, and other tobacco products. Out of sight, out of mind! Quit buying cartons of cigarettes – buy one pack at a time. Some people rearrange their furniture so the trigger to smoke (like in front of the TV set) isn’t as strong.

STEP 7. QUIT DAY On your quit date: Review your quit plan, quit all tobacco use, start NRT (if appropriate) and congratulate yourself!

STEP 8. PREPARE FOR CHALLENGES • Pat yourself on the back. You made a great choice! Follow these tips to help you prepare for challenges: • Spend your time in nonsmoking places. Just the sight or smell of smoke can trigger the urge to use tobacco. • Don’t rationalize. For example, don’t say to yourself, “Using tobacco just once to get me through this time will not hurt.” Other samples of rationalizations include: “Today is not a good day to quit.” “We all die of something.” “Aunt Marie smoked all of her life and lived to be 90 years old.” • Change your daily habits to decrease your chances of using tobacco. When you feel an urge, do something to take your mind off tobacco. • Avoid alcohol while quitting. Alcohol reduces your ability to say no to tobacco.

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• Practice relaxing. Try relaxation breathing. Breathe in through your nose and out through your mouth. If you miss the enjoyment of smoking, deep breathing helps you get more oxygen to the lungs and helps you relax. • Keep your hands busier than usual. Chew gum, doodle, or suck on straws or suckers when the urge hits. • Talk to your healthcare provider, respiratory therapist, nurse, support group or friend about any trouble you are having. Are you feeling depressed? If so, discuss this with your healthcare provider or support group. Support is very important when making any big change in your life. • Exercise, especially if you find you are snacking more than usual. Exercise will also increase beta-endorphins. Remember, those are the chemicals (like morphine) that decrease pain! Have you heard of the “runner’s high?” This happens when beta-endorphins are released and give you the feeling of euphoria. • Do not get focused on gaining a few pounds. Most people gain only a small amount of weight when quitting, and this weight gain can be lost after you quit for good. The most important thing you can do is to stop using tobacco. Using tobacco is much more dangerous than gaining a few pounds. • Drink water to help flush the toxins out of your body. Water also helps reduce your risk of dehydration. Dehydration can be very dangerous and can cause you to become more irritable. If you wait until you are thirsty, you will have waited too long. • Reduce your caffeine intake. The same amount you used before quitting tobacco may now cause you to be jittery or shaky, have anxiety, or have trouble sleeping. If you notice these side effects, evaluate your caffeine intake and try reducing your amount. You may need to reduce up to 50% of your pre-quit caffeine intake before noticing the improvement. Reducing more than 50% of your pre-quit caffeine intake is not advised, because you may have caffeine withdrawal symptoms in addition to nicotine withdrawal symptoms • Maintain support. Be sure to stay in contact with your tobacco treatment specialist for the first year. Strong emotional triggers may occur, and you want to be in control. Your tobacco treatment specialist is waiting to help you. Tell anyone who will support your quitting efforts and ask him or her to be your quit buddy.

Quitting is tough, but YOU can do it! It may take several tries, so don’t give up. STAY COMMITTED !

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YOUR PLAN TO QUIT To assist you in the process, complete these self-evaluation exercises:

1. What are my reasons for quitting? Look at the list you made earlier on page 3. (Pros)

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2. In what situations will I find it difficult not to use tobacco?

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3. How will I manage these triggers?

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4. What will I do if I relapse?

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5. Who may I call for help?

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6. My healthcare provider’s phone number:

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7. My support partner’s phone number:

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8. What withdrawal symptoms am I experiencing?

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If you are having intense cravings, you are probably not using enough nicotine replacement therapy. Talk to your healthcare provider. The good news is that withdrawal symptoms do not last forever and are much better after the first month or so.

WHAT IF I WANT TO START USING TOBACCO AGAIN? Any use of tobacco may increase your odds of returning to the previous level of dependency. If you are on your way to buy tobacco, buy gum or mints instead. Also consider using a short- acting nicotine replacement product for a short burst of nicotine

TAKE CONTROL! 1-800- QUIT-NOW www.smokefree.gov –The site provides live online support so you can chat with experts in tobacco cessation. You may also order free printed booklets from this website. www.becomeanex.org – Become an Ex smoker www.quitnet.com – The Quit Net www.ffsonline.org – Freedom from Smoking Online www.nicotine-anonymous.org – A 12-step approach to quitting.

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STEP 9. AVOID RELAPSE Slips may occur in the natural progression to total abstinence, so don’t feel bad if you have a slip. The problem happens when you let one slip lead to another and another. You will soon find yourself back to your old smoking patterns. If you have relapsed, don’t beat yourself up or start thinking of yourself as a failure. Instead, identify the trigger (s) that led to the relapse and start over. Contact your tobacco treatment specialist and make a plan to deal with the trigger(s) identified when you relapsed, because you may face the same problem(s) again in the future. Plan what you can do differently the next time to work through the triggers that let to your relapse.

1. I first slipped when ______

2. Next time, I will do the following instead: ______

3. My new quit date is: ______

4. Review your reasons for quitting. Remember, most people try to quit several times before they quit for good.

STEP 10. CONGRATULATE YOURSELF

Congratulations! You have quit tobacco! During the last six months, you have made it through withdrawal symptoms and ongoing triggers, and you have improved your coping skills.

Call your healthcare provider and tobacco treatment specialist to celebrate this day with you! You are now on your way to being tobacco free for life!

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Guide provided by your Respiratory Therapist at:

Printing was supported by a grant from Pfizer

www.aarc.org www.arcfoundation.org

American Association American Respiratory Care for Respiratory Care Foundation 9425 N. MacArthur Blvd. 9425 N. MacArthur Blvd. Suite 100 Suite 100 Irving, TX 75063-4706, USA Irving, TX 75063-4706, USA 1-972-243-2272 1-972-243-2272