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The updated clinical practice guideline, Treating Tobacco Use and Dependence (Fiore et al., 2008), discusses the use of the different forms of nicotine replacement therapy


Tobacco users attempting to quit should be prescribed one or more effective first-line pharmacotherapies for tobacco use cessation, including five nicotine replacement therapies (NRTs) (transdermal patch, gum, nasal spray, lozenges, or vapor inhaler) and nonnicotine replacement (bupropion sustained release [SR], or varenicline) (Eisenberg et al., 2008; Fiore et al., 2008) (SOR: A). Brief counseling (<3 minutes) doubles the spontaneous quit rate; intensive therapy can be even more effective and should be used whenever possible (Fiore et al., 2008) (SOR: A).

Age 52 with equivalent / FEV1 of a 75 year old/


Susceptible smoker Never smoked or not susceptible to smoke Disability Death

Age (years)

Age (years)

Susceptible smoker

Never smoked or not susceptible to smoke

Stopped smoking at 45

Stopped smoking at 65



Figure 50-5 A, Explaining lung age to participants. B, Graph of lung function against age showing how smoking accelerates age-related decline in lung function. (From Parkes G et al. BMJ 336:598-600,2008, Figs. 1 and 2)

and the other two FDA-approved prescription medications used for tobacco cessation, bupropion and varenicline (Box 50-3). Effective second-line agents include clonidine, delivered transdermally or orally, and nortriptyline (Fiore et al., 2008), but neither is FDA approved for this indication. All these medications in randomized clinical trials have two to four times the odds ratio for success compared with placebo for smoking cessation. Medication and treatments to avoid include antidepressants such as SSRIs, benzodiazepines, mecamylamine, hypnosis, acupuncture, laser therapy, and beta-adrenergic blocking agents, none of which has been found to have a beneficial effect (Fiore et al., 2008).

Box 50-3 Clinical Guidelines for Nicotine Withdrawal

Nicotine Patch

Patches should be applied as soon as patients waken on their quit day. At the start of each day, the patient should place a new patch on a relatively hairless location between the neck and waist. There should be no activity restrictions while using the patch. Treatment for 8 weeks or less is as effective as longer treatment periods. New research indicates that starting the patch 2 weeks before quit day increases success.


Nicoderm, Habitrol: 21 mg/24 hr for 4 wk, then 14 mg/24 hr for 2 wk, then 7 mg/24 hr for 2 wk

Nicotrol: 15 mg/16 hr for 4 wk, then 10 mg/16 hr for 2 wk, then 5 mg/16 hr for 2 wk.

ProStep: 22 mg/24 hr for 4 wk, then 11 mg/24 hr for 4 wk Nicotine Gum

Gum should be chewed slowly until a peppery taste emerges, then parked between the check and gum to facilitate nicotine absorption through the oral mucosa. The gum should be slowly and intermittently chewed and parked for about 30 minutes.

Acidic beverages (e.g., coffee, juices, soft drinks) interfere with the buccal absorption of nicotine, so eating and drinking anything except water should be avoided for 5 minutes before and during chewing. Instructing patients to chew the gum on a fixed schedule may be more beneficial than ad lib use. Patients often do not use enough gum to obtain the maximum benefit.


Nicorette: Available as 2 mg and 4 mg per piece. Smokers of more than one pack a day, those who smoke within 30 minutes of awakening, and those with a history of severe withdrawal symptoms should use 4 mg; light smokers should use 2 mg.

Chew one piece every 1-2 hr (at least 9/day) for 6 wk, then one piece every 2-4 for 3 wk, then one piece every 4-8 hr for 3 wk, then discontinue.

For the 2-mg dose, do not exceed 30 pieces/day; for the 4-mg dose, 20 pieces/day.

Nicotine Lozenge

Each lozenge is one 2-mg or 4-mg dose and should be dissolved in the mouth when the urge to smoke starts; lasts 20-30 minutes. Use 9-20/day for up to 12 weeks.

No eating or drinking during use or 15 minutes before use.

Side effects include sore teeth or gums, indigestion, throat irritation, and other symptoms similar to those with the nicotine gum.


Commit lozenge: 2 mg and 4 mg per piece. Smokers of more than one pack a day who smoke within 30 minutes of waking, and those with prior history of severe withdrawal, should use the 4-mg form. Light smokers should start with the 2-mg strength. Do not swallow, bite, or chew the lozenge.

Nicotine Inhaler

Local irritation in the mouth and throat occurs in 40% of patients. Coughing and rhinitis are also common. The severity and frequency of these symptoms decline with continued use.

In cold weather, the inhaler and cartridges should be kept in an inside pocket or warm area, because nicotine delivery declines significantly at temperatures below 40° F (4.4° C).


Nicotrol Inhaler: 10 mg/cartridge (4 mg delivered and 2 mg absorbed). Each cartridge lasts about 20 minutes with frequent puffing and is equivalent to about two cigarettes. Use 6 to 16 cartridges/day for the first 12 wk, then reduce gradually over 12 wk.

Nicotine Nasal Spray

Moderate nasal irritation for first 3 weeks or longer. Nasal congestion and transient changes in sense of smell and taste may also occur. Should not be used in patients with severe reactive airways disease. Do not sniff, swallow, or inhale through nose while administering doses.

Deliver with head tilted slightly back. Dosage

Nicotrol NS: One spray (0.5 mg) to each nostril (1.0 mg total). Use 1-2 doses/hr and 8 to 40 doses/day (maximum, 5 doses/hr). Each bottle contains 100 doses. Usual maximum, 12 weeks.

Bupropion SR

Contraindicated in patients with a history of significant head trauma, seizure disorder, or eating disorder, and in those who have used a monoamine oxidase inhibitor (MAOI) in the past 14 days. Side effects are insomnia and dry mouth. If insomnia is present, take the evening dose in the afternoon, but at least 8 hours after the first dose.


150-mg tablets; one every morning for 3 days and then twice daily. Start 2 weeks before the target quit date and continue for 12 weeks. Side effects are nausea (30% of patients), abnormal dreams, insomnia, headache, taste aversion, and flatulence.


Start 1 week before quit date.

Side effects are nausea (30% of patients), abnormal dreams, insomnia, headache, taste aversion, and flatulence. FDA warning addresses behavior changes and suicidal ideation.


Chantix: 0.5 mg (white tablet) once daily for 3 days, then twice daily for 4 days, then 1.0 mg (blue tablet) twice daily, for total of 12 weeks.


Some patients may prefer the nasal spray or inhaler, because the more rapid delivery of nicotine better simulates smoking. Others may prefer bupropion because it is nonnicotine therapy. Bupropion should be considered especially in those with a history of depression.

Modified from US Department of Health and Human Services. Treating Tobacco Use and Dependence: Clinical Practice Update. Rockville, Md, Agency for Health Care Policy and Research, Public Health Service, 2008.

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