Nicotine-replacement therapy

The gum should be chewed slowly, with intermittent parking of the gum at the side of the mouth, to avoid adverse effects (e.g., hiccups, heartburn, stomach upset). Only 50% of the nicotine in a piece of gum is systemically 

Patients who use the lozenge for smoking cessation should use one lozenge every 1-2 hours for the first 2— weeks, decreasing the interval to every 2-4 hours thereafter. Adverse effects that are common with the nicotine lozenge include heartburn, hiccups, and nausea (Shiffman et al. 2002). Because the product contains phenylalanine, the lozenge should not be used for smoking cessation by individuals with phenylketonuria. 

Transdermal nicotine (i.e., the nicotine patch) is also available over the counter for smoking cessation. This form of nicotine dehvery may be espe- 

Transdermal nicotine is available in a variety of formulations and dosing schedules (e.g., 15 mg/l6 hours 7, 14, and 21 mg/24 hours and 11 and 22 mg/ 24 hours) (Cinciprinni and McClure 1998). Peak nicotine concentrations for the various systems are reached 2-6 hours after application, and steady state conditions occur 2—3 days after continued patch use (Henningfield 1995). The highest-dose patch (i.e., 21 or 22 mg/24 hours or 15 mg/l6 hours) delivers approximately 0.9 mg of nicotine per hour transdermally (Henningfield 

The transdermal system is applied in the morning and removed either before bedtime or the next morning. Among individuals smoking 10 or more cigarettes per day, the highest dose patch should be used to start an intermediate 

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In general, for smokers with cardiac disease, the benefits of nicotine replacement therapy outweigh the potential risks. In a safety and efficacy study that included veterans with cardiac disease, smoking concurrently with the nicotine patch was not associated with an increase in adverse events (Joseph et al. 1996). Although bupropion SR is generally well tolerated by smokers, it has not been adequately studied in persons with cardiac disease, and definitive conclusions regarding its safety in this patient population cannot currently be made (Society for Research on Nicotine and Tobacco 2003). 

Symptomatic detoxification from nicotine is achieved with any of the currently available nicotine replacement therapies (NRTs) or a combination thereof.25 Several CNS neurotransmitters... 

Lerman, C.W.E., Patterson, F., Rukstalis, M., Audrain-McGovem, J., Restine, S., Shields, P.G., Kaufmann, V., Redden, D., Benowitz, N., Berrettine, W.H. The functional mu opioid receptor (OPRM1) Asn40Asp variant predicts short-term response to nicotine replacement therapy in a clinical trial. Pharmacogenomics J. 4 184, 2004. 

Nicotine is responsible for the highly addictive properties of tobacco products. Addiction occurs in 30% of those who experiment with tobacco products, and more than 80% of those who attempt to quit smoking will relapse within a year. Withdrawal from nicotine produces a syndrome characterized by nicotine craving as well as dysphoria, anxiety, irritability, restlessness and increased appetite. It is treated with nicotine replacement therapies, such as nicotine gum and patches, and/or with buproprion, a drug that is classified as an antidepressant but has multiple and complex effects in brain. Buproprion reduces craving in some smokers. Nicotine addiction has been reviewed recently at cellular and systems levels [38-41]. 

Assessment and reduction in the use of alcohol, tobacco, and other substances prior to pregnancy improve outcomes. For smoking cessation, behavioral interventions are preferred. Intermittent delivery formulations of nicotine replacement therapies are preferred over the patches. If patches are used, 16-hour patches are preferred over 24-hour patches. 

Interventions are more effective when they last greater than 10 minutes, involve contact with a professional, provide at least four to seven sessions, and provide nicotine-replacement therapy (NRT). Group and individual counseling is effective, and interventions are more successful when they include social support and training in problem-solving, stress management, and relapse prevention. 

Nicotine polacrilex (gum)0 First-line Initial dose depends on smoking history 2-4 mgevety 1-8 hours 12 weeks (taper down over time) Heart rate and blood pressure should be monitored periodically during nicotine replacement therapy. Al... 

Nicotine replacement therapies can be combined with each other and/or bupropion to increase long-term abstinence rates. bOo not abruptly discontinue. Taper up initially, and taper off once therapy is complete. cClonidine and nortriptyline are not FDA approved for smoking cessation. 

An understanding of the pharmacology of nicotine and how nicotine produces addiction and influences smoking behavior provides a necessary basis for therapeutic advances in smoking cessation interventions. This chapter provides a review of several aspects of the human pharmacology of nicotine. These include the presence and levels of nicotine and related alkaloids in tobacco products, the absorption of nicotine from tobacco products and nicotine medications, the distribution of nicotine in body tissues, the metabolism and renal excretion of nicotine, nicotine and cotinine blood levels during tobacco use or nicotine replacement therapy, and biomarkers of nicotine exposure. For more details and references on the pharmacokinetics and metabolism of nicotine, the reader is referred to Hukkanen et al. (2005c). 

Nicotine and Cotinine Blood Levels During Tobacco Use and Nicotine Replacement Therapy... 

In studies of smoking cessation, anatabine is recommended as nicotine replacement therapies will lead to the presence of nicotine and cotinine without any tobacco exposure... 

Jacob P, 3rd, Hatsukami D, Severson H, Hall S, Yu L, Benowitz NL (2002) Anabasine and anatabine as biomarkers for tobacco use during nicotine replacement therapy. Cancer Epidemiol Biomarkers Prev 11(12) 1668-1673... 

Women have greater vulnerability for smoking-related diseases (specifically myocardial infarction and lung cancer) than men, but are less successful in quitting smoking (Harris et al. 1993 Zang and Wynder 1996 Thun et al. 2002 Henschke and Miettinen 2004 Henschke et al. 2006). Men benefit from nicotine replacement therapy more than women (reviewed by Perkins 2001). A recent meta-analysis of nicotine versus placebo patch studies has shown a significantly better response to nicotine in men than women (Perkins and Scott 2008). 

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