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FM12 Family Medicine
Health Promotion and Counselling
Toronto Notes 2019
Table 7. Types of Nicotine Replacement Therapy
Nicotine Replacement Therapy for Smoking Cessation
Cochrane Database Syst Rev 2012;11:CD000146
Purpose: To determine the effect of nicotine replacement therapy (NRT) versus placebo and other pharmacotherapies for smoking cessation, and to determine whether abstinence rates are influenced by NRT form, single- therapy or combination therapy, dosage, timing of use, additional advice and support offered, or clinical setting of recruitment and treatment.
Results: 150 trials were identified. All forms of NRT relative to placebo was associated with a significant increase
in abstinence (risk ratio (RR) 1.60, 95% CI 1.53-1.68). A similar increase was seen by NRT form for the nicotine gum (RR 1.49, 1.40-1.60), nicotine patch (RR 1.64, 1.52- 1.78), oral tablets/lozenges (RR 1.95, 1.61-2.36), nicotine inhaler (RR 1.90, 1.36-2.67) and nicotine nasal spray (RR 2.02, 1.49-2.73). Effects were independent of duration of therapy, intensity of additional support or setting in which NRT was offered. Some evidence suggested combining a nicotine patch with rapid NRT delivery was more effective than a single type of NRT (RR 1.34, 1.18-1.51), though
not statistically significant. No evidence of a significant difference in efficacy relative to buproprion was found
(RR 1.01, 0.87-1.18), and combination therapy with the two was more effective than buproprion alone (RR 1.24, 1.06-1.45). While side-effects were noted, no evidence suggested increased risk of heart attacks with NRT. Conclusions: All commercially available forms of NRT (gum, transdermal patch, nasal spray, inhaler, and sublingual tablets/lozenges) are effective as part of a strategy to promote smoking cessation. They increase
the rate of quitting by 50-70% regardless of setting and independent on the level of additional support provided to the smoker. Compared to a single form of NRT, combining a nicotine patch with a rapid delivery form of NRT may be more effective.
Type
Nicotine Gum (OTC)
Nicotine Patch (OTC)
Nicotine Inhaler (OTC) Nicotine Nasal Spray (Rx)
Dosage
2 mg if <25 cig/d
4 mg if >25 cig/d
1 piece q1-2h for 1-3 mo (max 24 pieces/d)
Use for 8 wk 21 mg/d x 4 wk 14 mg/d x 2 wk 7 mg/d x 2 wk
6-16 cartridges/d up to 12 wk
Comment
Chew until “peppery” taste then “park” between gum and cheek to facilitate absorption
Continue to chew-park intermittently
for 30 min
Start with lower dose if <10 cig/d Change patch q24h and alternate sides
Nicotine inhaled through mouth, absorbed in mouth and throat not in lungs
Newer form of NRT
Side Effects
Mouth soreness Hiccups Dyspepsia
Jaw ache
Most are transient
Skin irritation Insomnia Palpitations Anxiety
Local irritation Coughing
Local irritation Coughing
Contraindications
Seizure disorder
Eating disorder
MAOI use in past 14 d Simultaneous use of bupropion (Wellbutrin®) for depression
Caution with pre-existing psychiatric condition
Table 8. Pharmacologic Treatments for Smoking Cessation
Drug
Bupropion
Varenicline
Mechanism
Inhibits re-uptake of dopamine and/or norepinephrine
Side effects: insomnia, dry mouth
Partial nicotinic receptor agonist, and partial nicotinic receptor competitive antagonist
Side effects: nausea, vomiting, constipation, headache, dream disorder, insomnia, increased risk of psychosis, depression, suicidal ideation
Dosage
1.150mgqAMx3d 2.Then150mgbidx
7-12 wk
3. For maintenance consider
150mgbidforupto6mo
1.0.5mgqAMx3d 2.Then0.5mgbidx4d 3. Continue 1 mg bid x 12
wk ± additional 12 wk as maintenance
Prescribing*
1. Decide on a quit date
2. Continue to smoke for first
1-2 wk of treatment and then completely stop (therapeutic levels reached in 1 wk)
1. Decide on a quit date
2. Continue to smoke for first wk of
treatment and then completely stop
Standard Drink Equivalents
One standard drink = 14 g of pure alcohol • Beer (5% alcohol) = 12 oz
• Wine (12-17% alcohol) = 5 oz
• Fortified wine = 3 oz
• Hard liquor (40%) = 1.5 oz
1. Relevance to patient
◆ relevant to patient’s disease status or risk, family or social situation (e.g. having children in the
home), health concerns, age, gender 2. Risks of smoking
◆ short-term: SOB, asthma exacerbation, impotence, infertility, pregnancy complications, heartburn, URTI
◆ long-term: MI, stroke, COPD, lung CA, other cancers
◆ environmental: higher risk in spouse/children for lung CA, SIDS, asthma, respiratory infections 3. Rewards: benefits
◆ improved health, save money, food tastes better, good example to children 4. Roadblocks: obstacles
◆ fear of withdrawal, weight gain, failure, lack of support 5. Repetition
◆ reassure unsuccessful patients that most people try many times before successfully quitting (average number of attempts before success is 7)
• recentquitter
■ highest relapse rate within 3 mo of quitting
◆ minimal practice: congratulate on success, encourage ongoing abstinence, review benefits and problems
◆ prescriptive interventions: address problem of weight gain, negative mood, withdrawal, lack of support
Alcohol
• seePsychiatry,PS23 Definition
• diagnosticcategoriesoccuralongacontinuum
Epidemiology
• 10-15%ofpatientsinfamilypracticeareproblemdrinkers
• 20-50%ofhospitaladmissions,10%ofprematuredeaths,30%ofsuicides,and50%offataltraffic
accidents in Canada are alcohol-related
• morelikelytomissdiagnosisinwomen,elderly,andpatientswithhighsocioeconomicstatus
*Bupropion and verenicline may be used in combination with nicotine replacement therapy
• unwillingtoquit
■ motivational intervention (5 Rs)