Quitting smoking is at the top of the resolutions list for most smokers, and each year the enthusiastic quitter will stop for a day—or maybe even 2. Unfortunately, most smokers fail on their first try. After learning how difficult quitting is, many will never attempt such a feat again.

What is wrong with this scenario? Plenty, including the possibilities that the smoker lacked a definite quit plan, did not seek individual and/or group help, did not substantially modify his or her behavior, and, perhaps, did not receive assistance regarding a medication choice.

Which Medication Works Best?

This is a common question because smokers want a medication that will be a sure-fire cure. In truth, that medication does not exist. Although a void exists for head-to-head trials that include all smoking-cessation medications, each has been shown to help twice as many smokers quit, when compared with placebo.¹ Thus, all medications are equally efficacious and better than quitting cold turkey when used properly. This is true even with prescription-only choices.

The choice of medication should be individualized, however. What factors should be considered in this choice? For patients new to cessation medication, the unique benefits and potential adverse effects of each medication should be explained. Also, the choice should be based on previous success/ failure with a medication, unique characteristics of the patient's cravings, and patient preference.

Should the Patient Switch Medications?

In general, patients should be encouraged to use medications that have brought past success. Even if the patient's success was moderate with a particular medication, he or she may wish to try it again, combined with a more definitive quit plan. If the previous failure was due to an adverse effect, however, trying a different medication this time may be more beneficial.

The pharmacist should discern the specific reason for the previous failure. If the roadblock was an adverse effect, the patient may not have known how to overcome the problem. For example, a significant number of nicotine patch users can develop skin irritation.² These patients whose cravings were alleviated with the patch could use OTC hydrocortisone cream and rotate their patches more frequently. Since the adhesive of a particular brand—and not the strength of the patch (a common misconception)—causes the skin irritation, switching to another brand is often effective for this problem. Likewise, some patients stop using nicotine gum due to gastrointestinal distress. This is often because they chew nicotine gum like any other gum. They should chew nicotine gum slowly, then park it between the cheek and gum once a "peppery" taste emerges.

Also, patients often mistake nicotine-withdrawal symptoms for adverse effects, including increased irritability, coughing, sweating, nervousness, insomnia, and vivid dreams. These symptoms can derail a cessation attempt when combined with intense cravings. The pharmacist should distinguish whether withdrawal symptoms or an actual adverse effect caused the previous relapse before suggesting another medication.

Counseling the Patient

OTC cessation medications are nicotine-replacement therapies (NRTs), including nicotine gum, lozenges, and patches. Each is appropriate first-line therapy, except for patients with underlying cardiovascular disease (recent myocardial infarction, severe angina, or life-threatening arrhythmias) and pregnant or lactating women. Without counseling, many patients misuse nicotine gum. If patients smoke >25 cigarettes per day, they should use 4 mg. If they smoke less, 2 mg is appropriate. Unless the gum is for combination therapy, the patient should chew according to a fixed schedule. This retrains the patient not to respond to cravings with nicotine. The patient should chew 1 piece every 1 to 2 hours for weeks 1 through 6, every 2 to 4 hours for weeks 7 through 9, and every 4 to 8 hours for weeks 10 through 12. Successful users chew an average of 9 pieces per day. Also, acidic beverages can decrease efficacy if consumed up to 15 minutes before or concurrently with the gum. The first sign of a peppery or minty taste occurs after about 15 to 30 chews. Then, as noted, the patient should tuck the gum between the cheek and gum and resume chewing when the taste fades. Most nicotine is buccally absorbed within 30 minutes.³

Counseling for the lozenge is similar to that for the gum, except that the recommended dose is determined differently. If the first cigarette is smoked within 30 minutes of awakening, 4 mg is appropriate. Also, the lozenge dissolves slowly; patients should not chew, bite, or swallow the lozenge. Finally, whereas the gum may delay weight gain for some patients, the lozenge will not.⁴

For many patients, the patch is easy to use. Patients should apply it daily upon awakening—it can cause insomnia and vivid dreams if applied at bedtime—to a hairless part of the upper body. They should rotate application areas daily and remove the patches at bedtime. The onset of effect will be about 30 minutes, and mild tingling and itching can occur. If the patient is smoking >10 cigarettes per day, he or she should start with the highest dose (21 mg) for 6 weeks; then the 14-mg and 7-mg doses can be used for 2 weeks each. Also, patients should not cut patches, reuse them, or place them on compromised skin. Patches can be exposed to showering or bathing, however.⁵

NRTs:Trading One Addiction for Another?

Even with the gum, nicotine delivered as NRT does not have as quick an onset as the bolus dose delivered with cigarettes.⁶ This is an important difference, because bolus dosing leads to increased cravings. Although NRTs will attenuate cravings, they will not be entirely eliminated. Thus, patients should be given other tools, like an individualized quit plan, to combat cravings. Finally, if the patch or gum is being used beyond the titration schedule, pharmacists can offer some helpful strategies: chewing regular gum in place of nicotine gum, using the gum or patch for half the allotted time, or using it every other day instead of daily.

Can Patients Use Combinations?

Studies are conflicting regarding combined nicotine patches and gums.^7,8 Long-time nicotine users of 2 or more packs per day with several unsuccessful attempts via monotherapy may be candidates, however. A basal NRT, such as a patch, could be combined with as-needed use of a gum or lozenge for breakthrough cravings. This is similar to the principle for pain-management medications. It should be noted that levels of nicotine with combination therapy may exceed recommendations, so only selected patients may benefit. Thus, pharmacists should proceed with caution.

Helping with a Quit Plan

To maximize success, pharmacotherapy is combined with a concrete quit plan. It is essential that patients recognize that long-term success depends on a complete behavioral change. They should take steps even before the quit date, such as obtaining group and/or family support, anticipating what causes cravings, and removing tobacco products from the household. NRT should be started on the quit date, and relapse-prevention counseling should begin as soon as possible. Counseling for behavioral change and cognitive stress management are also helpful.

Lack of follow-up by a health care provider is another common cause of relapse. The pharmacist should follow up soon after the quit date, either by phone or scheduled visit. If the pharmacist needs further training on smoking cessation, several programs are available, such as the "Prescription for Change" program from the University of California at San Francisco, and the University of Pittsburgh's certificate program.⁹ A wide variety of programs are available for smokers, including Internet sites, Nicotine Anonymous programs, and programs sponsored by state chapters of the American Heart Association.

Dr. Sherman is an associate professor of pharmacy practice at the University of Louisiana at Monroe College of Pharmacy.

References

1. Silagy C, Lancaster T, Stead L, Mant D, Fowler G. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev. 2004;3:CD000146.

2. Gourlay SG, Forbes A, Marriner T, McNeil JJ. Predictors and timing of adverse experiences during transdermal nicotine therapy. Drug Saf. 1999;20(6):545-555.

3. Nicorette Web site. GlaxoSmithKline. Available at: www.nicorette.com. Accessed February 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 for smoking cessation. Cochrane Database Syst Rev. 2002;4:CD000146.

7. Hughes JR, Lesmes GR, Hatsukami DK, et al. Are higher doses of nicotine replacement more 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 oneyear smoking 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.