Smoking-Cessation Products: Snuffing the Habit

The millions of individuals who attempt to quit smoking each year would probably agree that it is often easier said than done and, at times, can be challenging and overwhelming.¹

Pharmacists are in a pivotal position to assist patients in finding the most efficacious smoking-cessation methods and properly selecting OTC smokingcessation products.

According to the Centers for Disease Control and Prevention (CDC), an estimated 70% of adult smokers in the United States want to quit smoking and millions more have attempted to quit.² Moreover, the American Cancer Society reports that an estimated 4% to 7% of individuals are able to quit smoking without the use of smoking-cessation products.³ Results from one study show that 95% of “cold turkey” quitters start smoking again within a 6-to-12-month time frame, and patients who receive tobacco-cessation intervention from a health care provider are 1.7 to 2.2 times more likely to quit smoking and remain tobacco free for more than 5 months compared with those who quit without intervention.⁴

Statistics from the CDC for 2015 show that more than 16 million Americans are living with health complications or medical conditions related to smoking and that smoking is responsible for cancer, cardiovascular disease, stroke, diabetes, and pulmonary diseases including chronic obstructive pulmonary disease.⁵ Smoking is also associated with decreased fertility in females, osteoporosis, periodontitis, and cataracts.⁴ Annually in the United States, tobacco use is responsible for approximately 480,000 deaths (or 1 of every 5 deaths).⁵ Furthermore, an estimated 41,000 of these tobacco-related deaths are the result of exposure to secondhand smoke and, on average, smokers die a decade earlier than nonsmokers do.⁵ The CDC states that smoking can adversely affect almost every organ system in the body and can contribute to the manifestation of various medical conditions.²

Health Benefits of Smoking Cessation

Because smoking cessation often requires some degree of motivation, individuals may be inclined to quit if they are aware of the range of associated health benefits. Once an individual quits smoking, he or she may notice some immediate benefits, while others may become more apparent over time (Table 1^2,6,7).^2,6,7 Examples of these benefits may include^2,6,7:

• Better breath
• Stained teeth whiten
• Fingers and fingernails become less yellow
• Food tastes better or taste perception improves
• Sense of smell returns to normal
• Everyday activities (eg, climbing stairs, light housework) no longer cause shortness of breath

Table 1: Health Benefits of Smoking Cessation^6-8

Smoking Cessation :

• May significantly reduce the risk of premature death.
• May decrease the risk for lung cancer and other cancers.
• Reduces the risk of developing COPD and other respiratory symptoms
• Coronary heart disease risks are significantly reduced within 1 to 2 years of smoking cessation.
• Decreases the risks for stroke and peripheral vascular disease.
• Improves circulation and lung function by up to 30%.
• Smoking cessation before or during pregnancy may reduce the risk for low birth weight baby, preterm delivery, and reduced fertility in women.
• Ten years after quitting smoking, one's risk for lung cancer decreases by 50%

Nicotine Replacement Therapy

Nonprescription smoking-cessation products are classified as nicotinereplacement (NR) products and are available in a variety of dosage formulations, including gum, transdermal patches, and lozenges. These products (1) decrease the nicotine cravings and withdrawal symptoms that typically occur after an individual decides to abstain from tobacco and (2) enable patients to focus on the behavioral modifications necessary to quit smoking.^4,8-11

Nicotine Transdermal System

The nicotine transdermal system continually releases low levels of nicotine into the body over a 24-hour period.⁴ Transdermal products include the Nicoderm CQ patch (GlaxoSmithKline), the Habitrol patch (Novartis Consumer Health), and drugstore generic formulations. The patches are available in Steps 1 through 3 and in 21-mg, 14-mg, and 7-mg strengths.

