OTC Case Studies: Smoking Cessation

CASE 1: E-CIGARETTES

Q: RC is a 34-year-old male truck driver who is seeking information about the use of e-cigarettes. He reports that his primary care physician, who is treating RC’s diabetes, recommended smoking cessation. RC mentions that his friends have been trying to quit cigarette smoking via e-cigarettes. He is skeptical but asks about the latest recommendations. What recommendations do you have?

A: Let RC know that a study conducted in the United Kingdom compared the rates of smoking cessation using a particular brand of e-cigarettes versus nicotine replacement therapy. The 1-year abstinence rate was 18.0% in the e-cigarette group and 9.9% in the nicotine-replacement group.¹ In addition, given the variability in the composition of e-cigarette products and insufficient evidence supporting the use of e-cigarettes, the 2020 US Surgeon General’s Report on Oral Health does not make generalizations about the efficacy of e-cigarettes for smoking cessation. However, the report does acknowledge that findings from clinical trials suggest that e-cigarettes containing nicotine are associated with increased smoking cessation compared with e-cigarettes that contain no nicotine. Also, more frequent use of e-cigarettes is associated with increased smoking cessation compared with less frequent use. The report summarizes that if smokers were to use e-cigarettes, they would need to stop smoking cigarettes and other tobacco products completely before switching to e-cigarettes, with the ultimate goal of stopping using e-cigarettes as well.²

Although e-cigarettes contain fewer toxic chemicals than burned tobacco products, they still carry carcinogenic chemicals and tiny particles that reach deep into the lungs via aerosolization of the liquid. Furthermore, the FDA has not approved the use of nicotine-containing e-cigarettes for smoking cessation. FDA-approved agents for smoking cessation include nicotine replacement therapy using gum; an inhaler; lozenges; nasal spray; prescription medicines, such as bupropion and varenicline; and the transdermal patch.²

CASE 2: TECHNOLOGY IN SMOKING CESSATION

Q: VH is a 40-year-old woman who recently discussed smoking cessation with her primary care physician (PCP) and is picking up nicotine replacement patches and gum. Although her PCP had informed her about nicotine replacement therapy products and how they work, she asks if there is anything she can use on her smartphone, or alerts she can arrange to help her manage cravings and adhere to her quit plan. What recommendations do you have?

A: Tell VH that one option is to call the “quitline” 1-800-QUIT-NOW (1-800-784-8669), which is staffed by coaches who are trained in smoking cessation. Another option is the free quitSTART app for smartphones. This app, created by the FDA and the National Cancer Institute, assists the user in getting back on the road to cessation after a slipup by managing cravings, monitoring progress, and staying on track. A third option is SmokefreeTXT, a texting service that asks users screening questions about their smoking history and quit plans. After the questions are answered, the user receives 3 to 5 texts per day for 6 to 8 weeks to assist with smoking cessation. Topics discussed on SmokefreeTXT include cravings, nicotine withdrawal, triggers, and weight gain. Users can sign up by texting QUIT to 47848. Finally, there are a number of social media discussion groups on Facebook, Pinterest, Twitter, and YouTube where VH can find support.³

CASE 3: MEDICATIONS AND SMOKING CESSATION

Q: HS is a 42-year-old man who is picking up his clozapine prescription. He has been smoking 10 cigarettes per day for 15 years and is interested in quitting. HS asks about nicotine replacement products. What advice do you have?

A: Tell HS about smoking cessation, but also counsel him on the importance of speaking with the clozapine prescriber about his plan to quit smoking. Given that tobacco smoking induces cytochrome P450 1A2, patients who smoke require much higher doses of clozapine (a medication metabolized by 1A2) to achieve therapeutic levels.⁴ If HS were to quit smoking, he would be at risk for clozapine toxicity because of reduced 1A2 induction and increased serum concentration of clozapine if he continued taking the same dosage. The clozapine prescriber and HS should be urged to consider a clozapine dose reduction, monitor changes in smoking habits, and obtain baseline clozapine levels prior to smoking cessation. Inform HS that he could develop symptoms of clozapine toxicity 2 to 3 weeks after smoking cessation if he is not monitored appropriately.⁵

CASE 4: NICOTINE REPLACEMENTQ: CL is a 32-year-old woman who recently bought nicotine gum from the pharmacy to aid in smoking cessation and manage cravings. She returns a week later with complaints of hiccups and indigestion. These adverse effects are disrupting CL’s workday, and she asks for advice. What do you tell her?

A: Tell CL that the hiccups and indigestion may be a result of excessive nicotine release from chewing the gum too quickly. Inform her that it is not like regular gum and is meant for buccal absorption. Counsel CL on the chew-and-park method: First, chew the gum slowly until it begins to tingle; then place it between the cheek and gums until the tingle goes away; finally, repeat this process until the tingle is gone after 30 to 60 minutes. Remind CL that the gum’s effectiveness may be reduced by beverages or food, so she should not drink or eat anything 15 minutes before or while using the gum.⁶

Ammie J. Patel, PharmD, BCACP, is a clinical assistant professor of pharmacy practice and administration at the Ernest Mario School of Pharmacy and an ambulatory care specialist at RWJBarnabas Health in New Jersey.Rupal Patel Mansukhani, PharmD, CTTS, FAPhA, is a clinical associate professor at the Ernest Mario School of Pharmacy at Rutgers, the State University of New Jersey, and a transitions-of-care clinical pharmacist at Morristown Medical Center in New Jersey.

REFERENCES

• Hajek P, Phillips-Waller A, Przulj D, et al. A randomized trial of e-cigarettes versus nicotine-replacement therapy. N Engl J Med. 2019;380(7):629-637. doi: 10.1056/NEJMoa1808779.
• CDC. Adult smoking cessation—the use of e-cigarettes. CDC website. cdc.gov/tobacco/data_statistics/sgr/2020-smoking-cessation/fact-sheets/adult-smoking-cessation-e-cigarettes-use/index.html. Updated January 23, 2020. Accessed February 25, 2020.
• CDC. How to quit smoking. CDC website. gov/tobacco/campaign/tips/quit-smoking/index.html. Updated August 2, 2019. Accessed February 25, 2020.
• Tsuda Y, Saruwatari J, Yasui-Furukori N. Meta-analysis: the effects of smoking on the disposition of two commonly used antipsychotic agents, olanzapine and clozapine. BMJ Open. 2014;4(3):e004216. doi: 10.1136/bmjopen-2013-004216.
• Lowe EJ, Ackman ML. Impact of tobacco smoking cessation on stable clozapine or olanzapine treatment. Ann Pharmacother. 2010;44(4):727-732. doi:10.1345/aph.1M398.
• 2008 PHS Guideline Update Panel, Liaisons, and Staff. Treating tobacco use and dependence: 2008 update U.S. Public Health Service clinical practice guideline executive summary. Respir Care. 2008;53(9):1217-1222.