Yvette C. Terrie, BSPharm, RPh
Nicotine replacement therapy comes in a variety of dosage forms. Pharmacists can help patients choose the right OTC smoking cessation products to help them successfully quit smoking.
Quitting smoking is often more easily said than done. Finding the most efficacious means to quit may seem overwhelming and impossible to many patients. According to the Centers for Disease Control and Prevention, an estimated 70% of adult smokers in the United States want to quit smoking.1
Knowing the various health benefits associated with smoking cessation may help motivate many smokers to initiate a plan to quit. According to a 2004 publication of the Surgeon General’s report entitled The Health Consequences of Smoking
, smoking adversely affects almost every organ system in the body and can contribute to the development of various medical conditions.2
describes the health benefits of smoking cessation.
Over 35 million smokers attempt to quit each year, but less than 5% reach their 1-year anniversary.5
Furthermore, results from one study report that 90% of “cold turkey” quitters start smoking again within 6 months.6
Fortunately, there are a host of OTC nicotine replacement products on the market to assist those individuals who want to quit smoking.
Nicotine Replacement Therapy
OTC nicotine replacement therapy (NRT) is available in dosage formulations that include gum, patches, and lozenges (Table 2). The newest product on the market is Nicorette Mini Lozenges (GlaxoSmithKline). NRT products decrease nicotine cravings and withdrawal symptoms that typically occur after abstinence from tobacco products and enable patients to focus on the behavioral modifications that are also necessary to quit smoking.2,7,8
Nicotine Transdermal System
The nicotine transdermal system continually releases low levels of nicotine into the body over a 24-hour period.2
Transdermal products available include the Nicoderm CQ with Smart Control Patch (GlaxoSmithKline) and Habitrol Patch (Novartis Consumer Health), as well as generic formulations. These patches are available in steps 1 to 3 in decreasing strengths of 21, 14, and 7 mg of nicotine. The dosage of the patch is dependent upon the number of cigarettes an individual smokes daily. If an individual smokes more than 10 cigarettes per day, the 21-mg patch should be the initial strength used for 6 weeks, followed by the 14- and 7-mg patches for 2 weeks each. Individuals who smoke fewer than 10 cigarettes daily may start with the 14-mg dosage for 6 weeks and then switch to the 7-mg patch for 2 weeks.2,9,10
Local skin irritations, such as pruritus and erythema, are the most commonly reported adverse effects.2
Skin irritations can be reduced or prevented by rotating the application of patches on a daily basis. Some individuals using transdermal patches have reported having abnormal or vivid dreams, headache, or insomnia.2,9,10
Patients experiencing these effects should be advised to remove the patch at bedtime and apply a new patch upon waking in the morning.2
Nicotine polacrilex gum, such as Nicorette (GlaxoSmithKline), is a resin complex of nicotine and polacrilin in a sugar-free (containing sorbitol) chewing gum base.2,8
Available strengths include 2 and 4 mg in flavors such as original (tobacco), mint, fruit, cinnamon, and orange.2,8
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.2,8
Typically, the peak concentrations of nicotine are achieved within 30 minutes after beginning to chew the gum and then slowly decrease over the next 2 to 3 hours.2
To use this product properly, patients should be counseled to use the “chew and park” method, which involves chewing the gum and then letting it sit between the gums and cheek to allow for the absorption of the nicotine. The most common adverse effects are unpleasant taste, dyspepsia, jaw muscle soreness, hypersalivation, hiccups, and mouth irritation.2,8
Ingestion of acidic beverages may decrease the effectiveness of the gum. Patients should not eat or drink anything except water for about 15 minutes before or while chewing the gum. The recommended use of NRT gum is 1 piece of gum every 1 to 2 hours while awake during weeks 1 through 6; followed by 1 piece every 2 to 4 hours during weeks 7 through 9; and 1 piece every 4 to 8 hours during weeks 10 through 12. No more than 24 pieces per day should be used.2,8
