Nicotine Replacement Therapy: Administration and Overview

Barbara Hart, MPA and Claudia Lechuga, MSBronx BREATHEST: (718)430-2601

E: bhart@aecom.yu.edu / clechuga@aecom.yu.eduwww.bronxbreathes.org

June 15, 2009

Smoker Assessment

• History of usage• Previous quit attempts

– Withdrawal/abstinence symptoms• Motivational level for quit attempt• Current social environment

– Stressors– Triggers– Biological/medical assessment– Family and friend support/sabotage

Previous Quit Attempts

• Dates• Age• Method used to quit

– Medications or counseling used (if any)• Duration of that method• Problems and successes experienced• Reason for relapse• Withdrawal/Abstinence Symptoms

Current Quit Attempt

• Motivational Level– Confidence

• Main reason for considering/wanting to stop• Concerns about quitting

– Weight gain concerns

Use of NRT

Reasons for using NRT• Doubles the success rate• Treats nicotine withdrawal

– Helps patient feel more comfortable

• Safe– Patient receiving same drug

(nicotine) in a less addictive form over a relatively short period

Reasons for NOT using NRT• Medical conditions requiring

caution/physician input– i.e. recent MI, pregnancy,

current arrythmia• Age

– Under 18s require physician/parental input

• Specific issues– Allergy to patches– Personal aversion to medication

• Questionable efficacy– i.e. those smoking less than

10pd

Tobacco Cessation Medications

Nicotine Replacement• Patch *• Gum *• Lozenge *• Oral Inhaler ^• Nasal Spray ^

Non-nicotine medication• Bupropion ^

– (Zyban/Wellburtrin)

• Varenicline ^– (Chantix)

* Available OTC ^ prescription only

Nicotine Delivery Comparison

Nicotine Delivery DeviceNicotine in Product

Approx Amount of Nicotine Delivered to

UserComments

Marlboro Red 13 mg 1-3 mgMarlboro Light 13 mg 1-3 mgCigars 10-40 mg Highly Variable

Moist Snuff 3-12 mgVaries depending on pH and other characteristics

Nicotine Gum 2 mg piece Up to 0.8 mgNicotine Gum 4 mg piece Up to 1.5 mgNicotrol Patch (Pharmacia) 15 mg / 16 hoursNicoderm CQ Step 3 (Glaxo Smith Kline) 7 mg / 24 hoursNicoderm CQ Step 2(Glaxo Smith Kline) 14 mg / 24 hoursNicoderm CQ Step 1(Glaxo Smith Kline) 21 mg / 24 hours

Tobacco Products

Nicotine Replacement Products

Only delivers nicotine to the consumer

Also delivers a wide range of carcinogens and other

toxins

Medication Overview

Product Use Advantages Disadvantages Precautions Side Effects CostNicotine Patch

Apply each day to clean, dry, hairless skin. Start 21 mg patch if .10 cig per day; can taper to 14 mg in 4-6 weeks, then 7 mg in 2 weeks if no cravings

Place and forget; over the counter; can decrease morning cravings if worn at night

Passive - no actions to take when craving occurs

Not recommended to use while smoking; caution within 6 weeks of heart attack

Skin reaction (50% of patients; usually mild and can use hydrocortisone cream); Rotate sites; vivid dreams or sleep disturbances possible at night

$45/2 week supply (generics available and effective)

Nicotine Gum

Chew every 1-2 hours as needed; chew and park; 2 and 4 mg strength (4mg if around 1 ppd)

Use as needed; can self-dose; Over the counter

Difficult to chew Avoid food and acidic drinks 15 minutes before and while using (decreases absorption)

Jaw pain; nausea if swallowing saliva

$35-50/2 week supply

Use and Efficacy of combination therapy

• Multiple patch therapy (42 vs 21mg)– 20% increased abstinence– No significant increased sleep disturbances– (Dale 1995; Jorenby 1995)

• Patch + Gum– Kornitzer 1995; Puska 1995

• Early better rates – 7% increase at 6 months

• Not sustained at 1 year• No increase in adverse events

– 2008 OHS Guidelines Meta-analysis• Path + Gum/Spray OR = 1.9

– Compared to patch alone (OR=1)

– Fiore 2008• Abstinence rates

– Nicotine Patch = 23.4%– Nicotine Gum = 19.0%– Long term Patch + Gum = 36.5%

Important Points about NRT

• Nicotine is the addictive part of tobacco smoke but NOT the most dangerous part

• People do NOT generally become addicted to medication

• People DON’T use enough medication or stop TOO EARLY– Medications are SAFE and EFFECTIVE– Plan on minimum of 2 months of medication

• Combinations– Work better than single medications

• Use Long acting + Short acting

NRT Kits Available

Moderate Smokers• Smoke 10-20 per day• Includes:

– Novartis Step 1• 28 count 21 mg patches

Heavy Smokers• Smoke 20+ per day• Includes:

– Nicorelief Gum• 110 pieces of 4mg gum

– Novartis Step 1• 28 count of 21mg patches

NRT Enrollment Forms

Necessary for each course distributed

Full information required

Fax or email back to Bronx BREATHES

NRT Enrollment Forms (cont’d 1)

NRT Enrollment Forms (cont’d 1)

NRT Enrollment Forms (cont’d 1)