SMOKING CESSATION THERAPIES

Smoking cessation pharmacotherapy should be
used with a comprehensive behavioral smoking
cessation program. Nicotine replacement therapy
used in conjunction with a frequent, intensive,
high-quality smoking cessation program is more
successful than either used alone. Every smoker
should be offered smoking cessation therapy at
every office visit. Make first follow-up contact
within 2wks of anticipated quit date, second contact
within the first month, and additional follow-up
as needed. Intensive interventions are more
effective.

Patients must stop smoking before starting a
nicotine replacement regimen. Concomitant drugs
may need adjustment in dose when smoking is
stopped.

Pregnant or breastfeeding smokers should first be
encouraged to attempt to quit smoking without
pharmacologic therapy. They should be offered intensive
counseling treatment. Nicotine replacement
should be used during pregnancy only if the increased
likelihood of quitting smoking (and its benefits)
outweighs the risks of nicotine replacement therapy.

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Pediatric and adolescent patients should be
considered candidates for nicotine replacement therapy
only when there is clear evidence of nicotine
dependence and a clear desire to quit. Small amounts of
nicotine may be toxic to children and animals; these
products should be stored in a safe place away
from children and pets (including used patches).

Local skin reactions may occur with nicotine
patches. Treatment with a mild steroid cream may
be helpful.

Strict dieting and other strong measures should not
be undertaken to counteract weight gain during
a quit attempt. Using nicotine gum can delay weight
gain after quitting smoking.
Generic Brand Strength Adult Dose Notes
TRANSDERMAL
nicotine Habitrol OTC 21mg/
 day,
14mg/
 day,
7mg/
 day		 >10cigarettes/day:
21mg patch daily for 4wks; then 14mg patch daily for 2wks, then 7mg patch daily for 2wks, then stop
≤10cigarettes/day:
14mg patch daily for 6wks then 7mg patch daily for 2wks, then stop		 Apply to clean, dry, nonhairy site on trunk or upper outer arm. Rotate sites. Do not cut patch. Remove patch after 24hrs; if vivid dreams or other sleep disturbances occur, remove at bedtime and reapply in AM.
Nicoderm CQ OTC 21mg/
 24hr,
14mg/
 24hr,
7mg/
 24hr		 >10cigarettes/day:
21mg patch daily for 6wks; then 14mg patch daily for 2wks; then 7mg patch daily for 2wks; then stop
≤10cigarettes/day:
14mg patch daily for 6wks; then 7mg patch daily for 2wks; then stop		 Apply to clean, dry, nonhairy site on trunk or upper outer arm. Rotate sites. Remove after 16−24hrs; if vivid dreams or other sleep disturbances occur, remove at bedtime and reapply in AM.
CHEWING GUM
nicotine polacrilex Nicorette OTC 2mg, 4mg Use 1 piece every 1−2hrs for 6wks (at least 9 pieces/day), then every 2−4hrs for 3wks, then every 4−8hrs for 3wks, then stop; max 24 pieces/day. If strong or frequent cravings, may use 2nd piece within the hour; avoid continuous use. Use 2mg if patient smoked 1st cigarette >30mins after waking up; use 4mg if patient smoked 1st cigarette within 30mins of waking up. Do not eat or drink for 15min before and during use.
NASAL SPRAY
nicotine Nicotrol NS Rx 0.5mg/
 spray		 Individualize. Usually 1−2 doses/hr; max 5 doses/hr, 40 doses/day for up to 3mos; may discontinue abruptly or taper. Do not sniff, swallow, or inhale spray. Nasal vasoconstrictors may delay absorption.
INHALER
nicotine inhalation system Nicotrol Inhaler Rx 10mg/
 cartridge (4mg delivered)		 Individualize. Use at least 6 cartridges/day for 1st 3−6wks; max 16 cartridges/day for 1st 12wks, then reduce gradually over 12 more weeks. Each cartridge lasts about 20min with frequent continuous puffing and provides nicotine equivalent to about 2 cigarettes.
LOZENGES
nicotine polacrilex Nicorette Lozenge OTC 2mg, 4mg 1 lozenge every 1−2hrs (at least 9 lozenges/day) for 6wks, then every 2−4hrs for 3wks, then every 4−8hrs for 3wks, then stop; max 5 lozenges/6hrs (20 lozenges/day). Use 2mg if patient smoked 1st cigarette >30mins after waking up; use 4mg if patient smoked 1st cigarette within 30mins of waking up. Dissolve slowly in mouth; minimize swallowing. Do not eat or drink for 15min before and during use.
Nicorette Mini Lozenge OTC
TABLETS
varenicline tartrate Chantix Rx 0.5mg, 1mg Initially 0.5mg once daily for 3 days, then 0.5mg twice daily for 4 days, then 1mg twice daily. Treat for 12wks; may continue 12 more weeks if patient successfully stops smoking to further increase the likelihood of abstinence. Reduce dose in renal impairment. Begin therapy 1wk before target quit date. Alternatively, may begin therapy and then quit smoking between Days 8 and 35 of treatment. Take after eating with a glass of water. May reduce dose if intolerable nausea or other adverse effects occur.
bupropion 
HCl		 Zyban Rx 150mg
sustained-release
tablets		 Initially 150mg once daily for 3 days, then 150mg twice daily at least 8hrs apart; max 300mg/day in divided doses. Swallow whole. Set target quit date within 1−2wks after start. Treat for 7−12wks; reevaluate if no significant progress by Week 7; up to 6 mos’ therapy has been shown to be effective. Avoid bedtime dosing.
REFERENCES

Adapted from Clinical Practice Guidelines No. 18, AHCPR Pub. #96‑0692, 4/96 and product labeling. For more information see product entries.

(Rev. 3/2014)

This article originally appeared on MPR

Topics:

Chart Safe Medication Use