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Practice Points
• Over-the-counter smoking cessation products likely will be the most appropriate first-line choice for many individuals before trying prescription products.
• Instruct patients to avoid smoking while using nicotine replacement therapy and educate them about the immediate and long-term benefits of quitting.
• Encourage patients to seek psychosocial counseling along with pharmacotherapy.
• Urge patients to engage in other quitting strategies by referring them to online and telephone resources (Related Resources). Also, encourage them to attend follow-up appointments to assess cessation therapy.
Mr. T, age 56, has major depressive disorder that is well controlled with fluoxetine, 40 mg/d. He has smoked ≥1 packs of cigarettes per day for the last 25 years. On a recent visit, he indicates that he has begun using a 21-mg nicotine patch as advised by his pharmacist and that things are going OK, although he has had some “slip ups.” He is on week 7 of his quitting regimen and now is stepping down the patch dosage.
Upon further questioning he says that he has been cutting the 21-mg patches in half to save money. Mr. T also explains that occasionally he has given in to a strong urge to smoke because it was “too much to handle.” He states that he does not think this is a big deal because he uses electronic cigarettes and has heard that these products don’t contain “the bad cancer stuff.” At the end of Mr. T’s visit, he asks for something to help him sleep because has been unable to sleep consistently and has been having vivid dreams since starting the patch. He also wants to know how to reduce itching from the patch.
Approximately 46 million Americans smoke and cigarette smoking accounts for 1 of every 5 deaths in the United States each year.1 Since the advent of “Stop Smoking” campaigns, bans on smoking in public buildings, over-the-counter (OTC) nicotine replacement products, and Surgeon General recommendations, discussing smoking cessation with patients has become standard practice.
Research suggests that treatment to quit smoking should include a combination of pharmacotherapy and counseling, such as cognitive-behavioral strategies, support groups, and quitting hotlines.2 Pharmacotherapy consists of OTC nicotine replacement therapy (NRT) products and prescription medications. This article briefly highlights how to counsel patients about using OTC NRT products (Table 1).2-5 See Table 2 for a summary of prescription smoking cessation agents
Table 1
Over-the-counter nicotine replacement therapy products
| Product | Dosage | Side effects | Amount of nicotine | Costa | Comments |
|---|---|---|---|---|---|
| Nicotine transdermal patches | For patients who smoked >.5 PPD: 21 mg/d for 6 weeks; 14 mg/d for 2 weeks; 7 mg/d for 2 weeks | Local skin irritation, sleep disturbances, and vivid dreams | 7, 14, or 21 mg /d | 21 mg: $32 for 14 patches 14 mg: $32 for 14 patches 7 mg: $19 for 7 patches | Alternate sites. Do not cut. Do not leave on skin for longer than life of patch (24 hours). Washing, bathing, swimming are OK. Remove patch if undergoing MRI because of reports of burns |
| For patients who smoked <.5 PPD: 14 mg/d for 6 weeks; 7 mg/d for 2 weeks | |||||
| Nicotine polacrilex gum | For patients who smoked ≥1.25 PPD: 4 mg | Unpleasant taste, jaw soreness, hiccups, dyspepsia, hypersalivation, and nausea (from chewing gum too quickly) | 2 or 4 mg per piece | 4 mg: $50 for 170 pieces 2 mg: $50 for 170 pieces | Use “chew and park” method. As part of combination therapy, use only as needed. No more than 24 pieces per day; use caution with patients with jaw or mouth conditions |
| For patients who smoked <1.25 PPD: 2 mg Weeks 1 to 6: 1 piece every 1 to 2 hours Weeks 7 to 9: 1 piece every 2 to 4 hours Weeks 10 to 12: 1 piece every 4 to 8 hours | |||||
| Nicotine polacrilex lozenge | For patients who smoked 1st cigarette within 30 minutes of waking: 4 mg | Mouth irritation, hiccups, nausea, cough, and insomnia | 2 or 4 mg per lozenge | 4 mg: $43 for 72 lozenges 2 mg: $43 for 72 lozenges | Dissolve lozenge in mouth for 20 to 30 minutes. Rotate lozenge to different parts of mouth occasionally. Do not chew. No more than 5 lozenges in 6 hours or 20 per day. Same taper schedule as nicotine gum |
| For patients who smoked 1st cigarette >30 minutes after waking: 2 mg | |||||
| aAll prices taken from drugstore.com on September 26, 2011 PPD: packs per day Source: References 2-5 | |||||
Patches
Nicotine replacement patches are best used for maintenance treatment of nicotine cravings. They deliver a fixed amount of nicotine over 24 hours.3 Patches have a specially formulated transdermal matrix system and should not be cut. Doing so damages the drug delivery system and could lead to drug evaporation from the cut edges.4 Mr. T’s psychiatrist advises him not to cut patches but instead purchase the 14-mg patch because he is at this step of the smoking cessation regimen.