Quitting smoking is at the topof the resolutions list formost smokers, and each yearthe enthusiastic quitter will stop for aday—or maybe even 2. Unfortunately,most smokers fail on their first try.After learning how difficult quitting is,many will never attempt such a featagain.
What is wrong with this scenario?Plenty, including the possibilities thatthe smoker lacked a definite quit plan,did not seek individual and/or grouphelp, did not substantially modify his orher behavior, and, perhaps, did notreceive assistance regarding a medicationchoice.
Which Medication Works Best?
This is a common question becausesmokers want a medication that will bea sure-fire cure. In truth, that medicationdoes not exist. Although a voidexists for head-to-head trials thatinclude all smoking-cessation medications,each has been shown to helptwice as many smokers quit, whencompared with placebo.1 Thus, all medicationsare equally efficacious andbetter than quitting cold turkey whenused properly. This is true even withprescription-only choices.
The choice of medication should beindividualized, however. What factorsshould be considered in this choice?For patients new to cessation medication,the unique benefits and potentialadverse effects of each medicationshould be explained. Also, the choiceshould be based on previous success/failure with a medication, unique characteristicsof the patient's cravings,and patient preference.
Should the Patient SwitchMedications?
In general, patients should beencouraged to use medications thathave brought past success. Even if thepatient's success was moderate with aparticular medication, he or she maywish to try it again, combined with amore definitive quit plan. If the previousfailure was due to an adverseeffect, however, trying a different medicationthis time may be morebeneficial.
The pharmacist should discern thespecific reason for the previous failure.If the roadblock was an adverse effect,the patient may not have known how toovercome the problem. For example, asignificant number of nicotine patchusers can develop skin irritation.2 Thesepatients whose cravings were alleviatedwith the patch could use OTC hydrocortisonecream and rotate their patchesmore frequently. Since the adhesiveof a particular brand—and not thestrength of the patch (a common misconception)—causes the skin irritation,switching to another brand is ofteneffective for this problem. Likewise,some patients stop using nicotine gumdue to gastrointestinal distress. This isoften because they chew nicotine gumlike any other gum. They should chewnicotine gum slowly, then park itbetween the cheek and gum once a"peppery" taste emerges.
Also, patients often mistake nicotine-withdrawalsymptoms for adverseeffects, including increased irritability,coughing, sweating, nervousness, insomnia,and vivid dreams. These symptomscan derail a cessation attemptwhen combined with intense cravings.The pharmacist should distinguishwhether withdrawal symptoms or anactual adverse effect caused the previousrelapse before suggesting anothermedication.
Counseling the Patient
OTC cessation medications are nicotine-replacement therapies (NRTs),including nicotine gum, lozenges, andpatches. Each is appropriate first-linetherapy, except for patients withunderlying cardiovascular disease(recent myocardial infarction, severeangina, or life-threatening arrhythmias)and pregnant or lactating women.Without counseling, many patientsmisuse nicotine gum. If patients smoke>25 cigarettes per day, they should use4 mg. If they smoke less, 2 mg is appropriate.Unless the gum is for combinationtherapy, the patient should chewaccording to a fixed schedule. Thisretrains the patient not to respond tocravings with nicotine. The patientshould chew 1 piece every 1 to 2 hoursfor weeks 1 through 6, every 2 to 4hours for weeks 7 through 9, and every4 to 8 hours for weeks 10through 12. Successful userschew an average of 9 piecesper day. Also, acidic beveragescan decrease efficacy ifconsumed up to 15 minutesbefore or concurrently withthe gum. The first sign of apeppery or minty tasteoccurs after about 15 to 30chews. Then, as noted, thepatient should tuck the gumbetween the cheek and gumand resume chewing whenthe taste fades. Most nicotineis buccally absorbedwithin 30 minutes.3
Counseling for the lozenge is similarto that for the gum, except that therecommended dose is determined differently.If the first cigarette is smokedwithin 30 minutes of awakening, 4 mgis appropriate. Also, the lozenge dissolvesslowly; patients should notchew, bite, or swallow the lozenge.Finally, whereas the gum may delayweight gain for some patients, thelozenge will not.4
For many patients, the patch is easyto use. Patients should apply it dailyupon awakening—it can cause insomniaand vivid dreams if applied at bedtime—to a hairless part of the upperbody. They should rotate applicationareas daily and remove the patches atbedtime. The onset of effect will beabout 30 minutes, and mild tinglingand itching can occur. If the patient issmoking >10 cigarettes per day, he orshe should start with the highest dose(21 mg) for 6 weeks; then the 14-mgand 7-mg doses can be used for 2weeks each. Also, patients should notcut patches, reuse them, or placethem on compromised skin. Patchescan be exposed to showering orbathing, however.5
NRTs:Trading One Addiction forAnother?
