Nicotine Replacement Therapy and Related Other Possible Medication: Ways to Quit Smoking

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Nicotine Replacement Therapy and Related Other Possible Medication: Ways to Quit Smoking

Summary

Nicotine replacement therapy (NRT) is the use of various forms of nicotine delivery methods intended to replace nicotine obtained from smoking or other tobacco usage. These products are intended for use smoking cessation efforts to deal with withdrawal symptoms or cravings caused by the loss of nicotine from cigarettes. Several forms of NRT have been marketed, including the nicotine gum, nicotine patch, inhalernasal spray, gum, sublingual tablet and lozenge. NRT is thought to be useful and beneficial for tobacco users who want to quit their addiction and is for most people perfectly safe. Cigarettes on the other hand cause the early deaths of about 5 million people each year. These people are not killed by the nicotine in the cigarette, but by other constituents of tobacco smoke such as Carbon Monoxide and tars. It is the nicotine that keeps the smoker addicted. Cigarettes can be viewed as a “dirty” and dangerous method of delivering nicotine, while NRT is a “clean” and safe method. NRT delivers nicotine to the smoker’s brain in much slower way than cigarettes do. It helps to damp down the urges to smoke that most smokers have early days and weeks after quitting, rather than remove them totally. It gives the smoker the chance to break smoking cues in their daily lives, and might provide a more comfortable exit from smoking habit. NRT however is best used with some form of support, ideally from someone who knows something about smoking cessation. In 2005 the Committee on the Safety of Medicines recommended that NRT be given to pregnant smokers and also to adolescent smokers. However, in the opinion of many independent nicotine researchers, the Committee of the Safety of Medicines has got its new advice of NRT dramatically wrong. Tobacco researchers who have received finding from the pharmaceutical industry have acted as consultants to the Committee. Ginzel et al. (2007) reviewed the dangers of nicotine for the developing the brain (journal of Health Psychology 12, 215). Recent diversification of nicotine products and their placement on the free market are solely in the interest of industry and will not help to reduce youth smoking, but could serve as a gateway drug for nonsmokers. The recommendation of AHS to use NRT even without stopping smoking will create dependencies on both cigarettes and NRT (used simultaneously or alternating), again in the interest of industry only. Family doctors will be appropriately cautions about prescribing a drug that is a poison and carries many potential dangers to the fetus and adolescent smokers and indeed to all smokers who use NRT and yet continue to smoke tobacco. A small number of people who use NRT, especially nasal spray and nicotine gum will go on to use it on a longer term basis. These are usually highly nicotine dependent smokers who would not have been able to quit without the help of such medication. There currently no evidence that such long term usages is harmful to health, especially when compared to smoking. Findings from a recent Cochrane review of controlled trials testing NRT products indicated that smokers using NRT were 1.5 to 2 times more likely to be abstinent from smoking at the follow up and those in placebo or control treatment condition. However, this statement is controversial, and critics have pointed out that real world trials rather than artificial ones yield results rather than artificial ones yield results for NRT that are hardly better than those obtained for non-NRT controls.

Objectives

This is an information based project. Through internet research and book consultation this project is prepared. The main objective of this project is to highlight the therapy that can replace the nicotine, a harmful chemical for our body, with less possible side effects. As a pharmacist it is one of our duties to select a therapy which will provide maximum therapeutic activity with less adverse effect and have the capability to replace the nicotine successfully.

Introduction

Nicotine (C₁₀H₁₄ N₂) is a naturally occurring liquid alkaloid. An alkaloid is an organic compound made out of carbon, hydrogen, nitrogen and sometimes oxygen. These chemicals have potent effects of the human body. For example, many people regularly enjoy the stimulating effects of another alkaloid, caffeine, as they quaff a cup of two of coffee in the morning.

Nicotine normally makes up about 5% of a tobacco plant, by weight. Cigarettes contain 8 to 20 milligrams (mg) 0f nicotine (depending on the brand) but only approximately 1mg is actually absorbed by the body when human smoke cigarette.

Nicotine is the drugs in tobacco leaves. Whether someone smokes, chews, or sniffs tobacco, he or she is delivering nicotine to the brain. Each cigarette contains about 10 mg of nicotine. Nicotine is what keeps people smoking despite its harmful effects. Because the smoker inhales only some of smoke from a cigarette and not all of each puff is absorbed in the lungs, a smoker gets about 1 to 2 mg of the drug from each cigarette. Nicotine is one of the most heavily used additive drugs in the United States. Cigarette smoking has been the most popular method of taking nicotine since the beginning of the 20^th century.

Figure-1.1: Nicotiana tobacum

In 1989, the U.S. Surgeon General issued a report that concluded that cigarettes & other forms of tobacco, such as cigars, pipe tobacco, & chewing tobacco, are additive & that nicotine is the drug in tobacco that causes addiction. In addiction, the report determined that smoking was a major cause of stroke and the third leading cause of death in the United States.

Nicotine and Its effects

Nicotine, 4,000 chemicals found in the smoke from tobacco products such as cigars, and pipes, is the primary component in tobacco that acts on the brain. Smokeless tobacco products such as snuff & chewing tobacco also contain many toxins as well as high levels of nicotine. Nicotine, recognized as one of the most frequently used as additive drugs, is a naturally occurring colorless liquid that turns brown when burned & acquires the odor of tobacco when exposed to air. Since nicotine was first identified in the early 1800s, it has been studied extensively & shown to have a number of complex and sometimes unpredictable effects on the brain & the body. It is very important to get the use of this drug stopped. One of the ways to do that is to do regular urine drug testing person who is using this drug.

Nicotine is absorbed through the skin & mucosal lining of the mouth & nose or by inhalation in the lungs. Depending on how tobacco is taken, nicotine can reach peak levels in the blood stream & brain rapidly.

