Smoking Cessation Pharmacotherapy Options

Dr. Jake Decker delivered this evening's talk on smoking cessation with an emphasis on pharmacotherapy options.

Many of our chronic disease patients smoke. Smoking is a learned behavior and a physical addiction to nicotine. Combining counseling with pharmacologic therapy is most effective.

Nicotine Withdrawal Syndrome:

• Depressed mood
• Insomnia
• Irritability, frustration, anger
• Anxiety
• Difficulty concentrating
• Restlessness
• Increased appetite
• Weight gain

Options

Nicotine Replacement Therapy:

• Provides nicotine without using tobacco 
• Reduce withdrawal allowing breaking of behavior
• Dependence to NRT is rare
• In general NRT use is recommended for 2-3 months
• longer use is ok if risk for relapse
• Combinations of different NRTs are more effective than either alone.

Transdermal Patch:

• Dose the strength of patch by how much the patient smokes
• Use patch on nonhairy part of body as it's changed each morning. 
• They should quit smoking while on the patch because patients can't self regulate their own nicotine toxicity, results in symptoms of nausea.
• There can be irritation at the skin site so don't put it in the same spot each day.

Gum:

• Dosed based on how much patients smoke, use as needed to keep a basal level of craving. 
• A certain amount of nicotine is released when chewed, "park" it in your gums until nicotine is absorbed via buccal mucosa and taste goes away, chew again. 
• Acidic beverages should be avoided before and during.

Lozenge:

• Like the gum, dosed based on how many cigarettes in a day. 
• More user-friendly but chalky and not palatable.

Inhaler:

• Different than the e-cigarette, used as an inhaler puff as needed
• Delivers vapor to oropharynx and absorbed into buccal mucosa
• Fights craving and addresses behavioral addiction. 
• Patients love this method but is costly and not covered by insurance.
• Must be prescribed and not available OTC
• Helpful to patients with pulmonary disease.

Nasal Spray:

• puffs in nose
• not as well tolerated by patients as it causes runny nose, sneezing, and tearing.

Comparing Methods of NRT:

• The NRT patch high dose is twice better than placebo. The gum is a little less effective, followed by inhaler. 
• Combining patch and gum/spray is much more effective.
• The patch will give continuous nicotine but people will have cravings so the gum counters that. 
• Chantix has abstinence rate of 33.2% and can be used in combination with NRT but the safety is not yet clear.