Even with the gum, nicotine deliveredas NRT does not have as quick anonset as the bolus dose delivered withcigarettes.6 This is an important difference,because bolus dosingleads to increased cravings.Although NRTs will attenuatecravings, they will notbe entirely eliminated. Thus,patients should be givenother tools, like an individualizedquit plan, to combatcravings. Finally, if the patchor gum is being used beyondthe titration schedule,pharmacists can offer somehelpful strategies: chewingregular gum in place ofnicotine gum, using thegum or patch for half theallotted time, or using it every otherday instead of daily.
Can Patients Use Combinations?
Studies are conflicting regardingcombined nicotine patches andgums.7,8 Long-time nicotine users of 2or more packs per day with severalunsuccessful attempts via monotherapymay be candidates, however. Abasal NRT, such as a patch, could becombined with as-needed use of agum or lozenge for breakthrough cravings.This is similar to the principle forpain-management medications. Itshould be noted that levels of nicotinewith combination therapy may exceedrecommendations, so only selectedpatients may benefit. Thus, pharmacistsshould proceed with caution.
Helping with a Quit Plan
To maximize success, pharmacotherapyis combined with a concrete quitplan. It is essential that patients recognizethat long-term success dependson a complete behavioral change. Theyshould take steps even before the quitdate, such as obtaining group and/orfamily support, anticipating whatcauses cravings, and removing tobaccoproducts from the household. NRTshould be started on the quit date, andrelapse-prevention counseling shouldbegin as soon as possible. Counselingfor behavioral change and cognitivestress management are also helpful.
Lack of follow-up by a health careprovider is another common cause ofrelapse. The pharmacist should followup soon after the quit date, either byphone or scheduled visit. If the pharmacistneeds further training on smokingcessation, several programs areavailable, such as the "Prescription forChange" program from the Universityof California at San Francisco, and theUniversity of Pittsburgh's certificateprogram.9 A wide variety of programsare available for smokers, includingInternet sites, Nicotine Anonymousprograms, and programs sponsored bystate chapters of the American HeartAssociation.
Dr. Sherman is an associate professorof pharmacy practice at theUniversity of Louisiana at MonroeCollege of Pharmacy.
1. Silagy C, Lancaster T, Stead L, Mant D, Fowler G. Nicotine replacement therapy forsmoking cessation. Cochrane Database Syst Rev. 2004;3:CD000146.
2. Gourlay SG, Forbes A, Marriner T, McNeil JJ. Predictors and timing of adverseexperiences during transdermal nicotine therapy. Drug Saf. 1999;20(6):545-555.
3. Nicorette Web site. GlaxoSmithKline. Available at: www.nicorette.com. AccessedFebruary 2, 2007.
4. Commit Lozenge Web site. GlaxoSmithKline. Available at: www.commitlozenge.com.Accessed February 2, 2007.
5. Nicoderm CQ Web site. GlaxoSmithKline. Available at: www.nicodermcq.com.Accessed February 2, 2007.
6. Silagy C, Lancaster T, Stead L, Mant D, Fowler G. Nicotine replacement therapy forsmoking cessation. Cochrane Database Syst Rev. 2002;4:CD000146.
7. Hughes JR, Lesmes GR, Hatsukami DK, et al. Are higher doses of nicotine replacementmore effective for smoking cessation? Nicotine Tob Res. 1999;1:169-174.
8. Tonnesen P, Paoletti P, Gustavsson G, et al. Higher dosage nicotine patches increase oneyearsmoking cessation rates: results from the European CEASE trial. Eur Respir J.1999;13:238-246.
9. Prescription for Change. Available at:www.calmedfoundation.org/rxchange/cessation/cessation1.html. Accessed January 30, 2007.