Chemical structure:

Figure-2: Chemical structure of nicotine

Nicotine changes the brain & body function. Nicotine can both invigorate & relax smoker, depending on how much & how often they smoke. Nicotine initially causes a release of adrenaline, the “fight-or-fight” hormone. For this reason, its effects are: rapid heartbeat, increased blood pressure, rapid, shallow breathing. Adrenaline also plays a role of the body to dump some of its glucose stores into blood.

Nicotine itself may also block the release of hormone insulin. Insulin acts the cells to take up excess glucose from blood. This means that nicotine makes some people somewhat hyperglycemic, having more sugar than usual in their blood. Some people think that nicotine also curbs their appetite so that they eat less. The cause of this hyperglycemia their bodies & brain may seethe excess sugar & down-regulate the hormones and other signals that are perceived as hunger.

Nicotine may also increase the basal metabolic rate slightly. Over the long nicotine can increase the level of LDL cholesterol that damages the arteries resulting in heart attack or stroke.

When nicotine enters in the body by smoking the lots of effects are included. Nicotine delivers into the body which readily diffuses through

• Skin
• Lungs
• Mucous membranes ( such as lining of nose or gums)

Nicotine moves right into the small blood vessels that line the tissues listed above. From there nicotine travels through your blood stream, to the brain, & then it’s delivered to the rest of the body.

Nicotine can act as both a stimulant & sedative. Immediately after exposure to nicotine, there is a kick caused in part by the drug’s stimulation of the adrenal glands & resulting discharge of epinephrine (adrenaline). The rush of adrenaline stimulates the body and causes a sudden release of glucose as well as increase in blood pressure, respiration &heart rate. Nicotine also suppresses insulin out put from pancreas, which means that smokers are always slightly hyperglycemic. In addition nicotine also release of dopamine in the brain regions that control pressure and motivation. Nicotine can also exert a sedative effect depending on the level of the smoker’s nervous system arousal and the dose of nicotine taken.

Nicotine’s effect is short lived, lasting only 40 minutes to a couple of hours. This leads people to smoke or chew tobacco periodically throughout the day to dose themselves to nicotine. So the smokers need to use more and more nicotine to reach the same degree of stimulation or relaxation resulting in people would quickly move from smoking one cigarette to pack a day a habit.

Synthesis of nicotine

Nicotine, a plant defense alkaloid, is a pale yellow to dark brown liquid with a slight, fishy odor when warm.

Biologically, production of nicotine requires nicotinic acid (a ka vitamin B3 or niacin) & an N-methyl-pyrrolinium cation, which is delivered from ornithine (a non protein amino acid derived from Krebs cycle intermediates)

Figure-2: Synthesis of nicotine from nicotinic acid and omithine

Precursors

In Nicotiana sylvestris, nicotine production is induced by jasmonic acid signals in response to leaf damage (2, 3, and 12). Synthesis occurs in the roots, followed by transport throughout the plant. By using jasmonic acid as a chemical signal, the defense becomes inducible. Induced plants have about 6% of their total nitrogen content locked up in nicotine (3, 12), & synthesis also diverts fixed carbon out of the TCA cycle (a-ketogluutarate is an ornithine precursor).

Nicotine is isolated from tobacco by a variety of methods, many of which can be found at the US Patent Office. Some of the most recent include supercritical CO2 extraction, where carbon dioxide is compressed to a supercritical state (between a liquid & a gas) under high pressure, thus becoming a non-polar solvent. When the extraction is done, the CO2 evaporates leaving behind nicotine.

Pharmacological Effects of Nicotine

Pharmacokinetics:

As nicotine enters the body, it is distributed quickly through the bloodstream & can cross the blood-brain barrier.

On average it takes about seven seconds for the substance to reach the brain when inhaled. The half of nicotine in the body is around two hours. The amounts of nicotine inhaled with tobacco smoke are a fraction of the amount contained the tobacco leaves. The amount of nicotine absorbed by the body from smoking depends on many factors, including the type of tobacco, whether the smoke is inhaled, & whether a filter is used. For chewing tobacco, dipping tobacco and snuff, which are haled in the mouth between the lip and gum, or taken in the nose, the amount released into the body tends to be much greater than smoked tobacco. Nicotine is metabolized in the liver by cytochrome P450 enzymes (mostly CYP2A6, & also by CYP2B6). A major metabolite is continuing.

Pharmacodynamics:

Nicotine acts on the nicotinic acetylcholine receptors. In small concentrations it increases the activity of these receptors, among other things leading to an increased flow of adrenaline (epinephrine), a stimulating hormone. The release of adrenaline causes an increase in heart rate, blood pressure & respiration, as well as higher blood glucose levels.

The sympathetic nervous system, acting via splanchnic nerves to the adrenaline medulla, stimulates the release of epinephrine. Acetylcholine released by preganglionic sympathetic fibers of these nerves acts on nicotinic acetylcholine receptors, causing cell depolarization & an influx of calcium through voltage-gated calcium channels. Calcium triggers the exocytosis of chromaffin granules and thus the release of epinephrine (and norepinephrine) into the bloodstream. Cotinine is a byproduct of the metabolism of nicotine which remains in the blood for up to 48 hours & can be used as an indicator of a person’s exposure to smoke. In high doses, nicotine will cause a blocking of the nicotinic acetylcholine receptor, which is the reason for its toxicity and its effectiveness as an insecticide.

Students have shown that smoking tobacco inhibits monoamine oxidase (MAO), an enzyme responsible for breaking down monoamine oxidase (MAO), an enzyme responsible for breaking down monoaminergic neurotransmitters such as dopamine, in the brain. It is currently believed that nicotine by itself does not inhibit the production of monoamine oxidase (MAO), but that other ingredients in inhaled tobacco smoke are believed to be responsible for this activity.

