Because cigarette smoking is the leading cause of preventable disease and death in the United States, more individuals should entertain the thought of quitting.1 Many smokers, however, would agree that quitting is easier said than done. It is estimated that >35 million smokers attempt to quit smoking every year, but <5% actually reach their 1-year anniversary.2 Statistics show that 70% of adult smokers in the United States want to quit smoking.3 Yet, for many smokers, finding the most efficacious means to do so may seem overwhelming or impossible.
Results from a study showed that many individuals who tried to quit cold turkey started smoking again within 6 months.4 For individuals seeking assistance, various OTC nicotine-replacement therapy (NRT) products are on the market. Three dosage forms currently are available: gum, patch, and lozenge.
NRT products provide smokers with a nontobacco source of nicotine, which aids in reducing cravings and withdrawal symptoms while maintaining nicotine levels. Thus individuals are able to focus on behavioral modifications to quit smoking, too.1
Nicotine polacrilex gum, such as Nicorette (Glaxo-SmithKline), is a resin complex of nicotine and polacrilin in a sugarfree chewing gum base (containing sorbitol).1 It is available in 2- and 4-mg strengths and in various flavors, including original, fresh mint, fruit chill, and mint. The 2-mg strength is recommended for those who smoke <25 cigarettes per day; those who smoke more should use the 4-mg strength. In general, the peak concentration of nicotine is achieved within 30 minutes; then it slowly decreases over the next 2 to 3 hours.
Pharmacists should inform patients about the proper use of this product, including the "chew and park" method. This method involves chewing the product initially and then letting it sit between the gums and the cheek to allow for the absorption of the nicotine.
Adverse effects include unpleasant taste, dyspepsia, hypersalivation, hiccups, and mouth irritation.1 Ingestion of acidic beverages can decrease the effectiveness of the gum. Patients should not eat or drink for ~15 minutes before or while chewing the gum. Patients should be counseled on the proper use of this product:
Using 1 piece of gum every 1 to 2 hours during weeks 1 through 6
Using 1 piece every 2 to 4 hours during weeks 7 through 9
Using 1 piece every 4 to 8 hours during weeks 10 through 12
Using no more than 24 pieces per day1,6
Nicotine Transdermal System
The nicotine transdermal system continually releases low levels of nicotine into the body over a 16- to 24-hour period.1 Transdermal products available include the Nicoderm CQ patch (Glaxo-SmithKline), the Habitrol patch (Novartis Consumer Health), and generic formulations. Patches are available in steps 1 to 3 in various strengths (21, 14, and 7 mg).
The dosage of the patch to be used is dependent on the number of cigarettes an individual smokes daily. If an individual smokes >10 cigarettes per day, he or she should use the 21-mg patch initially for 6 weeks, then the 14-mg patch and the 7-mg patch each for 2 weeks. An individual who smokes fewer cigarettes may start with the 14-mg dosage for 6 weeks and then use the 7-mg patch for 2 weeks.2,6
The most common adverse effects are local skin irritations, such as pruritus and erythema. Skin irritations can be reduced or prevented by rotating the site of application on a daily basis. Some individuals may experience abnormal or vivid dreams, headache, or insomnia.1
Nicotine Polacrilex Lozenges
In 2002, the FDA approved the nicotine polacrilex lozenge (Commit lozenge; GlaxoSmithKline). It is a resin complex of nicotine and polacrilin in a sugar-free, mintflavored lozenge (containing aspartame). A new cherry flavor was introduced recently. The product is available in 2- and 4-mg strengths. The 4-mg strength should be used by those individuals who smoke their first cigarette within 30 minutes of waking up. Although 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, due to the complete dissolution of this dosage form.1
Individuals should not use >5 lozenges in 6 hours. The maximum dosage of lozenges is 20 per day. The recommended dosing intervals are similar to those for nicotine gum.1,4 Adverse effects and interactions with acidic beverages are similar to those associated with the gum.
The Role of the Pharmacist
Pharmacists can assist individuals in the selection of smoking-cessation products that. Pharmacists are key in identifying possible drug interactions and contraindications. In addition, pharmacists can encourage patients to incorporate nonpharmacologic methods in conjunction with the use of these OTC smokingcessation products.
The following patients always should consult their primary care provider before using any of these products1:
Patients with preexisting medical conditions - such as individuals who have experienced recent myocardial infarctions, those with severe angina, or those with a history of arrhythmia, uncontrolled hypertension, or active pulmonary disease
Women who are pregnant or breastfeeding
Individuals younger than 18 years of age
Pharmacists also can encourage patients to seek assistance from counseling services to increase their motivation and success with regard to smoking cessation.
For one such program, sponsored by the US Department of Health and Human Services, patients should call 800-QUITNOW (800-784-8669) or visit the Web site at http://1800quitnow.cancer.gov.
One study linked multiple pregnancies to an increased risk of developing atrial fibrillation later in life, and another investigated the association between premature delivery and cardiovascular disease.
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