Cigarette smoking is the leading cause of preventable disease and death in the United States. Many individuals are seeking methods to positively affect their health and quality of life. The decision to quit smoking is a vital one that may add 10 or more years to an individual's life and reduce the risk associated with developing various pulmonary disorders, lung cancer, cardiovascular disease, and/or stroke.
For most individuals, simply deciding to quit smoking or quitting without the assistance of either pharmacologic or nonpharmacologic methods is not the most efficacious method. The majority of smokers develop a tolerance to the effects of nicotine, and stopping abruptly may trigger the various manifestations of nicotine withdrawal, such as anxiety, irritability, difficulty in concentrating, hunger, irregular or rapid heartbeat, and nervousness. Fortunately, for the many individuals contemplating the possibility of quitting smoking, various smoking-cessation products are available as nonprescription products.
The approval of nicotine-replacement products has had a significant impact for many fighting the battle to quit smoking. These products are designed to reduce cravings and withdrawal symptoms while maintaining nicotine levels. Nicotine-replacement therapy (NRT) can greatly affect the success of an individual's attempt to quit smoking by treating the symptoms of nicotine withdrawal. Currently, 3 dosage forms of NRT are available without a prescription: gum, patch, and lozenge.
Nicotine polacrilex gum, such as Nicorette (GlaxoSmith-Kline), is a resin complex of nicotine and polacrilin in a sugar-free (containing sorbitol) chewing gum base.1 It also contains buffering agents that increase the pH of the saliva, thus increasing the absorption of nicotine within the buccal mucosa area. It is available in 2-and 4-mg strengths and in various flavors, including regular, orange, and mint. Peak concentrations of nicotine typically are achieved 30 minutes after chewing the gum, and they decrease over the next 2 to 3 hours. The 2-mg strength is recommended for those who smoke fewer than 25 cigarettes per day; those who smoke more should use the 4-mg strength.
Patients should be advised not to chew the gum continuously, but to initially chew it and then let it sit between the gums and the cheek to allow for the absorption of the nicotine. This is often referred to as the "chew and park"method. If the gum is chewed continually, an individual may experience nausea, hiccups, lightheadedness, or mouth irritation.1 Patients should be advised that the effectiveness of the gum could be decreased by the ingestion of acidic beverages. Patients should not eat or drink for about 15 minutes before or while chewing the gum. No more than 24 pieces of the gum should be used per day.
Nicotine Transdermal System
The nicotine transdermal system continually releases low levels of nicotine into the body over a 16-to 24-hour period. The Nicoderm CQ patch (GlaxoSmithKline) and other generic formulations are for 24-hour usage. The Nicotrol patch (Pharmacia) is a 16-hour patch that should be applied in the morning and removed before bedtime. The dosage of the patch is dependent on the number of cigarettes an individual smokes daily. The most common adverse effects reported among users of the patch are local skin irritations such as pruritus and erythema. Other users may report abnormal or vivid dreams, headache, or insomnia.
Nicotine Polacrilex Lozenges
In 2002, the FDA approved the nicotine polacrilex lozenge, Commit (GlaxoSmithKline), which is a resin complex of nicotine and polacrilin in a sugar-free (containing aspartame), mint-flavored lozenge. It is available in 2-and 4- mg strengths and generally is designed for those individuals who smoke their first cigarette within 30 minutes of waking up. Whereas the pharmacokinetics of both the gum and the lozenge are comparable, the lozenge delivers approximately 25% more nicotine than the equivalent dose of nicotine gum because the lozenge is completely dissolved.1 The maximum dosage of lozenges is 20 per day. Adverse effects and interactions with acidic beverages are similar to those associated with the use of the gum.
The Role of the Pharmacist
It is estimated that >70% of adult smokers would like to quit, but very few are able to do so without some assistance.1 Pharmacists can be a vital source of information for individuals who wish to quit smoking. They can aid in the proper selection of pharmacologic smoking-cessation products and encourage patients to take a multistep approach by using nonpharmacologic methods in conjunction with a smoking-cessation product. Patients also should be urged to consult their physician prior to using any smoking-cessation product, especially if they have preexisting conditions. Patients should be advised never to smoke while using NRT products.
Pharmacists can be instrumental in identifying and informing the patient of key drug interactions that may occur when an individual smokes while taking certain medications. Smoking may lead to a decrease in the pharmacologic effects of certain drugs. By taking an active role as health care providers, pharmacists can help many individuals "kick"the habit and improve the quality of their lives.
Ms. Terrie is a clinical pharmacy writer based in Slidell, La.
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