Project TEAM

Nicotine Lozenges: A "Commit" Mint

Called "Commit," this newly approved NRT delivers about 25% more nicotine than an equivalent gum dose and is available in a 2-mg and a 4-mg mint-flavored lozenge.

Unlike other NRT formulations in which the dosage is based on the number of cigarettes smoked per day, the nicotine lozenge is dosed based on the how long the patient can wait until the first cigarette of the day. Patients who smoke their first cigarette of the day within 30 minutes of waking should use the 4-mg strength lozenge. Patients who smoke their first cigarette of the day more than 30 minutes after waking should use the 2-mg strength. It is recommended that during the first six weeks of therapy patients take no more than 20 lozenges per day but no fewer than nine. In general, patients should use one lozenge every one to two hours while awake. Lozenges take about 20–30 minutes to dissolve, but may take longer. By the seventh week, patients should extend the interval between doses to about half the initial dose (1 lozenge every 2–4 hours). After 3 weeks on that schedule, the recommended dosage is cut again to about half (1 lozenge every 4–8 hours).

Difficult for some patients are the restrictions on eating and drinking associated with lozenge use. Proper use of the lozenge requires the patient to refrain from chewing or swallowing it (to prevent excessive release of nicotine) and to occasionally rotate the lozenge to different areas of the mouth while it dissolves (to reduce mouth irritation). Furthermore, patients must not eat or drink for 15 minutes before or while using the lozenge so as not to decrease nicotine absorption across the lining of the mouth. Although the lozenge may satisfy some of the oral cravings patients experience while trying to quit, it will not provide the rapid satisfaction that smoking provides. The lozenge is generally well tolerated with nausea, hiccups, cough, heartburn, headache, flatulence, insomnia reported in less than 5% of patients.

Table 4: Bottom Line For Nicotine Lozenges Advantages Disadvantages Patients can titrate therapy to manage withdrawal symptoms. Lozenge use may help satisfy oral cravings. Lozenge is easy to use and to conceal. Side effects can cause both physical discomfort and social embarrassment (e.g., nausea, hiccups, flatulence). Abiding by food and drink intake restrictions is sometimes difficult.

Nicotine Nasal Spray: Old Method, New Use

Rapidly absorbed across the nasal mucosa, nicotine nasal spray delivers 0.5 mg nicotine in each metered 50-µL dose of spray. One dose (1 mg nicotine) includes a metered spray in each nostril. Patients usually start with 1–2 doses per hour, but dosing should not increase beyond 5 doses per hour daily. Patients should use at least 8 doses daily for the first 6-8 weeks of therapy. Gradually tapering the dose over an additional 4–6 weeks should successfully lead to termination of therapy. Patients need about one bottle of spray per week.

Side effects during the first week are similar to those of a typical cold: sneezing, coughing, watery eyes, and a runny nose. Accompanying these is a hot peppery feeling in the back of the throat or the nose. Though these effects of the spray are irritating, with regular use, they should lessen during the first week of therapy. If patients experience persistent irritation, they should contact the prescriber. At this follow-up visit, it is important to make sure that the patient is not using the product more than five times per hour or 40 times per day. Patients with chronic nasal disorders (e.g., rhinitis, polyps, sinusitis) or patients with severe reactive airway disease should not use this form of NRT because of the irritant effects of the spray.

Table 5: Bottom Line For Nicotine Nasal Spray Advantages Disadvantages Patients can easily titrate therapy to rapidly manage withdrawal symptoms. Nose and throat irritation may be bothersome. Dependence may result. A delay of five minutes after application is required before patients may drive or operate heavy machinery. Patients with chronic nasal disorders or severe reactive airway disease should not use the spray.

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