Project TEAM

For patients unable to quit with monotherapy, there is evidence of benefit when agents are used in combination. For example, the use of bupropion with the nicotine patch increased quit rates an estimated 5.2 percentage points, from 30.3% to 35.5% (Fig. 3).

Pharmacotherapy is thought to be effective because it reduces the effects of physical withdrawal from nicotine, permitting patients to focus on behavioral and psychological aspects of tobacco cessation. Nicotine replacement therapy results in lower levels of nicotine than smoking and does not provide the rapid satisfaction as that of smoking. Here we will examine first-line medications for cessation. Each section concludes with the bottom line—advantages and disadvantages of the recommended therapy. The medications cannot be rank ordered by effectiveness because there is insufficient information to demonstrate superiority of one agent over another. Instead the medications are organized by their non-prescription verses prescription classes. We begin with over the counter therapies (nicotine gum, transdermal nicotine patch, and nicotine lozenge) and conclude with prescription therapies (nicotine nasal spray, nicotine oral inhaler and bupropion).

Nicotine Gum: Gum That Requires Instructions

Nicotine gum, sold without a prescription since 1996, remains a commonly used nicotine-replacement therapy. Nicorette and its generic form offer nicotine in a resin complex with polacrilin in a sugar-free chewing gum base. Like the nicotine lozenges, nicotine gum is available in two formulations (2 mg and 4 mg). It also may be purchased in regular, mint, or orange flavors. Choosing the right dose is based on how many cigarettes the patient smokes per day: if the patient smokes fewer than 25 cigarettes per day, the prescriber should choose the 2-mg form; if the patient smokes 25 or more cigarettes per day, then the 4-mg dose is recommended. The gum appears to be particularly helpful with patients who have weight gain concerns or who report boredom as a trigger for smoking. However, those with dental appliances or dentures sometimes find it is the one nicotine replacement therapy they cannot use because the highly viscous gum can cause havoc with expensive dental work.

Chewing nicotine gum requires careful patient education. Patients should be instructed on when to chew and when not chew the gum. This is because chewing releases the nicotine, and once the tingling sensation of nicotine affects the buccal membranes, the gum should be not be chewed —it should be "parked"—until the tingle fades. Here are the instructions every patient needs to use nicotine gum effectively:

1. Follow the recommended dosing schedule: one piece of gum every 1 or 2 hours during weeks 1–6, one piece every 2–4 hours during weeks 7–9, and one piece every 4–8 hours during weeks 10–12. Just like nicotine lozenges, nicotine gum allows patients to titrate use to reduce cravings and mitigate withdrawal symptoms.
2. Chew gum slowly so that at the first taste of a tingly sensation—a peppery, minty, or citrus taste—chewing can be stopped. This may take about 15 chews.
3. Once the tingle begins, "park" the chewing gum between the cheek and the gum. This allows the nicotine to be absorbed across the buccal mucosa.
4. Once the tingle fades, resume chewing until the taste or tingle returns.
5. When the tingle returns, park gum in a different location in the mouth.
6. Continue the chew-park cycle until all the nicotine has been released and the gum fails to produce a sensation. This generally takes about 30 minutes.

Chew too slowly and the nicotine craving may not be satisfied promptly. Chew too quickly and excessive nicotine may be released, causing lightheadedness, nausea and vomiting, feelings of indigestion, irritation of throat and mouth, and hiccups. It is recommended that patients who want to improve their chances of quitting not use less than nine pieces of gum daily at the initiation of therapy. The effectiveness of nicotine gum may be reduced by acidic beverages such as coffee, juices, wine, or soft drinks. These beverages transiently reduce the salivary pH, resulting in decreased absorption of nicotine across the buccal mucosa. Patients should be advised not to eat or drink for 15 minutes before or while using the nicotine gum.

Despite the importance technique takes on when using nicotine gum, be reassured that it can be mastered and about a fifth of all patients who use it are able to be tobacco free at more than 5 months after quitting. Like other nicotine- replacement therapies, nicotine gum should be tapered off. Some patients like to decrease the time they chew each piece; others like to decrease the number of pieces they chew.

Table 1: Bottom Line For Nicotine Gum Advantages Disadvantages Patients can titrate therapy to manage withdrawal symptoms. Chewing gum may satisfy some oral cravings. Using gum may delay weight gain. Patients must master proper chewing technique to achieve effect and to minimize untoward symptoms from a burst of nicotine. In some settings, gum chewing may not be acceptable. Dentures and other dental fixtures in the mouth can make using gum chewing difficult because the gum may stick to them. Abiding by food and drink intake restrictions is sometimes difficult.

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