Nicotine Replacement Therapy Benefits Tobacco Cessation Efforts

In an interview with Pharmacy Times, Elisa K. Tong, MD, MA, discussed the landscape of tobacco cessation and nicotine replacement therapy, particularly in pharmacies. Helping patients overcome barriers to accessing these treatments is a vital role for pharmacists, who can support patients who are looking to quit.

Q: What sorts of tools are available for tobacco cessation, and what are their access barriers?

Elisa K. Tong, MD, MA: Sure, so tobacco treatment is one of the most difficult things because nicotine is so addictive, and the products now are maybe even more [addictive] and there's even a broader variety. So, the 2 principles of tobacco treatment in the clinic are coaching them through that behavior change, and then also helping them with medications. So, there's 7 FDA approved medications, and they're covered if you get a prescription. I think a lot of what people think of is ‘Oh, that's available over the counter for nicotine, patch gum, or lozenge.’ But if you have a prescription, it's covered, right? And it's actually expensive—$40 for like a box of nicotine 1 month, a box of nicotine patches, whereas your cigarettes, you know, now it's more expensive, but it's like $8 to $10, right? Or maybe cheaper if you buy it in bulk.

So, for us, one thing is we use the pharmacy team so much, and by state law, and in several other states, pharmacists can furnish nicotine medications and do the counseling. And actually, in California, the pharmacy students are actually trained and get much more training than the physicians do for tobacco treatment and counseling. So, in terms of access barriers, it's harder to make an appointment and see your physician and most people don't do it for quitting tobacco. Sometimes they'll do it because they have a cold and then it comes up. But at a pharmacy, you can just walk in, and it's a lot more accessible to many people. You know, I think there's something that says the majority of people in the US live within 5 miles [of a pharmacy], so how do you get access in-person? We do have our free state quick lines that can help, but in California, you won't get your full covered medication benefit that way. But if you go to a pharmacist and they can help you with getting covered medication, then you kind of combined the best of both worlds. So, we've had that law in California for over 10 years that pharmacists are allowed to have the authority to furnish, which means that they can prescribe, but the implementation of it has been a lot harder.

Q: What is nicotine replacement therapy, and what does it entail?

Tong: Yeah, so of those 7 FDA-approved medications for helping someone to quit tobacco, there's 5 that are nicotine cessation medications. So, the 3 that people most know most often are the patch, and then the gum and lozenge. So, the patch is sort of a long-acting thing you put on every day, you replace every day, it gives you kind of this steady state level of nicotine, so you don't have cravings. The other 2 are nasal spray and inhaler, which is not like an asthma inhaler. It looks like a little plastic stick or vape pen, but none of these go into your lungs like vapes or E-cigarettes do, so you don't get that problem of inflammation and particles and chemicals into your lungs. All of this is either through your skin or the gum and lozenges through your cheek—not like those new oral nicotine pouches that are out on the market, which you put into your gums. And that's like a supercharged dose of nicotine.

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All of this is meant to sort of have some level of coverage so that you have time to do that behavior change and coaching. And the amount of nicotine that you get from these medications is not the same as like the rush you get from the first minute of a cigarette or vape or, you know, something where those things are designed to give you like a high dose of nicotine within the first minute, and very high levels, and nicotine is one of the most addictive chemicals. But the idea is to be off for good, so usually if you're getting a prescription or getting it furnished, it's usually like 2 to 3 weeks at a time at a time to get over the worst first couple of days and weeks of that feeling of withdrawal. And those feelings of withdrawal from nicotine are usually people getting super irritable, super down, super cranky. I've seen people in the hospital really act out when they've been in the hospital and haven't had any nicotine for a while because we have a smoke-free campus and people act out because they can get that irritable and anxious from it.

Q: What does the legal landscape look like for pharmacists to be able to provide nicotine replacement therapy?

Tong: Robin Kelly and Karen Huffman, who are pharmacy faculty—Robin is at UCSF and Karen is, I believe that she’s at Purdue—they're the pharmacist experts who are helping with those laws. So, I want to say it's not all the states but in some of the states the pharmacist can furnish the 2 pills, which are Chantix—that's the trade name; varenicline is the generic name—and then bupropion. So, some states can do more than nicotine medication, just not California yet.