Psychoactive effects:

Nicotine’s mood altering effects are different by report. First causing a release of glucose from the liver & epinephrine (adrenaline) from the adrenaline medulla, it causes stimulation. Subjectively, users report feelings of relaxation, calmness, and alertness. It is even reported to produce a mildly euphoric state. By reducing the appetite & raising the metabolism, some smokers may lose weight as a consequence. It also allows the mouth to be stimulated without food & the taste of tobacco smoke may curb the appetite.

When a cigarette is smoked, nicotine-rich blood passes from the lungs to the brain within seven seconds and immediately stimulates the release of many chemical messengers including acetylcholine, norepinephrine, epinephrine, vasopressin, arginine, dopamine & beta-endorphin. This results enhanced pleasure, decreased anxiety & a state of alert relaxation. Nicotine enhances concentration learning memory due to the increase of acetylcholine. It also enhances alertness due to the increase of acetylcholine & norepinephrine. The effects of nicotine last from 5minutes to 2 hours.

Toxicological Effects of Nicotine

The LD50 of nicotine is 50mg / kg for rats & 3mg / kg for mice. 40-60mg (.5-1.0mg/kg) can be a lethal dosage for adult humans. This makes it an extremely deadly poison. It is more toxic than many other alkaloids such as cocaine, which has an LD50 of 95.1mg/kg when administered two mice.

The carcinogenic properties of nicotine in standalone form, separate from tobacco smoke, have not been evaluated by the IARC, & it has not been assigned to an official carcinogen group. The currently available literature indicates that nicotine, on its own, does not promote the development of cancer in healthy tissue & has no mutagenic properties.

Its teratogenic properties have not yet been adequately researched, and while the likelihood of birth defects cost by nicotine is believed to be very small or nonexistent, nicotine replacement product manufactures recommend consultation with a physician before using a nicotine patch or nicotine gum while pregnant or nursing. However, nicotine & the increased cholinergic activity it causes have been shown to impede apoptosis, which is one of the methods by which body destroys unwanted cells (programmed cell death). Since apoptosis helps to remove mutated or damaged cells that may eventually become cancerous, the inhibitory actions of nicotine create a more favorable environment for cancer to develop. Thus nicotine play an indirect role in carcinogenesis. It is also important to note that its addictive properties are often the primary motivating factor for tobacco smoking, contributing to the proliferation of cancer.

At least one study has concluded that exposure to nicotine alone, not simply as a component of cigarette smoke, could be responsible for some of the neuropathological changes observed in infants dying from Sudden Infant Death Syndrome (SIDS).

It has been noted that the majority of people diagnosed with schizophrenia smoke tobacco. Estimates for the number of schizophrenics that smoke range from 75% to 90%. It was recently argued that the increased level of smoking in schizophrenia may be due to a desire to self-medicate with nicotine. More recent research has found the reverse that it is a risk factor without long-term benefit, used only for its short term effects. However, research on nicotine is administered through a patch or gum is ongoing.

Nicotine is highly addictive. It is both stimulant & sedative to the central nervous system. The ingestion of nicotine results in a discharge of epinephrine from the adrenal cortex. This cause is a sudden release of glucose. Stimulation is then followed by depression & fatigue, leading the abuser to seek more nicotine.

In addition to nicotine, cigarette smoke is primarily composed of gases (mainly carbon monoxide) & tar. The tar in a cigarette exposes the user to high risk of lung cancer, emphysema & bronchial disorders. The carbon monoxide in the smoke increases the chance of cardiovascular diseases.

Doses of Nicotine

Research suggests that when smokers wish to achieve a stimulating effect, they take short quick puffs, which produces a low level of nicotine. This stimulates nerve transmission. When they wish to relax, they take deep puffs, which produce a high level of blood nicotine, which depresses the passage of nerve impulses, producing a mild sedative effect. At lower doses, nicotine potently enhances the actions of norepinephrine & dopamine in the brain cursing a drug effect typical of psycho stimulates. At higher doses, nicotine enhances the effect of serotonin & opiate activity, producing a calming, pain killing effect. Nicotine is unique in compression to most drugs, as its profile changes from stimulating to sedative / pain killer in increasing dosages & use.

It is important to note that nicotine-product users moderate their use of the products to adjust the level of their effects:

Smokers can hold the smoke less long, let the cigarette burn longer between inhalations.

Smoked Nicotine Dosages

Threshold	0.2-0.3 mg
Light	0.3-0.8 mg
Common	0.6-1.5 mg
Strong	1-2 mg
Heavy	2-4mg

Onset: 5-60 seconds

Duration: 10-30 minutes

Normal After Effects: 1-3 hours

Oral Nicotine Dosage

Light	.5-2 mg
Common	1-4 mg
Strong	2-6 mg

Onset: 2-15 minutes

Duration: 1-2 hours

Normal After Effects: 3-6 hours

Intranasal (Nasal Spray) Nicotine Dosages

Threshold	0.2-0.3 mg
Light	0.3-1.0 mg
Common	0.8-2.0 mg
Strong	1.5-4 mg
Heavy	3-8 mg

Onset: 20-90 seconds

Duration: 10-30 minutes

Normal After Effects: 1-3 hours

Smoking and adolescence:

There are nearly 4 million American adolescents who have used to tobacco product in the past month. Nearly 90 percent of smokers start smoking by age 18 and of smokers under less than 18 years of age; more than 6 million will die prematurely from a smoking related disease.

Tobacco use in teens is not only the result of psychosocial influences, such as peer pressure; recent research suggests that there may be biological reasons for this period of increased vulnerability. In deed, even intermittent smoking can result in the development of tobacco addiction of some teens. Animal models of teen smoking provide additional evidence of increased vulnerability. Adolescent rats are more susceptible to the reinforcing effects of nicotine than adult rats, and take more nicotine when it is available than do adult animals.

