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TOBACCO DEPENDENCE: a 2‐PART PROBLEM Tobacco Dependence

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TOBACCO DEPENDENCE: a 2‐PART PROBLEM Tobacco Dependence TOBACCO DEPENDENCE: A 2‐PART PROBLEM Tobacco Dependence Physiological Behavioral MEDICATIONS for CESSATION The addiction to nicotine The habit of using tobacco Treatment Treatment Medications for cessation Behavior change program Treatment should address the physiological and the behavioral aspects of dependence. NICOTINE WITHDRAWAL SYMPTOMS: Time Course* and Management PHARMACOTHERAPY Irritability / Frustration / Anger “ Anxiety Most symptoms manifest within Clinicians should encourage all patients Difficulty concentrating the first 1–2 days, peak within Restlessness / Impatience attempting to quit to use effective Depressed mood / Depression the first week, and subside Insomnia within 2–4 weeks. medications for tobacco dependence Impaired task performance Increased appetite 6 months treatment, except where contraindicated Weight gain Can persist for months Cravings or for specific populations* for which there to years after quitting 1 week 4 weeks 12 weeks is insufficient evidence of effectiveness.” Quit Former Recent quitter * Includes pregnant women, smokeless tobacco users, light smokers, and adolescents. date tobacco user Cognitive & behavioral coping strategies Medications significantly improve success rates. Medications for cessation Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. *Timeline aspect of the figure is not according to scale. Data from Hughes. (2007). Nicotine Tob Res 9:315–327. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008. PHARMACOTHERAPY: FDA‐APPROVED MEDICATIONS Use in SPECIAL POPULATIONS for CESSATION Pharmacotherapy is not recommended for: Nicotine polacrilex gum* Nicotine inhaler * Pregnant smokers . Nicorette (OTC) . Nicotrol (Rx) Insufficient evidence of effectiveness . Generic nicotine gum (OTC) Nicotine nasal spray * Smokeless tobacco users Nicotine lozenge* No FDA indication for smokeless tobacco cessation . Nicotrol NS (Rx) . Nicorette (OTC) Individuals smoking fewer than 10 cigarettes per day . Generic nicotine lozenge (OTC) Bupropion SR Adolescents . Generic (Rx) Nonprescription sales of nicotine replacement therapy (NRT) products Nicotine transdermal patch* (i.e., patch, gum, lozenge) are restricted to adults ≥18 years of age . Habitrol (OTC) Varenicline NRT use in minors requires a prescription . NicoDerm CQ (OTC) . Chantix (Rx) . Generic nicotine patches (OTC) Recommended treatment is behavioral counseling. * Nicotine replacement therapy (NRT) products. Copyright © 1999‐2021 The Regents of the University of California. All rights reserved. Updated January 2021. 1 NICOTINE REPLACEMENT THERAPY PLASMA NICOTINE CONCENTRATIONS (NRT) RATIONALE for USE for NICOTINE‐CONTAINING PRODUCTS . Reduces physical withdrawal from nicotine Cigarette 25 Moist snuff Cigarette . Eliminates the immediate, reinforcing effects of 20 Moist snuff Nasal spray nicotine that is rapidly absorbed via tobacco (mcg/l) 15 smoke Inhaler nicotine 10 . Allows patient to focus on behavioral and Lozenge (2mg) Plasma 5 psychological aspects of tobacco cessation Gum (2mg) 0 1/0/1900 1/10/1900 1/20/1900 1/30/1900 2/9/1900 2/19/1900 2/29/1900 Patch 0 10 20 30 40 50 60 NRT products approximately doubles quit rates. Time (minutes) NICOTINE GUM NRT: PRECAUTIONS Nicorette; generics Resin complex Patients with underlying cardiovascular disease Nicotine Recent myocardial infarction (within past 2 Polacrilin weeks) Sugar‐free chewing gum base Serious arrhythmias Contains buffering agents to enhance buccal absorption of nicotine Serious or worsening angina Available: 2 mg, 4 mg; original, cinnamon, fruit, and mint (various) flavors NRT products may be appropriate for these patients if they are under medical supervision. NICOTINE LOZENGE NICOTINE GUM & LOZENGE: Nicorette Lozenge, Nicorette Mini Lozenge; generics DOSING . Nicotine polacrilex formulation Dose based on the “time to first cigarette” (TTFC) . Delivers ~25% more nicotine as an indicator of nicotine dependence than equivalent gum dose Use the 2 mg gum/lozenge: . Sugar‐free mint, cherry flavors If first cigarette of the day is smoked . Contains buffering agents to more than 30 minutes after waking enhance buccal absorption of Use the 4 mg gum/lozenge: nicotine If first cigarette of the day is . Available: 2 mg, 4 mg smoked within 30 minutes of waking Copyright © 1999‐2021 The Regents of the University of California. All rights reserved. Updated January 2021. 