Nicotine Gum Nicotine absorbed mucosal membranes 2mg and 4mg strength Rule of thumb: < 24 cigarettes - 2mg > 24 cigarettes - 4mg Each piece is good for 20-30 minutes Chew gum until “peppery” taste; “park” between gum and cheek until peppery taste is gone, repeat process Beginners should park on the upper jaw

Nicotine Gum Pros: Easily imitates individual’s nicotine loading pattern Nicotine reaches brain 5-10 minutes Can be prescribed on regular schedule and/or PRN use Flexibility of use

Nicotine Gum Cons: Not user friendly; must follow instructions Difficult with dental work & gum chewers Makes saliva; GI problems Hold gum on upper jaw for first week Spit saliva out Minimal chewing Restrictions with eating and drinking OTC, expensive Difficulties getting off the gum

Nicotine Patch Six dosages: 21mg, 14mg, 7mg or 15mg, 10mg, 5mg Both OTC and prescription 16-24 hour doses Place on non-hairy area above the waist Place on a “non-boney” area

Nicotine Patch Delivery Pattern 8 - 10 hours 8 - 10 hours Application 2 hours

TYPICAL SMOKING PATTERN Nicotine level before bedtime 1 -1.5 hours First 2 hours

Nicotine Patch Pros: User friendly: just stick on and go Once a day dosing Cons: Dosing issues, Steady-state dosing ≈ 2 hrs to reach therapeutic level Skin reactions Sleep disturbance if worn at night Can cause “dull” pain on “boney” areas Passive aid

Dosing the Nicotine Patch For patients who smoke: Dose < 5 cigarettes/day None 5-10 cigarettes/day 14mg/qd 11-20 cigarettes/day 21mg/qd 21-40 cigarettes/day 35mg/qd > 40 cigarettes/day 42mg/qd

Nicotine Spray Nicotine absorbed through nasal mucosa 1 spray to each nostril after exhale. SHOULD NOT BE INHALED Each bottle contains 100 doses (200 sprays) Not recommended for use more than 5 times an hour or 40 times in 24 hours Prescription medicine

Nicotine Spray Pros: Quickest absorption (< 5 minutes) Prescription-covered by most insurance plans Flexibility Cons: First week difficult; burning eyes, throat, nasal discharge, sneezing Poor compliance Problems getting off nasal spray

Nicotine Inhaler Absorbed through mucosal membranes Mouthpiece with 10mg cartridge nicotine User “sucks” on mouthpiece to deliver nicotine 3-4 puffs per minute for 5 minutes replaces 1 cigarette Each cartridge good for 80 puffs or 20 minutes Minimum use: 6 cartridges per day Maximum use: 16 cartridges per day

Nicotine Inhaler Pros: Flexible dosing Hand to mouth behavior Relatively quick delivery, 5-10 minutes Cons: Frequent use to achieve adequate dosing Throat irritation Prescription medication, expensive; not always covered by insurance plans

Nicotine Lozenge < 24 cigarettes use 2mg lozenge Nicotine is absorbed from mucosal membranes Lozenge dissolves while held between cheek and gum User must not suck, chew or swallow lozenge 2mg and 4mg strengths – general rule: < 24 cigarettes use 2mg lozenge >24 cigarettes use 4mg lozenge Use up to 20 lozenges per day – no more than 5 in one hour

Nicotine Lozenge Pros: Flexibility of use Relatively quick absorption Cons: Many of same issues as gum Chalky buildup at lozenge site Hard for people not to chew/suck OTC - expensive

Bupropion Wellbutrin – antidepressant Zyban – smoking cessation aid Similar effects on brain as nicotine (60% people) Prescription required Begin treatment 7-10 days before quit date 3-6 days 150mg; 4th day 150mg bid Pregnancy Category B Contraindications: seizure disorder, active eating disorder, recent MI, unstable angina, other antidepressants

Bupropion Pros: Reduces nicotine withdrawal Reduces urge to smoke Quit rates improved: close to 30% abstinence at 12 months Combination bupropion + NRT’s May be used together 20-30% quit rates NRT or bupropion alone Almost 40% quit rate when combined with NRT

Bupropion Cons: Can increase blood pressure Patient with blood pressure issues alone or with NRT Patient sense of discomfort Sleep disturbance Cost

Second-line Medications Clonidine Primary use as antihypertensive Research indicates that Clonidine doubles the abstinence rates when compared to a placebo Transdermal or oral delivery Side effects – dry mouth, drowsiness, dizziness, sedation, constipation Can have serious effects if person abruptly stops medication

Second-line Medications Nortriptyline Tricyclic antidepressant Increases the rate of abstinence when compared to placebo Side effects – Sedation, dry mouth, blurred vision, urinary retention, lightheadedness, shaky hands May cause arrhythmias, changes in blood flow and contractility – not best for CVD patients