Adolescents may also be more sensitive to the reinforcing effects of nicotine in combination with other chemical found in cigarettes, thus increasing susceptibility to tobacco addiction. Acetaldehyde increases nicotine’s addictive properties of adolescent, but not adult animals. That is, adolescent animals performing a task to receive nicotine showed greater response rats to nicotine when combined with acetaldehyde. NIDA continues to actively support research aimed at increasing our understanding of why and how adolescents become addicted, and to develop prevention, intervention and treatment strategies to meet the specific needs of teens.

Alternatives

Some individuals simply are able to stop smoking. For others, studies have shown that pharmacological treatment combined with behavioral treatment including psychological support & skills training to overcome high-risk situations. Nicotine replacement therapy has been used as alternative chemical or drugs.

Nicotine replacement therapy:

Nicotine was the first pharmacological agent approved by the food & drug administration (FDA) for use in smoking cessation therapy. Nicotine replacement therapies such as nicotine gum, the transdermal patch, nasal spray and inhaler have been approved for use in the United States. They are used to relieve withdrawal symptoms, because they produce less severe physiological alterations than tobacco based systems & generally provide users with lower overall nicotine levels than any receive with tobacco. An added benefit is that these forms of nicotine have little abuse potential since they do not produce the pleasurable effects of tobacco products-nor do they contain the carcinogens and gases associated with tobacco smoke. Behavioral treatments, even beyond what is recommended on the packaging labels, have been shown to enhance the effectiveness of NRTs and improve long term outcomes.

The FDA’s approval of nicotine gum in 1984marked the availability (by prescription) of the first NRT on the U.S. market. In 1996, the FDA approved nicotine gum over-the-counter (OTC) sales. Whereas the nicotine gum provides some smokers with the desired control over dose and the ability to relieve cravings, others are unable to tolerate the taste and chewing demands. In 1991 & 1992, the FDA approved four transdermal nicotine patches, two of which became OTC products in 1996. In 1996 a nicotine nasal sprays, and in 1998 a nicotine inhaler also became available by prescription, thus meeting the needs of many additional tobacco users. All the NRT products-gum, patch, spray and inhaler-appear to be equally effective. NRT is way of getting nicotine into the blood stream without smoking. There are nicotine gums, patches, inhalers, tablets, lozenges & sprays.

Additional medications:

Although the major focus of pharmacological treatments of tobacco addiction has been nicotine replacement, other treatments are also being studied. For example, the antidepressant bupropion was approved by FDA in 1997 to help people quit smoking, and is marketed as Zyban. Varenicline tartarate (Chantix) is new medication that recently received FDA approval for smoking cessation. This medication which acts at the sites in the brain affected by nicotine, may help people quit by easing withdrawal symptoms and blocking the effects of nicotine if people resume smoking.

Several other nonnicotine medications are being investigated for the treatment of tobacco addiction, including other antidepressants and an antihypertensive medication, among others. Scientists have also investigating the potential of a vaccine that targets nicotine for use in relapse prevention. The nicotine vaccine is designed to stimulate the production of antibodies that would block to access to nicotine to the brain and prevent nicotine’s reinforcing effects.

Behavioral treatments:

Behavioral interventions play an integral role in smoking cessation treatment, either in conjunction with medication or alone. They employ a variety of methods to assist smokers in quitting, rangingfrom self-help materials to individual cognitive behavioral therapy. These interventions teach individual cognitive behavioral therapy. These interventions teach individuals to recognize high risk smoking situations, develop alternative coping strategies, manage stress, improve problem solving skills as well as increase social support. Research has also shown that the more therapy is tailored to a person’s situation, the greater the chances are for success.

Traditionally, behavioral approaches were developed and delivered through formal settings, such as smoking-cessation clinics and community and public health settings. Over the first decade, however researchers have been adapting these approaches or mail, telephone, and Internet formats, which can be more acceptable and accessible to smokers who are trying to quit. In 2004, the U.S. Department of Health and Human Services (HHS) established a national toll-free number, 800-QUIT-NOW (800-784-8669), to serve as a single access point for smoking seeking information and assistance in quitting. Callers to the number are routed to their state’s smoking cessation quitlines or, in states that have not established quitlines, to one maintained by the National Cancer Institute.

Quitting smoking can be difficult. While people can be helped during the time an intervention is delivered, most intervention programs are short-term (1-3 months). Within 6 months, 75-80 percent of people who try to quit smoking relapse. Research has now shown that extending treatment beyond the typical duration of a smoking cessation program can produce quit rates as high as 50 percent at 1 year.

Counseling:

As one of the public’s accessible patient educators, pharmacists are trained to provide information about prescription and nonprescription medication. Since 1996, when nicotine gum and patches became available without prescription, pharmacists have been fated with the new challenge of providing counseling for an addictive behavior among persons who may not have first met with a physician. However, with this challenge also comes opportunity. For each smoker that buys nicotine patches or gum, the pharmacist has the chance to counsel and help with the quit attempt.

If California’s 20,084 licensed pharmacists are willing and able to take an active role in helping their patients quit smoking, it could have a tremendous public health impact. Although studies have shown that pharmacists can have a very important impact on whether a person is able to quit smoking or not; other studies have shown that pharmacists typically are not active in providing smoking cessation counseling. The reasons for this are not known. The goal of the proposed study is to gain a clear picture of pharmacist’s stance on smoking cessation counseling and to understand what would be needed to enable pharmacists to take a more active role in helping smokers to kick the habit for good. Using a written questionnaire, we will ask 2,300 pharmacists in Northern California questions about issues such as:

• Their knowledge of nicotine patches and gum
• If and how they counsel patients who purchase patches or gum
• How confident they feel when helping patients quit smoking
• If it is possible to counsel smokers, given the number of prescription customers that they serve each day, and
• The benefits of and barriers of providing smoking cessation counseling.