The dosage of the patch a patient starts with depends on the number of cigarettes he or she smoked daily.^4,8,9 If an individual smokes more than 10 cigarettes per day, the 21-mg patch should be the initial strength used for 6 weeks, followed by the 14-mg and 7-mg patches for 2 weeks each. Individuals who smoke fewer cigarettes may start with the 14-mg dosage for 6 weeks and then the 7-mg patch for 2 weeks.^4,8,9

Common adverse effects (AEs) include local skin irritations such as pruritus and erythema.⁴ Patients should be advised that skin irritations may be decreased or prevented by rotating patch application to a clean, dry, hairless area on the upper body and the upper outer part of the arm on a daily basis.⁴ The same area should not be used again for at least 1 week.⁴ Some individuals have reported abnormal or vivid dreams, headache, or insomnia.^4,8,9 Patients experiencing this AE should be advised to remove the patch at bedtime and apply a new patch upon waking in the morning.⁴

Nicotine Polacrilex Gum

Nicotine polacrilex gum, such as Nicorette (GlaxoSmithKline), is classified as a resin complex of nicotine and polacrilin in a sugar-free chewing gum base.^7,10 Available strengths include 2 mg and 4 mg in 6 flavors: original (tobacco), mint, fresh mint, white ice mint, fruit chill, and cinnamon surge.^4,10 The 2-mg strength is recommended for those who smoke fewer than 25 cigarettes per day; patients who smoke more cigarettes should use the 4-mg strength.^4,10 In general, peak concentrations of nicotine are achieved within 30 minutes of administration and slowly decrease over the next 2 to 3 hours.⁴

The recommended use of NR gum is 1 piece of gum every 1 to 2 hours while awake during weeks 1 through 6, followed by 1 piece every 2 to 4 hours during weeks 7 through 9 and 1 piece every 4 to 8 hours during weeks 10 through 12.^4,10 On average, each piece of gum lasts 30 minutes, and no more than 24 pieces per day should be used.^4,10 Patients should be counseled on the proper use of these products, particularly the chew-and-park method, which involves initially chewing the gum and then letting it sit between the gums and cheek to allow for the absorption of the nicotine. The most common AEs are unpleasant taste, dyspepsia, jaw muscle soreness, hypersalivation, hiccups, or mouth irritation.^4,10 Because ingesting acidic beverages may decrease the effectiveness of the gum, patients should not eat or drink (except water) for about 15 minutes before or while chewing the gum.⁴

Nicotine Polacrilex Lozenges

The nicotine polacrilex lozenges include Nicorette lozenges (GlaxoSmithKline), a resin complex of nicotine and polacrillin, available in regular, mint, or sugar-free (aspartame) cherry flavors. Nicorette Mini Lozenges (GlaxoSmithKline) also are available in mint flavor and come in a pocket-size package for easy portability. These lozenges are available in 2-mg and 4-mg strengths.^4,11 The 4-mg strength should be used by individuals who smoke their first cigarette within 30 minutes of waking up, while the 2-mg strength is for those who smoke their first cigarette more than 30 minutes after waking.^4,11

Although the pharmacokinetics of both the gum and lozenge are comparable, the lozenge delivers approximately 25% more nicotine than the equivalent dose of nicotine gum due to the complete dissolution of the dosage form.^4,11 During the initial 6 weeks of therapy, patients should use 1 lozenge every 1 to 2 hours while awake.^4,11 They can use additional dosages, but should be advised to not use more than 5 lozenges in 6 hours and to not use more than 20 lozenges in a 24-hour period.^4,11 The recommended dosing intervals for lozenges are similar to that of nicotine gum, and the AEs and interaction with acidic beverages are comparable to those associated with use of the gum.^4,11

Table 2: Patient Counseling Tips for Using NRT Products^8-12

• Individuals with pre-existing medical conditions should consult their primary health care provider prior to using NRT products
• Never smoke while using NRT products.
• Only use NRT products as directed.
• Stop using nicotine lozenges if experiencing persistent indigestion or sore throat.
• Stop using nicotine gum if experiencing problems with the teeth, mouth, or jaw area.
• Stop using topical patches if a rash or redness of the skin develops and does not go away after 4 days
• Wash hands before and after applying NRT patch to skin
• Use nicotine gum or lozenges on a scheduled basis to minimize withdrawal symptoms.
• Do NOT use more than one form of NRT at the same time unless directed by a primary healthcare provider to use combination therapy.
• Stop the use of NRT if experiencing irregular heartbeat or palpitations, or experiencing any signs of nicotine overdose, such as nausea, vomiting, dizziness, diarrhea and weakness.
• Lozenges should NOT be chewed or swallowed
• Do NOT use more than 5 lozenges in 6 hours or more than 20 lozenges per day and only use one lozenge at a time.