Nicotine Polacrilex Lozenges
Available nicotine polacrilex lozenges include Commit Lozenges (GlaxoSmith- Kline), which is a resin complex of nicotine and polacrilin that is available in regular, mint, or cherry sugar-free (aspartame) lozenges. Nicorette Mini Lozenges (GlaxoSmithKline) are available in mint flavor. Both brands of lozenges are available in 2- and 4-mg strengths.2,11
The 4-mg strength should be used for those individuals who smoke their first cigarette within 30 minutes of waking up, and the 2-mg strength is for those who smoke their first cigarette more than 30 minutes after waking.2,11
While the pharmacokinetics of both the gum and lozenge are comparable, the lozenge delivers approximately 25% more nicotine than the equivalent dose of nicotine gum due to the complete dissolution of the dosage form.2,11
During the initial 6 weeks of therapy, patients should use 1 lozenge every 1 to 2 hours while awake.2,11
Patients can use additional dosages and should be advised to not use more than 5 lozenges in 6 hours or 20 lozenges in a 24-hour period. The recommended dosing intervals, adverse effects, and interaction with acidic beverages are comparable to those associated with use of the gum.2,11
The Role of the Pharmacist
Patients aged 18 years or younger and those with preexisting medical conditions, such as recent myocardial infarctions, severe angina, a history of arrhythmia, uncontrolled hypertension, and active peptic ulcer disease, or women who are pregnant or breastfeeding, should always consult their primary care provider prior to using any OTC NRT products.2
Because tobacco smoke interacts with various pharmacologic agents through pharmacokinetic or pharmacodynamic mechanisms that may result in decreased therapeutic efficacy or, less commonly, increased toxicity, pharmacists are key in identifying possible drug interactions and contraindications associated with tobacco use.2
Examples of drug interactions with tobacco smoke include hormonal contraceptives, beta-blockers, theophylline, and benzodiazepines.2
Pharmacists can provide patients with suggestions of nonpharmacologic methods that can be used in conjunction with OTC smoking cessation products and encourage patients to seek assistance from counseling services to increase the chances of successful smoking cessation.
Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia
Smoking cessation use. Centers for Disease Control Web site. Available at: www.cdc.gov/tobacco/data_statistics/fact_sheets/cessation/quitting/index.htm. Accessed May 27, 2010.
Kroon L, Hudmon K, Corelli R. Smoking cessation. In: Berardi R, Newton G, McDermott JH, et al. Handbook of Nonprescription Drugs. 16th Ed. Washington, DC: American Pharmacists Association; 2009:894-913.
Health benefits of smoking cessation. Centers for Disease Control Web site. Available at: www.cdc.gov/tobacco/data_statistics/fact_sheets/cessation/quitting/index.htm. Accessed May 29, 2010.
Guide to quit smoking. American Cancer Society Web site. Available at: www.cancer.org/docroot/ped/content/ped_10_13x_guide_for_quitting_smoking.asp. Accessed May 30, 2010.
Nicotine and addiction. The #1 reason smokers keep smoking. Commit Lozenge Web site. Available at: www.commitlozenge.com/Nicotine.aspx. Accessed May 30, 2010.
Cold turkey or not. Commit Lozenge Web site. Available at: www.commitlozenge.com/Nicotine_Cold.aspx. Accessed May 30, 2010.
Nicorette Mini Lozenges [Product Information]. GlaxoSmithKline website. Available at: www.nicorette.com/Products/Nicorette-mini.aspx. Accessed May 30, 2010.
Nicorette gum [product information]. GlaxoSmithKline Web site. Available at: www.nicorette.com/Products/Nicorette-Gum.aspx.Accessed May 30, 2010
Nicoderm CQ [product information]. GlaxoSmithKline Web site. Available at: www.nicodermcq.com/NicodermCQ.aspx. Accessed May 30, 2010.
Habitrol [product information]. Novartis Consumer Health Web site. Available at: www.habitrol.com/index.html. Accessed May 30, 2010.
Commit lozenges [product information] GlaxoSmithKline Web site. Available at: www.commitlozenge.com/Commit.aspx. Accessed May 30, 2010.