The information that we learn from this study will help us to design a program to train and motivate pharmacists to join the nation’s antismoking efforts.

How does NRT work:

NRT stops or reduces the symptoms of nicotine withdrawal. This helps you to stop smoking, but without having unpleasant withdrawal symptoms. NRT does not make stop smoking. It should be determined to break the smoking habit.

How do I use NRT?

• Take advice from a GP, practice nurse, pharmacist or stop smoking clinic.
• Decide on which type of NRT will suit you best.
• Set a data to short. Smoking & start NRT straight way. Some people prefer to stop smoking at the end of one day, & start NRT when they wake following day.
• Do not smoke at the same time as taking NRT.
• It should be used NRT regularly at first, & not now and then.
• It should be used an adequate dose of NRT. The higher dose is used if anyone smoked more than 18-20 per day.
• To use NRT for at least 8-12 weeks for the best chance of stopping smoking long term.
• The dose of NRT is typically reduced in the later part of the course, and then stopped.

A doctor, nurse, pharmacist or Stop Smoking Clinic may give to stop smoking support. Also the manufacturer of NRT often support such as telephone counseling, tapes, internet sites, personalized written programmed etc. The details come on the packets of the various NRT products. It is strongly advised that is taking of any offer of support whilst going through the difficult time of giving smoking.

How effective is NRT?

If anyone really want to stop smoking, smokers are twice as likely to succeed in giving up with the help of NRT. This means that up to 1 in 5 smokers who want to stop will do it with the help of NRT. A combination of NRT with support or counseling gives the best chance of success.

Which form of NRT is best?

There is not much difference in how well the different types of NRT work. Personal preference usually determines whish one to use. Below are listed some points about each form of NRT.

Nicotine gum:

Two strength are available – 2mg & 4mg. It should be used the 4mg strength if anyone smoking 18 or more cigarettes a day. Smokers need about 12-15 pieces of gum per day to start with (about one per hour). To release the nicotine, chew the gum slowly until the test is strong. Then rest it between the cheek & the gum to allow absorption of nicotine into the blood stream. Chew the gum again when the test fades & rest it again when the test is strong, etc. To use a fresh piece of gum after about an hour. After 2-3 months smokers should use the gum less and less. For example, reduce the chewing time, cut the gum into smaller pieces, or alternate the nicotine gum with sugar free gum. Gradually stop the gum completely.

Nicotine gums delivers nicotine to the brain quickly than the patch however unlike smoke, which passes almost instantaneously into the blood through the lining of the lung; the nicotine in the gums takes several minutes to reach the brain. This makes the hit less intense with the gum than with a cigarette.

Nicotine gum provides take the edge off cigarette cravings without providing the tars and poisonous gases found in cigarettes. It is temporary aid that reduces symptoms of nicotine withdrawal after quitting smoking. Nicotine gum must be used properly in order to be effective.

The disadvantage of gum is that some people do not like the taste or always having something in their mouth. Gum is not suitable if smoker wear dentures.

The average price for nicotine gum is approximately $4.50 (10 pieces) a day for average usage during the first six weeks of use.

Nicotine patches:

A patch that is stuck onto the skin release nicotine into the blood stream. Some patches last 16 hours, which smokers wear only when they are awake. Other types last 12 hours they wear these the whole time. The 24 hour patch may disturb sleep, but is thought to help with early morning craving for nicotine. Patches are discreet, & easy to apply.

The patch comes in different strengths. The manufacturers normally recommend that they gradually reduce the strength of the patch over time before stopping completely. However, research studies suggest that stopping abruptly is probably just as good without the need to gradually reduce the dose.

The nicotine patch releases a constant amount of nicotine in the body. Unlike the nicotine in tobacco smoke this passes almost instantaneously into the blood through the lining of the lungs, the nicotine in the patch takes up to three hours to pass through the layers of skin and into the user’s blood.

The patches are similar to adhesive bandages and are available in different shapes & sizes. A large patch delivers more nicotine through the skin.

The patch must be worm all day, can not be put on and removed as a substitute for a cigarette. Most of the patch products are changed once every 24 hours. One particular patch is worn only during the waking hours and is removed during sleep. Wearing the nicotine patch lessens chances of suffering from several of the major smoking withdrawal symptoms such as tenseness, irritability, drowsiness, and lack of concentration.

The disadvantages of patches are that a steady amount of nicotine is delivered. This does not mimic the alternate high & low levels of nicotine when they smoke, or with chewing nicotine gum. Skin irritation beneath the patch occurs in some users. Some side effects from wearing the patch may include: skin irritation, dizziness, racing heartbeat, sleep problems, headache, nausea, vomiting, muscle aches and stiffness.

Average retail price for over-the-counter transdermal nicotine patches is approximately $4 a day.

Nicotine lozenge:

In 2002, the first and only over the counter nicotine lozenges meant to help smokers kick the habit was introduces to the market. Nicotine lozenge comes in the form of hard candy, and release nicotine as it slowly dissolves in the mouth. Eventually, the quitter will use fewer and fewer lozenges during the 12- week program until he or she is completely nicotine-fare. Biting or chewing the lozenge will cause more nicotine to be swallowed quickly and result in indigestion or heartburn.

Nicotine lozenge is available in 2mg or 4 mg doses. One lozenge is one dose; maximum dosage should not exceed 20 lozenges per day. Each lozenge will last about 20-30 minutes and nicotine will continue to leach through the lining of the mouth for a short time after the lozenge has disappeared. Do not eat or drink 15 minutes before using the lozenge or while it is in smoker mouth. Do not use nicotine lozenges for longer than 12 weeks. If they feel the need to continue using the lozenges after12 weeks, contact their healthcare professional.

The most common side effects of lozenge use are:

• Soreness of the teeth and gums
• indigestion
• Throat irritation
• The average retail price for nicotine lozenge is approximately $6 a day for average usage (12 doses) and up to $12 a day for maximum usage (20 doses) during the first six weeks use.

