1. Nicotine Gum Nicotine absorbed mucosal membranes 2mg and 4mg strength
Rule of thumb: < 24 cigarettes - 2mg
> 24 cigarettes - 4mg
Each piece is good for 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

2. 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

3. 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

4. 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

5. Nicotine Patch Delivery Pattern
hours hours
Application
2 hours

6. TYPICAL SMOKING PATTERN
Nicotine level before bedtime
hours
First 2 hours

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

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

18. 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

19. 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