Pharmacy Times

Smoking Cessation: Not Just Blowing Smoke

Author: Lauren Schlesselman, PharmD

The use of tobacco products remains a significant health problem in the United States. In this country alone, nearly 500,000 people die each year from smoking-related diseases, accounting for nearly 1 of every 5 deaths.(1-4)Smokers create a drain on the country?s health care system because they have more frequent and more severe health issues. They also raise costs for employers because of lost productivity. Thus, smokers place an annual economic burden on the US economy that exceeds $100 billion.(3,5)

Smoking is the leading preventable health risk in the United States. With most smokers wishing to quit, the situation should be viewed as an opportunity for health care workers to impact the health and economy of this country. Since many products are available over the counter, pharmacists can play a critical role in counseling patients on health risks and treatment regimens.

Medical Concerns
Smoking is responsible for numerous pulmonary and cardiovascular disorders. The cause of this increased risk is the 4000 chemicals (including 200 poisons and 43 carcinogens) contained in cigarette smoke.(6)Smoking is the leading cause of lung cancer. The risk for lung cancer increases with prolonged smoking, because the disease typically occurs after patients reach the age of 65. Smoking also is associated with cancers of the trachea, mouth, larynx, esophagus, kidney, bladder, breast, cervix, prostate, liver, pancreas, and skin.(3)Even if lung cancer does not develop, smokers are at risk for chronic bronchitis and emphysema. Smoking causes narrowing of arteries throughout the body, which may result in coronary heart disease and increased blood pressure. The risk for sudden death from coronary heart disease is 2 to 4 times higher in smokers than in nonsmokers.(3)This risk is reduced to that of nonsmokers within 3 years after smoking cessation.(7)When the arteries leading to the brain are affected, they are unable to adequately supply oxygen to the brain, and stroke is more likely. Smoking also produces narrowing of peripheral blood vessels. This narrowing causes pain upon walking, gives rise to nonhealing ulcers, and may even bring about the loss of limbs.

Smoking also affects platelets and serum lipids. Platelet hypercoagulation and elevated serum lipids add to the risk for myocardial infarction and peripheral vascular disease.

OTC Options
The approval of nicotine replacement therapy signified a major breakthrough in the fight against nicotine dependency. The transfer of some of these products to OTC status marked another breakthrough. The disadvantage of OTC products is that patients often do not get counseling because they do not consult a health care provider. Although the nasal spray remains a popular product, patients can obtain nicotine gum and patches simply by making a trip to the local pharmacy.

The first nicotine replacement product on the market was nicotine polacrilex gum. It is designed to reduce cravings and withdrawal symptoms while maintaining nicotine levels. The gum is available in 2 strengths, 2 and 4 mg. For patients who smoke less than 2 packs of cigarettes per day, the 2-mg gum is recommended. Patients who smoke more than 2 packs per day will need the higher-strength gum. Nicotine is released from the ion-exchange resin and is rapidly absorbed through the buccal mucosa when the gum is chewed. The gum should not be chewed continuously, but rather placed in the cheek and chewed when an urge to smoke develops. Patients should not chew more than 24 pieces per day for up to 12 weeks. Adverse effects include hiccups, throat irritation, and flatulence.

For patients who desire a discreet therapy option, transdermal patches are now sold without a prescription. The patches are available in a 21-, 14-, and 7-mg regimen, in a 22- and 11-mg regimen, and in a 15-mg regimen. The 3-strength regimen is dosed at 21 mg for 4 weeks, 14 mg for 2 weeks, and then 7 mg for 2 weeks. The 15-mg patch is used for 16 hours daily for 8 weeks. Whether to use the 2- or 3-strength regimen is purely a matter of patient preference. The advantage of the 3-strength regimen is the ability to step the dose down more gradually, whereas the advantage of the other regimens is less confusion over dosing.  Regardless of the patch regimen, overall efficacy at the end of treatment was 27% (vs 17% for placebo) and 22% (vs 9% for placebo) at 6 months, according to a meta-analysis of 17 studies.(8)Combining the use of the patch and the gum may improve outcome, compared with using either agent alone. Skin irritation remains the most common event associated with patch use.

In many countries, nicotine oral inhalers also are available without a prescription. Along with providing nicotine, these inhalers provide the hand-to-mouth behavior that many smokers crave. The oral inhaler consists of a plastic mouthpiece resembling a cigarette holder into which a cartridge is inserted. The cartridge contains a porous plug impregnated with nicotine and menthol. The menthol is added to reduce oral irritation to nicotine. The amount of nicotine released during puffing is determined by the temperature and volume of air drawn through the plug. It typically takes 80 puffs to receive 1 mg of nicotine.(9)Adverse effects include oral irritation, coughing, and rhinitis.

The FDA recently granted approval for a nicotine lozenge, which is to be sucked whenever the urge to smoke develops. Advantages of this formulation include providing patients with a means to replace the hand-to-mouth routine, along with providing nicotine for their dependence.

Although the packaging for each nicotine replacement product states a finite length of therapy, patients often will continue their use past this time. The goal always should be complete abstinence from nicotine. Yet, the use of nicotine replacement therapy, even if it is for a period longer than recommended, is an improvement over smoking. According to the Public

Health Service?s practice guideline, nicotine replacement products are safer than tobacco use because they do not contain such toxic substances as tar and carbon monoxide, cause sharp increases in blood nicotine levels, or produce strong dependence.(4)

Counseling
Positive and enthusiastic reinforcement remains a critical component of any smoking cessation program. Patient compliance with a program is enhanced by as little as 3 minutes of empathic counseling.(10)Concurrent nicotine replacement therapy and counseling during the initial period of cessation have proven to increase long-term abstinence rates.

Counseling should cover how to deal with the urge to smoke. Options include walking or exercising, avoiding environments in which smoking normally occurs, and substituting an alternative behavior.

For patients on nicotine replacement therapies, instructions on their use also should be provided. These instructions should cover the recommended dosing regimen and duration of therapy, along with how to decrease the dose. Patients always should be counseled not to smoke while taking nicotine replacement therapy.

The most effective smoking cessation program is the program in which the patient is highly motivated to stop. If the patient is not motivated, the likelihood of success is extremely low. For any regimen to work, the patient must learn to change behavior. The continuous support of friends, family, and health care providers is crucial. The most important point to remember when trying to quit or to support someone who is quitting is that there are many good reasons to quit smoking, but no good reason to continue smoking.

For a list of references, send a stamped, self-addressed envelope to: References Department, Attn. D. Campagnola, Pharmacy Times, 241 Forsgate Drive, Jamesburg, NJ 08831; or send an e-mail request to: dcampagnola@mwc.com.