Nicotine nasal spray:

The nicotine in the spray is rapidly absorbed into the blood stream from the nose. This form of NRT most closely mimics the rapid increase in nicotine level that smokers get from soking cigarettes. This may help to relieve sudden surges of craving.

Nicotine nasal spray, dispensed from a pump bottle similar to over-the-counter decongestant sprays, relieves cravings for a cigarette. Nicotine is rapidly absorbed through the nasal membranes and reaches the blood stream faster than any other NRT product, giving a rapid nicotine hit. This feature makes it attractive to some highly dependent smokers

A usual single dose is two sprays, one in each nostril. The maximum recommended dose is 5 doses per hour or 40 doses total per day.

The side effects are nose and throat irritation, coughing, and watering eyes for a short time after use, do not use in whilst driving

The average retail price for nicotine nasal sprays is approximately $5 a day for average use (13 doses) and up to $15 a day for maximum usage (40 doses).

Nicotine inhaler:

This resembles a cigarette. Nicotine cartridges are inserted into it, and inhaled in an action similar to smoking. Each cartridge provides up to 20 minutes sessions. It should be used about 6-12 cartridge a day for eight weeks, then gradually reduce over four further weeks. It is particularly suitable if smokers miss the hand-to- mouth movements of smoking.

The nicotine inhaler consists of a plastic cylinder containing a cartridge that delivers nicotine when smokers puff on it. To use the inhaler when they have a craving for a cigarette. To use no more than 16 cartridge a day for up to 12 weeks. Although similar in appearance to a cigarette, the inhaler delivers nicotine into the mouth, not the lung and enters the body much more slowly than the nicotine in cigarettes. The nicotine inhaler is available only by prescription.

Each cartridge delivers up to 400 puffs of nicotine vapor. It takes qt least 80 puffs to obtain the equivalent amount of nicotine delivered by one cigarette. The initial dosage is individualized. The best effect is achieved by frequent continuous puffing for 20 minutes. One cartridge will last for 20 minutes of continuous puffing and deliver 4 mg of nicotine; only 2 mg are actually absorbed. This is the equivalent of about 2 cigarettes. The maximum suggested dose is 16 cartridges per day.

The side effects include irritation of the throat and mouth in the beginning. Smokers may also start to cough but they should get over this after a while, if not make sure to consult with their doctor.

The average retail of the cost of nicotine inhaler is approximately $45.00 for a package (42 cartridges).

Non-nicotine pill-Zyban:

Bupropion hydrochlorides (Zyban) was approved in 1997 to help smokers quit. The drug, available by prescription only, is also sold as an antidepressant under the name Wellbutrin.

Common side effects include insomnia, dry mouth and dizziness.

Treatment with bupropion begins while the user is still smoking, one week prior to the quit data. Treatment is continued for 7 to 12 weeks. Length of treatment is individualized. Dosing should begin at 150 mg per day, starting on the 4 day of treatment. The maximum recommended dose is 300 mg /day, given as 150 mg twice daily. An interval of at least 8 hours between successive doses is advised.

People who have not made significant progress towards abstinence by the seventh week of the therapy are unlikely to successfully quit during attempt, and bupropion is approximately $2 per day.

Chantix-tablets :

The newest prescription drug Chantix. Vareniclinic tartarate, only the second nicotine-free smoking-cessation drug to gain FDA approval. The active ingredient varenicline works in two ways by cutting the pleasure of smoking and reducing the withdrawal symptoms that leads smokers to light up again and again.

The tablet will be taken twice daily for 12 weeks, a period that can be doubled in patients who successfully quit increasing the likelihood they remain smoking free.

The most common adverse side effects include: nausea, vomiting, headache, gas, insomnia, abnormal dreams and a change in taste perception.

It is necessary with all types of medication to follow the doctor’s orders and use the products only as prescribed and according to labeling.

Studies suggest that everyone can quit smoking. Smoker situation or condition can give you a special reason to quit:

• Pregnant women or new mothers. By quitting, they protect their baby’s health their own.
• Hospitalized patients. By quitting, their reduce health problems and help healing.
• Heart attack patients. By quitting, they reduce their risk of a second heart attack.
• Lung, head and neck cancer patients. By quitting, they reduce their chance of a second cancer.
• Parents of children and adolescents. By quitting, they protect their children and adolescents. By quitting they protect their children and adolescents from illness caused by second-hand smoke.

The goal in using nicotine replacement therapy is to stop smoking completely. If smokers plan to take nicotine medications begin using them on the day they quit. If they continue to have strong urged to smoke or are struggling to stop smoking completely. Ask their healthcare provider about additional help.

World Recognized Nicotine Substitutes / Nicotine replacement therapy:

AHA recommendation and Advocacy Position

The American Heart Association believes that nicotine transdermal patches and other nicotine substitution drug products, such as nicotine gum, can help smokers quit when used as part of a comprehensive smoking cessation program. There are public safety issues concerning the patches including indications, contraindications, warnings and precautions & issues such as effectiveness, potential abuse and advertising and marketing. These are appropriately regulated by the U.S. Food and Drug Administration (FDA). The American Heart Association will continue to review the science concerning the use of nicotine patches and other nicotine substitution products and to make comments to the FDA, when appropriate.

Nicotine Replacement therapy (NRT) has been shown to be safe and effective in helping people stop using cigarettes when used as part of a comprehensive smoking cessation program. NRT medicines are available as gum and patches over the counter. They can be used by people outside formal stop smoking programs, but they are less effective when used that way. NRT is also available by prescription as a nasal spray and as a puffer (inhaler). The consistent use of one of these products doubles a person’s chances of quitting smoking. However, NRT does not make smokers stop smoking. Behavior change and support are essential. A smoking cessation program can take many forms, including self help booklets and telephone counseling. In general the more intense the behavior modification therapy, the greater the chance of success.

