Treatment

Pharmaceutical Options

• Buproprion, HCL
• Nicotine Replacement Therapies

Buproprion, HCL

Bupropion HCL is available by prescription only, as the product ZybanŽ. This medication is appropriate as a first line treatment for smoking cessation, and is not a nicotine replacement product. 

Some precautions exist for patients considering the usage of this product including: 

1. Pregnant smokers are encouraged to quit smoking without this treatment, unless the benefits of smoking cessation with bupropion outweigh the risks. 
2. Hypertension has been reported to be caused by bupropion. 
3. Insomnia (found in 30-45% of users) and dry mouth (10% of users) are the most common side effects. 
4. Bupropion is contraindicated in those with seizure disorders, eating disorders or using another form of bupropion. 

Other considerations with bupropion HCL include: 

1. Patients should begin this therapy 1-2 weeks before they quit smoking. 
2. If insomnia is experienced, then the PM dose can be taken in the afternoon. 
3. Alcohol should be used in moderation with concurrent use of bupropion. 
4. Average cost per day of this product is $3.33.

Nicotine Replacement Therapies

Except in special circumstances, EVERY smoker should be offered nicotine replacement, via gum or patch. Cardiovascular patients who have had a recent myocardial infraction (within 4 weeks), those with serious arrhythmias, and severe or worsening angina should be considered carefully. Pregnant women should first be advised to attempt cessation without pharmacologic treatment.

Nicotine Gum

Recommendations: Nicotine gum can be purchased over the counter, and clinicians are encouraged to discuss replacement therapy with all smokers.

• Gum improves cessation rates by 40-60% through 12 months. Gum is more efficacious compared to placebo, regardless of adjuvant psychosocial intervention. Whenever possible, concomitant psychosocial interventions are to be encouraged. (See intensive treatment above)
• Use of 4 mg gum is more effective than 2 mg gum.
• Technique for administration:
  • No smoking while using the gum.
  • Gum should be chewed slowly until a "peppery" taste emerges, then "parked" between cheek and gum to improve absorption through oral mucosa. When taste disappears, repeat process until all nicotine is extracted from gum (Usually takes about 30 minutes).
• Chew gum on a fixed dose schedule of at least one piece every 1-2 waking hours ( not more than 30 pieces a day for 2 mg or 20 pieces a day for 4 mg) for a least 1-3 months.
• Avoid acidic beverages (coffee, cola, juices) while chewing. Wait 15 minutes before or after using gum. Water may be taken at any time.
• Common side effects include: mouth soreness, hiccups, dyspepsia, and jaw ache. Correct chewing instructions reduce these effects.
• Factors which support use of gum over patch:
  • patient preference
  • previous failure with patch severe skin reaction to patch

For more specific consumer-oriented information see www.nicorette.com

Nicotine Patch

Patch recommendations: transdermal nicotine patch doubles 6-12 months abstinence rates and is more efficacious, regardless of intensity of adjuvant psychosocial intervention. As with nicotine gum, the concomitant use of psychosocial interventions is recommended. Nicotine patch is available over-the-counter and clinicians should discuss its use with all tobacco users. Nicotine patch is associated with fewer compliance problems, as compared to the gum. Technique for administration:

• No smoking while on the patch.
• At the start of each day, place a new patch on a relatively hairless location between neck and waist.
• Rotate location site of patch daily.
• Dispose of used patches carefully so as to avoid contact by pets/children.
• Nicotine patch has several brand names with varying dosages and duration of use. These include:

Brand	Duration	Dosage
Nicoderm and Habitrol
	4 weeks	21 mg/24 hours
	then 2 weeks	14 mg/24 hours
	then 2 weeks	7 mg/24 hours
Prostep
	4 weeks	22 mg/24 hours
	then 4 weeks	11 mg/24 hours
Nicotrol
	4 weeks	22 mg/16 hours
	then 2 weeks	10 mg/16 hours
	then 2 weeks	5 mg/16 hours

Nicotine Nasal Spray- Nicotrol NS

This product is sold by McNeil Consumer Products Co. of Fort Washington, PA., under license from Pharmacia of Sweden. The FDA approved this product based on the following results of a 730 patient study. 54% of the patients who were given the spray stopped smoking for six weeks, as opposed to 27% of the patients who were given the placebo. About 25% of patients receiving the drug stopped smoking for at least one year, while only 13% in the placebo group reached this goal. It is recommended that patients only use this product for three months due to the addictive nature of nicotine. The chance of becoming dependent on the nasal spray increases after six months. Therefore, this product should not be used for more than six months.

Nicotrol Inhaler

The Nicotrol Inhaler, developed by Pharmacia & Upjohn Inc. but marketed by McNeil Consumer Products has recently been approved by the FDA and is available by prescription. The inhaler looks like a fat plastic cigarette, and a foil-wrapped nicotine cartridge is inserted into a white tube. Each puff of the inhaler contains eight to ten times less nicotine than a puff of a cigarette, and none of the tar and toxins from regular cigarettes. The inhaler provides a "hand-to-mouth" behavior, and it provides a sensation on the back of the throat similar to the feeling of inhaling a cigarette. Nicotine inhaled through the mouthpiece is absorbed bucally (through the mouth), rather than through the lungs.

NRT Type	Time period Peak Venous Blood Concentration
patch	4-6 hours 10-15 ng/ml slowest absorption
2mg gum	10-30 minutes 10ng/ml somewhat faster
1 mg nicotine nasal spray	11.5 minutes 8.1ng/ml faster still
Inhaler - 80 puffs	20 minutes 8.1ng/ml slower absorption, lower blood levels
1.2 mg cigarette	5 minutes 25ng.ml fastest absorption, highest blood levels

Additional Information

Nicotine Replacement Factsheet from the American Lung Association