2 NICOTINE GUM & LOZENGE: NICOTINE GUM: DOSING (cont’d) DIRECTIONS FOR USE Chew slowly Recommended Usage Schedule Stop chewing at first Weeks 1–6 Weeks 7–9 Weeks 10–12 Chew again when peppery taste or sign of peppery taste 1 piece q 1–2 h1 piece q 2–4 h1 piece q 4–8 h tingle fades or tingling sensation Park between Do not use more than 24 pieces of GUM cheek & gum or 20 LOZENGES per day. NICOTINE LOZENGE: NICOTINE GUM/LOZENGE: DIRECTIONS for USE ADDITIONAL PATIENT EDUCATION . Place in mouth and allow to dissolve slowly . To improve chances of quitting, use at least nine pieces (nicotine release may cause warm, tingling daily during the first 6 weeks sensation) . The gum/lozenge will not provide the same rapid satisfaction that smoking provides . Do not chew or swallow . The effectiveness of the nicotine gum/lozenge may be . Occasionally rotate to different areas of the mouth reduced by some foods and beverages: . Lozenges will dissolve completely in about 2030 − Coffee − Juices minutes − Wine − Soft drinks Do NOT eat or drink for 15 minutes BEFORE or while using the nicotine gum or lozenge. NICOTINE GUM/LOZENGE: NICOTINE GUM/LOZENGE: ADD’L PATIENT EDUCATION (cont’d) ADD’L PATIENT EDUCATION (cont’d) . Chewing the lozenge or using incorrect gum chewing . Adverse effects of nicotine gum and lozenge: technique can cause excessive and rapid release of . Mouth and throat irritation nicotine, resulting in: . Hiccups . Lightheadedness/dizziness . Gastrointestinal complaints (dyspepsia, nausea) . Nausea and vomiting . Adverse effects associated with nicotine gum: . Hiccups . Jaw muscle ache . Irritation of throat and mouth . May stick to dental work Copyright © 1999‐2021 The Regents of the University of California. All rights reserved. Updated January 2021. 3 NICOTINE GUM/LOZENGE: TRANSDERMAL NICOTINE PATCH SUMMARY Habitrol; NicoDerm CQ; generic ADVANTAGES DISADVANTAGES . Continuous (24‐hour) nicotine delivery system Might serve as an oral substitute Need for frequent dosing can compromise for tobacco adherence . Nicotine is well absorbed across the skin Might delay weight gain Gastrointestinal adverse effects (nausea, . Transdermal delivery to systemic circulation avoids hepatic Can be titrated to manage hiccups, and dyspepsia) may be bothersome first‐pass metabolism withdrawal symptoms Specific to nicotine gum: . Plasma nicotine levels are lower and fluctuate less than Can be used in combination with . Might be problematic for patients with significant other agents to manage situational dental work with smoking urges . Proper chewing technique is necessary for effectiveness and to minimize adverse effects Relatively inexpensive . Chewing might not be acceptable or desirable for some patients TRANSDERMAL NICOTINE PATCH: TRANSDERMAL NICOTINE PATCH: DOSING DIRECTIONS for USE . Choose an area of skin on the Product Light Smoker Heavy Smoker upper body or upper outer part of 10 cigarettes/day >10 cigarettes/day the arm Step 2 (14 mg x 6 weeks) Step 1 (21 mg x 6 weeks) NicoDerm CQ . Make sure skin is clean, dry, Step 3 (7 mg x 2 weeks) Step 2 (14 mg x 2 weeks) hairless, and not irritated Step 3 (7 mg x 2 weeks) . Apply patch to different area each 10 cigarettes/day >10 cigarettes/day day Habitrol Step 2 (14 mg x 6 weeks) Step 1 (21 mg x 4 weeks) . Do not use same area again for at Generic Step 3 (7 mg x 2 weeks) Step 2 (14 mg x 2 weeks) least 1 week Step 3 (7 mg x 2 weeks) TRANSDERMAL NICOTINE PATCH: TRANSDERMAL NICOTINE PATCH: DIRECTIONS for USE (cont’d) DIRECTIONS for USE (cont’d) . Remove protective liner and . Wash hands: Nicotine on hands can get into eyes apply adhesive side of patch to skin or nose and cause stinging or redness . Peel off remaining protective . Do not leave patch on skin for more than 24 covering hours—doing so may lead to skin irritation . Press firmly with palm of . Adhesive remaining on skin may be removed with hand for 10 seconds rubbing alcohol or acetone . Make sure patch sticks well to skin, especially around . Dispose of used patch by folding it onto itself, edges completely covering adhesive area Copyright © 1999‐2021 The Regents of the University of California. All rights reserved. Updated January 2021. 4 TRANSDERMAL NICOTINE PATCH: TRANSDERMAL NICOTINE PATCH: ADDITIONAL PATIENT EDUCATION ADD’L PATIENT EDUCATION (cont’d) Water will not harm the nicotine patch if it is applied correctly; Common adverse effects include: patients may bathe, swim, shower, or exercise while wearing the patch . Irritation at the patch application site (generally Do not cut patches to adjust dose within the first hour) . Mild itching Can unpredictably effect nicotine delivery . Burning Patch may be less effective . Tingling Keep new and used patches out of the reach of . Sleep disturbances children and pets . Abnormal or vivid dreams . Insomnia Remove patch before MRI procedures TRANSDERMAL NICOTINE PATCH: TRANSDERMAL NICOTINE PATCH: ADD’L PATIENT EDUCATION (cont’d) SUMMARY . After patch removal, skin may appear red for 24 hours ADVANTAGES . If skin stays red more than 4 days or if it swells or a rash DISADVANTAGES appears, contact health care provider—do
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