Nicotine-Based Products

Nicotine-Free Products

Pharmacologic Aids to Smoking Cessation

Cigarettes are highly addictive, which makes giving them up very hard. Nonetheless, abstinence can be achieved. Every year, about 41% of Americans who smoke make one or more attempts to quit. Of those who try to quit without formal help, only 4% to 7% achieve long-term success. In contrast, when a combination of counseling and drugs is employed, the 6-month abstinence rate approaches 25%. However, even with the aid of counseling and drugs, the first attempt usually fails. In fact, most people try quitting 5 to 7 times before they ultimately succeed. As time without a cigarette increases, the chances of relapse get progressively smaller: Of those who quit for a year, only 15% smoke again; and of those who quit for 5 years, only 3% smoke again.

Long-term smokers should be assured that quitting offers important health benefits. Regardless of how long you have smoked, quitting can reduce the risk for developing a tobacco-related disease, slow the progression of an established tobacco-related disease, and increase life expectancy. These benefits apply not only to people who quit while they are young and healthy, but also to people who quit after age 65 years and to those with established tobacco-related disease. Data from the Nurses’ Health Study indicate that former smokers eventually achieve the same disease-risk status as never smokers, even with respect to lung cancer. The risk for chronic obstructive pulmonary disease or death from a heart attack declines to that of never smokers in 20 years, and the risk for lung cancer reaches that of never smokers in 30 years.

Seven drug products have been shown to aid smoking cessation (Table 32.1). Of these seven products, five contain nicotine and two don’t. The nicotine-based products—nicotine gum, nicotine lozenge, nicotine patch, nicotine inhaler, and nicotine nasal spray—are employed as nicotine replacement therapy (NRT). The nicotine-free products—sustained-release bupropion (bupropion SR) [Zyban, Buproban] and varenicline [Chantix, Champix ]—are taken to decrease nicotine craving and to suppress symptoms of withdrawal. The most effective drug therapies for smoking cessation are varenicline alone and the nicotine patch combined with a short-acting nicotine product (e.g., nasal spray or gum). At this time, we cannot predict who will respond best to a particular product. Accordingly, selection should be based on patient preference, success with a particular product in the past, and side effects.

TABLE 32.1

Pharmacologic Aids for Smoking Cessation

Product	Common Side Effects	Advantages	Disadvantages	Preparation	Usual Adult Use	Length of Use
NICOTINE-BASED PRODUCTS
Nicotine patch [NicoDerm CQ]	Transient itching, burning, and redness under the patch; insomnia	Nonprescription; provides a steady level of nicotine; easy to use; unobtrusive	User cannot adjust dose if craving occurs; nicotine released more slowly than in other products	See table 32.3	See table 32.3	See table 32.3
Nicotine gum [Nicorette, others]	Mouth and throat irritation, aching jaw muscles, dyspepsia	Nonprescription; user controls dose	Unpleasant taste; requires proper chewing technique; cannot eat or drink while chewing the gum; can damage dental work and is difficult for denture wearers to use	2 mg/piece and 4 mg/piece	Low to moderate nicotine dependence: 2 mg >25 cigarettes daily: 4 mg-piece 9–12 pieces a day is reasonable	Use beyond 6 mo is not recommended
Nicotine lozenge [Nicorette Lozenge, Thrive ]	Hiccups, dyspepsia, mouth irritation, nausea	Nonprescription; user controls dose; easier to use than nicotine gum	Cannot eat or drink while the lozenge is in the mouth	2 mg/lozenge and 4 mg/lozenge	First cigarette 30 min or more after waking: 2 mg First cigarette within 30 min of waking: 4 mg No more than 5 lozenges every 6 hr or 20 daily	Dosing should decrease over a period of 12 wk Dosing should stop after 12 wk
Nicotine nasal spray [Nicotrol NS]	During 1st week: mouth and throat irritation, rhinitis, sneezing, coughing, teary eyes	User controls dose; fastest nicotine delivery and highest nicotine levels of all nicotine-based products	Prescription required; most irritating nicotine-based product; device visible when used	10 mg within a sealed cartridge	Frequent puffs over 20 min 6–16 cartridges daily	After 3 mo, taper use to complete cessation over additional 2–3 mo
Nicotine inhaler [Nicotrol Inhaler, Nicorette Inhaler ]	Mouth and throat irritation, cough	User controls dose; mimics hand-to-mouth motion of smoking	Prescription required; slow onset and low nicotine levels; frequent puffing needed; device visible when used	0.5 mg per activation	One spray per nostril 1–2 times per hour No more than 40 doses per day	Decrease use after 4–6 wk
NICOTINE-FREE PRODUCTS
Varenicline [Chantix, Champix ]	Nausea, sleep disturbances, headaches, abnormal dreams	Easy to use (pill); no nicotine; most effective pharmacologic aid to smoking cessation	Prescription required; may cause neuropsychiatric disturbances, including suicidal thoughts and actions	150 mg tablets	150 mg PO daily × 3 days, 150 mg PO twice daily × 7–12 wk Begin 1–2 wk before smoking cessation	Decrease use after 7-12 weeks
Bupropion [Zyban, Buproban]	Insomnia, dry mouth, agitation	Easy to use (pill); no nicotine; promotes weight loss, which may limit cessation-related weight gain; first-choice drug for smokers with depression	Prescription required; carries a small risk for seizures	0.5- and 1-mg tablets	0.5 mg PO daily × 3 days, 0.5 mg PO twice daily × 3 days, then 1 mg PO twice daily × 12 wk If abstinence is achieved, an additional 12 wk of treatment is warranted Begin 8–35 days before smoking cessation	Decrease use after 12 weeks

Interventions for smoking cessation can be found in Treating Tobacco Use and Dependence: 2008 Update, a clinical practice guideline issued by the U.S. Public Health Service. As stated in the guideline, tobacco dependence is a chronic condition that warrants repeated intervention until long-term abstinence is achieved. This is the same philosophy that guides treatment of dependence on other highly addictive substances, including cocaine and heroin. Tobacco dependence can be treated with two methods: drugs and counseling. Both methods are effective, but a combination of both is more effective than either one alone. Accordingly, the guidelines recommend that all patients who want to quit be offered (1) at least one smoking cessation drug (bupropion, varenicline, or a nicotine-based product) along with (2) counseling, be it one-on-one, in a group, or over the phone (dial 1-800-QUITNOW in the United States or 1-877-513-5333 in Canada). The overall intervention strategy is summarized in the “5 A’s” model for treating tobacco use and dependence:

Stay updated, free articles. Join our Telegram channel

Join