The American Heart Association commends the FDA for approving a variety of medicines to treat tobacco dependence and for determining that cigarettes and smokeless tobacco products are drugs and devices under the Food, Drug and Cosmetic Act. The association strongly supports the agency’s effort to defend its jurisdictional determination in court. We also support Congressional efforts to give the FDA full authority to regulate all tobacco products and medicines to treat tobacco dependence in parallel, using what the agency does with one class of products to inform what it does with the other.

How does nicotine replacement product help?

Nicotine is the additive substance in tobacco products. NRT provides nicotine in a safe form so the body does not endure nicotine withdrawal while a person adapts to not stop smoking. Trying to learn skills to help in quitting smoking while dealing with nicotine withdrawal makes it harder to successfully quit. Nicotine withdrawal symptoms include irritability, difficulty concentrating, feeling of depression, difficulty sleeping, increased appetite cravings and headache. These symptoms often start just a few hours after the last cigarette. The first 72 hours of quitting are the hardest, but symptoms may persist for weeks. Smokers have learned that a cigarette will relieve these symptoms in a few moments. But taking nicotine in another way can suppress withdrawal. NRT products only provide nicotine. They contain none of the carcinogens or toxic gases found in cigarette smoke.

NRT may not be suitable user are pregnant or have heart disease :

Pregnancy: while the use of replacement products during pregnancy is not risk free, it’s much less dangerous they and their baby than smoking. If they are pregnant and planning to become pregnant and want to stop smoking, talk to their healthcare professional before deciding on a course of action. Most professionals will recommend trying other ways to change their behavior before suggesting a nicotine replacement product.

Heart diseases: NRT has been shown to be safe in most people with heart disease. However, if you have recently had heart problems, such as an irregular or rapid heartbeat or chest pain, consult their doctor before using nicotine replacement products.

Side effects: All forms of nicotine replacement have side effects. Many of them become easier to tolerate over time. In a recent article, the Institute of Safe medication Practices addresses another hazard that many people may not know about –transdermal medication patches, like those that deliver nicotine, can cause burns if a patent wears them during an MRI procedure.

Tell user doctor that they use a medication patch if they are going to undergo an MRI.

What about smoking while using NRT?

It’s not unusual for people trying to stop smoking using NRT still give in to an occasional cigarette. Most success full quitters have two or three relapses before they quit smoking for life. (A relapse is a return to the behavior they are trying to eliminate).

Combining the nicotine from the NRT with the nicotine from cigarettes is a concern. If someone is smoking only a few cigarettes while trying to quit, it makes sense to continue the NRT and resolve how to avoid each of the last few remaining cigarettes. But if the person is smoking as much (or nearly as much) on NRT as off of it, they should stop the NRT and prepare better before trying to quit smoking again.

What about withdrawal from NRT:

Most of the time people who use NRT to stop smoking gradually reduce or stop NRT medicine as prescribed without any difficulty. Some people keep using the gum, nasal spray or inhaler for a long time. Using NRT is always preferable to using tobacco products. If the choice is between an NRT product & a tobacco product, the person should keep using NRT. If a person feels that gradually stopping NRT is very hard, he or she should speak with a doctor.

What about nicotine replacement therapy? Does it help?

• Quitting smoking is a two-step process that includes:
• overcoming the physical addiction to nicotine and
• breaking the smoking habit

Nicotine replacement therapy helps take care of the nicotine addiction so that the smoker can work on breaking the habit. Research has shown that smokers who use some form of nicotine replacement therapy and participate in a behavior change program like Freedom from Smoking can double their chances of quitting for good.

These products work best for people who are addicted to nicotine and are really trying to quit. Smokers can now obtain these nicotine replacement products both with a doctor’s prescription and over-the-counter. These products are designed to reduce cravings for cigarettes and relieve the withdrawal symptoms people experience while trying to quit smoking.

Are these nicotine replacement products just as bad as smoking cigarettes?

No they do not have all the tars and poisonous gases that are found in cigarettes. Furthermore, they provide less nicotine than a smoker gets from cigarettes.

These products should not be used by pregnant or nursing women. People with other medical conditions should check with their doctor before using any nicotine replacement product. Most important is that quit completely before starting to use these products. They should not smoke any cigarettes while using the patch.

Are there other nicotine replacement products?

Yes. There is an inhaler and a nasal spray that are available by prescription. A doctor should be contacted to discuss the use of these products and whether they are right for person. There is also a non-nicotine pill, buopropine hydrochlorides or Zyban, that was approved in 1997 to help smokers quit. The drug only available by prescription is also sold as an antidepressant under the name Wellbutrin.

What’s good way to help a cigarette smoker quit?

The first move has to come from the smoker. People who really want to quit smoking stand a better chance of sticking their decision. Letting a person know they care and that “they are there” of them big help.

Asking a smoker, “how can I help”? If the person can’t come up with ideas right away, wait until they get smoke clues. Most smokers would like to be free of cigarettes.

What do former smokers say about the benefits of quitting?

• People who quit smoking are proud of themselves for breaking the addiction. By quitting, smokers get many health benefits. They cut down on their risk of having lung diseases, a heart attack or getting cancer.
• Former smokers are glad to be rid of cigarette stain on their fingers, hacking coughs and the smell of state cigarette smoke on their clothing.
• Other pleasing side effects of quitting are an improved sense of and taste.
• Stopping smoking as early as possible is important but cessation at any age provides meaningful life extensions.
• Life expectancy among smokers who quit at age 35 exceeded that of continuing smokers by 6.9 to 8.5 years for men and 6.1 to 7.7 years from women. Smokers who quit qt younger age realize greater life extensions. However, even those who quit much later in life gained some benefits: among smokers who quit at age 55 years men gained 1.4 to 2.0 years of life, and women gained 2.7 to 3.7 years.