The Role of the Pharmacist

Prior to recommending the use of NR products, patients with pre-existing medical conditions—such as recent myocardial infarctions, severe angina, or a history of arrhythmia, uncontrolled hypertension, or active peptic ulcer disease— and patients who are pregnant or breast-feeding or individuals younger than 18 years should always consult their primary care provider.⁴ Because tobacco smoke interacts with various pharmacologic agents through pharmacokinetic or pharmacodynamic mechanisms that may result in decreased therapeutic efficacy or, less commonly, increased toxicity, pharmacists are key in identifying possible drug interactions and contraindications associated with tobacco use.⁴ Examples of drugs that interact with tobacco smoke include hormonal contraceptives, beta-blockers, inhaled corticosteroids, warfarin, theophylline, and benzodiazepines.⁴

During counseling, pharmacists can also provide patients with suggestions for various nonpharmacologic methods that can be used in conjunction with these nonprescription smoking-cessation products and encourage patients to seek assistance from counseling services for motivation and to increase their chances of successful smoking cessation (Table 2^7-11). Patients should be advised that the combination of smoking-cessation medications and counseling is more effective than medication or counseling alone. Patients who have been unsuccessful with nonprescription NR products should be encouraged to discuss prescription products for smoking cessation to see if they are candidates for taking these medications (Table 3).

Table 3: Nonprescription NRT Products

Brand Name

Strengths Available

Nicorette Gum

2 mg, 4 mg

Nicoderm CQ Patch

Habitrol Patch

Step 1: 21 mg

Step 2: 14 mg

Step 3: 7 mg

Nicorette Mini Lozenges

2 mg, 4 mg

Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia.

References

• Why is it so hard to quit smoking? American Cancer Society website. www.cancer.org/healthy/stayawayfromtobacco/guidetoquittingsmoking/guide-to-quitting-smoking-why-so-hard-to-quit. Updated February 6, 2014. Accessed June 27, 2015.
• Quitting smoking. Centers for Disease Control and Prevention website. www.cdc.gov/tobacco/data_statistics/fact_sheets/cessation/quitting/index.htm#benefits. Updated May 21, 2015. Accessed June 27, 2015.
• A word about success rates for quitting smoking. American Cancer Society website. www.cancer.org/healthy/stayawayfromtobacco/guidetoquittingsmoking/guide-to-quitting-smoking-success-rates. Updated February 6, 2014. Accessed June 29, 2015.
• Martin B, Wopat M. Tobacco cessation. In: Krinsky D, Berardi R, Ferreri S, et al, eds. Handbook of Nonprescription Drugs. 18th ed. Washington, DC: American Pharmacists Association; 2015.
• Fast facts. Centers for Disease Control and Prevention website. www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/. Updated April 15, 2015. Accessed June 29, 2015.
• Guide to quitting smoking. American Cancer Society website. www.cancer.org/healthy/stayawayfromtobacco/guidetoquittingsmoking/guide-to-quitting-smoking-toc. Accessed June 25, 2015.
• Benefits of quitting tobacco. US National Library of Medicine website. www.nlm.nih.gov/medlineplus/ency/article/007532.htm. Updated November 1, 2013. Accessed June 29, 2015.
• Nicoderm CQ [product information]. Philadelphia, PA: GlaxoSmithKline. www.nicodermcq.com/?_ga=1.268465201.1913247086.1435538685. Accessed June 29, 2015.
• Habitrol [product information]. Princeton, NJ: Dr. Reddy's Laboratories Inc; 2015. http://habitrol.com/how-the-nicotine-patch-works. Accessed June 29, 2015.
• Nicorette Gum [product information]. Philadelphia, PA: GlaxoSmithKline; 2015. www.nicorette.com/what-is-nicotine-gum.html. Accessed June 29, 2015.
• Nicorette Mini Lozenges [product information]. Philadelphia, PA: GlaxoSmithKline; 2015. www.nicorette.com/products/nicorette-mini-lozenge.html. Accessed June 29, 2015.