Are there gender differences in tobacco smoking?

Several researches now indicate that men and women differ in their smoking behavior. For instance, women smoke fewer cigarettes per day, tend to use cigarettes with lower nicotine content, and do not inhale as deeply as men. However, it is unclear whether this is due to differences in sensitivity to nicotine and other factors that affect women differently, such as social factors or the sensory aspects of smoking.

The number of smokers in United States declined in the 1970s and 1980s, remained relatively stable throughout the 1990s, and declined further through the early 2000s. Because this decline in smoking was greater among men and women, the prevalence of smoking is only slightly higher for men than women. Several factors appear to be contributing to this narrowing gender gap, including increased initiation of smoking among female teens and women being less likely than men to quit.

Large-scale smoking cessation trials show that women are less likely to initiate quitting and may be more likely to relapse if they do quit. In cessation programs using nicotine replacement methods, such as the patch or gum, the nicotine does not seem to reduce craving effectively for women as for men. Other factors that may contribute to women’s difficulty with quitting are that withdrawal may be mare intense for women or that women are more concerned about weight gain.

Although post cessation weight gain is typically modest (about 5-10 pounds), concerns about this may be an obstacle to treatment success. In fact NIDA research has found that women’s weight concerns were addressed cognitive-behavior therapy; they were more successful at quitting than women who were in program designed only at attenuate post cessation weight gain. Other NIDA researchers have found that medication used for smoking cessation, such as bupropine and naltrexone, can also attenuate weight gain could become an additional strategy for enhancing success.

It is important for treatment professionals to be aware that standard regimens may have to be adjusted to compensate for gender differences in nicotine sensitivity and in other related factors that contribute to continue smoking.

Are there effective treatments for tobacco addiction?

Yes, extensive research has shown that treatments for tobacco addiction do work. Although some smokers can quit without help, may individuals need assistance in quitting. This is particularly important because smoking cessation can have immediate health benefits. For example, within 24 hours of quitting, blood pressures of chances of heart attack decrease. Long term benefit of smoking cessation includes decreased risk of stroke, lung and other cancers and coronary heart disease. A 35- year-old man who quits smoking will, on average, increased has life expectancy by 5.1 years.

Cost effectiveness:

A number of cost-effectiveness studies have been reviewed. Outcomes from these studies have been expressed in a variety of ways as cost per long term quitter, cost per life gained (LYG), or cost per quality-adjusted life year (QUALY) gained. Estimates of LYGs ranged from 0.3 to 2.4, depending on the model used and discount rate. Estimates of QUALYs gained from quitting are somewhat higher than LYGs, because the quality of life of a non-smoker is estimated to be on average higher than that of smoker.

Incremental cost effectiveness of NRT over and above brief advice was estimated to be $4,500 per LYG at 1992 product prices and using discount rates of 6% for both costs and benefits, but a later estimate, at 1998 prices ranged from $350 to $800 per LYG, using a discount rate of 6% for costs and 1.5% for benefits. US figures (using discount rates of 5% or 6% for both costs and benefits) are mostly closer to the higher end of the scale, but would be towards the lower end if benefits were discounted at 1.5%.

The independent model, produced by the authors of the Assessment Report, assumed a quit rate of 4% for advice only or 10% for counseling. The quit rate of 4% for the intervention was then estimated from these figures, given an odds ratio for NRT of 1.67 tan\ken from clinical effectiveness studies. For each quitter, it was assumed that 2 discounted life years were gained. The incremental cost per LYG for advice alone against doing nothing and for counseling against doing nothing, were both less than $1,000. For either NRT or bupropion in addition to brief advice, the incremental cost per LYG was less than $2,500, and for either NRT or bupropion in addition to counseling, the incremental cost per LYG was not more than $1,000. Some researchers in the area believe the costs per LYG for the interventions quoted above may be even less than the above estimates.

The three manufacturers have been performed separate calculations, which also yield low estimates of mean incremental costs per LYG, broadly consistent with those in above description.

Further Research:

Since there are only two head-to-head trials of bupropion against NRT, only one of which shows a significant difference between the treatments, further such studies comparing these methods of smoking cessation should be carried out. Combination of bupropion and NRT should be considered one arm.

Optimal use of resources to maximize health gains from smoking cessation strategies requires more detailed knowledge than is currently available. Important areas where more information was required are the roles of advice/counseling and smoker motivation in conjunction with NRT or bupropion, and the relationships between smoking cessation aids and smoking dependency, age, social support systems and their interactions.

Since smoking cessation therapies are such cost effective means of providing health-care, the extension of these therapies to smokers who are less motivated to quit may also be cost effective. Innovative strategies to encourage quitting should be investigated.

Implementation:

• NHS Trusts, primary care teams, local health groups, community pharmacists, hospital-based clinical services and health authorities should review policies and practices regarding smoking cessation take account of the guidance.
• Local guidelines or care pathways, particularly those on cardiac or respiratory consideration of action to be taken for the patient who is a smoker.
• Arrangements should be made to ensure that smoking cessation advice and support is available to patients at both community and hospital locations.

To measure compliance locally with the guidance, the following criteria should be used:

• NRT and bupropion are available for prescription for smokers who have expressed as desire to quit smoking.
• Smokers who are under the age of 18 years, who are pregnant or breastfeeding or who have unstable cardiovascular disorders discuss the use of NRT with a relevant health-care professional before it is prescribed.
• Bupropion is not prescribed for people under the age of 18 year or for women who are pregnant or breast-feeding.
• Initial prescriptions for 2 weeks only (for NRT) and 3-4 weeks only (for bupropion), if minimum pack size permits, or one month otherwise. A second prescription for the remaining period of treatment is given only to people whose quit attempt is continuing re-assessment.
• Advice and encouragement is available to smokers who ar