Medications | Boston Medical Center
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Medications

Appropriate use of pharmacotherapy, such as nicotine replacement therapy (NRT), bupropion or varenicline, can double a person's chances of successfully quitting tobacco.

There are different medications and therapies that may help during the quitting process. Learn more.

How to use NRT products

Nicotine Replacement Therapies (NRTs)

  • With smoking, nicotine is delivered via the lungs to the brain in 7-10 seconds, offering almost instantaneous effects.
  • Among NRTs, nasal spray has the most rapid absorption, followed by the gum, lozenge, and inhaler; absorption is slowest with the transdermal formulations.
  • Because NRTs deliver nicotine more slowly and at lower levels (e.g., 30-75% of those achieved by smoking), these agents are far less likely to be associated with dependence.
  • Aim of NRT is to replace nicotine from cigarettes without other harmful components of tobacco smoke.
  • Using nicotine replacement therapies double one's likelihood of successfully quitting smoking by reducing withdrawal symptoms.
  • Careful consideration should be used when recommending NRT for persons with active or uncontrolled heart disease:
    • Patients with recent MI (within 2 weeks)
    • Patients with underlying arrhythmias or worsening angina
  • Although NRT is not absolutely contraindicated for pregnant and lactating women, it should only be prescribed when it is determined that the benefits of taking NRT outweigh the risks.
  • NRT has not been approved by the FDA for use in youth.

Nicotine Chewing Gum (Nicorette)

  • Nicotine is released from the gum and absorbed through the gum tissue to reduce cravings.
  • Most common adverse effects: gastrointestinal disturbances, dyspepsia, nausea and hiccups, occasional headache if the gum is chewed too quickly, jaw pain, and dental problems.
  • Tips for Use
    • Chew gum slowly until peppery or tingling sensation appears (~15 to 30 chews).
    • Park gum between cheek and gum.
    • Resume chewing when sensation fades.
    • Repeat chew/park steps until sensation does not reappear.
    • Park gum at different parts of the mouth.
    • No food or drink 15 minutes before or during use.
     
Patients who smoke their first cigarette >30 minutes after waking

2 mg

One piece can be chewed every 1-2 hours or as needed
Maximum 24 pieces per day
Minimum duration 12 weeks

Patients who smoke their first cigarette <30 minutes after waking

4 mg

One piece can be chewed every 1-2 hours or as needed
Maximum 24 pieces per day
Minimum duration 12 weeks

Nicotine Lozenge (Nicorette)

  • Most effective when dissolved in the mouth; avoid chewing or swallowing.
  • Most common adverse effects: gastric and throat irritation.
  • Tips for Use
    • Allow to dissolve in mouth slowly (20-30 minutes); nicotine release may cause a tingling sensation.
    • Rotate to different areas of mouth.
    • No food or drink 15 minutes before or during use
     
Patients who smoke their first cigarette >30 minutes after waking

2 mg

One lozenge can be used every 1–2 hours or as needed
Maximum 20 per day
Minimum duration 12 weeks

Patients who smoke their first cigarette within 30 minutes of waking

4 mg

One lozenge can be used every 1–2 hours or as needed.
Maximum 20 per day
Minimum duration 12 weeks

Nicotine Patch (NicoDerm CQ)

  • The patch provides a low continuous dose of nicotine that is absorbed through the skin.
  • The patch is applied once a day and worn for 16-24 hours.
  • Duration of therapy for at least 8 to 12 weeks.
  • Tips for use:
    • Apply one new patch every 24 hours on skin that is dry, clean and hairless.
    • Wash hands after applying or removing patch.
    • Do not cut patch and do not wear more than once patch at a time.
  • The most common adverse reaction is skin irritation.
  • If sleep disturbance occurs, apply for 16 hours and remove at night.
     

>10 cigarettes/day

21 mg/24 hour patch

At least 8 to 12 weeks
Tapering not required

<10 cigarettes/day

14 mg/24 hour patch

At least 8 to 12 weeks
Tapering not required

Nicotine Inhaler (Nicotrol Inhaler) Prescription only and require PA for Medicaid coverage

  • Nicotine is absorbed through the throat and mouth when inhaling.
  • Recommended dose for monotherapy: 6-16 cartridges per day for the first 6-12 weeks.
  • Start tapering over the next 6-12 weeks.
  • Initial dosing of the nicotine inhaler is individualized "as needed" and tapered over the course of therapy.
  • Often used as needed in combination with nicotine patches.

Nicotine nasal spray (Nicotrol NS) Prescription only and require PA for Medicaid coverage

  • Can be used up to five times an hour, and no more than 40 times in a day.
  • Usual dose is two sprays, one in each nostril.
  • For monotherapy start at 1-2 doses/hour; maximum dose is 5 doses/hour or 40 doses/day.
  • Treatment for up to 8 weeks then stopping or tapering dose for 4-6 weeks.
  • Can also be used as needed in combination with nicotine patches.
  • The spray has not been widely used because many find it irritating and uncomfortable.

Non-Nicotine Oral Therapy

Bupropion SR (Wellbutrin, Zyban)

  • Exact mechanism is unknown; it is thought to work by enhancing dopamine levels.
  • Helps to reduce withdrawal symptoms.
  • Should be started one to two weeks before one's quit date.
  • Recommended dose: 150 mg once per day for 3 days, increasing to 150 mg twice per day for 12 weeks.
  • Can be combined with NRT to help improve success rates
  • Main adverse effects: insomnia, headache, dry mouth, nausea, dizziness, and anxiety
  • Serious adverse events: rare incidences of seizures
  • Bupropion is contraindicated in the following patients:
    • Allergy to bupropion
    • Current use of bupropion (Wellbutrin) therapy
    • Past or current seizures
    • Known central nervous system tumors
    • Patients undergoing abrupt withdrawal from alcohol or benzodiazepines
    • Current or previous history of bulimia or anorexia nervosa
    • Use of monoamine oxidase inhibitors within the past 14 days
  • Monitor for neuropsychiatric symptoms (changes in behavior, agitation, depressed mood, and suicidal ideation).
  • Use caution with renal and liver failure.

Varenicline (Chantix)

  • Chantix prevents nicotine from stimulating the brain and reduces the pleasure received when smoking, helping to reduce cravings and withdrawal symptoms.
  • Smokers are often instructed to start varenicline one week before quit date, but a longer preloading period (e.g. 1 month) is also effective in helping smokers stop cigarettes.
  • The dose is gradually up titrated to minimize side-effects:
    • Take one white tablet daily (0.5mg) for 3 days
    • Then one white tablet (0.5 mg) twice daily for 4 days
    • Then one blue tablet (1mg) twice daily for up to 12 weeks
  • Can be combined with NRT to help improve success rates.
  • Monitor for neuropsychiatric symptoms (changes in behavior, agitation, depressed mood, and suicidal ideation).
  • Other adverse effects include nausea (can be minimized by taking with food and a full glass of water, abnormal/vivid dreams, and insomnia.
  • Dose reduction is required in patients with kidney disease and on hemodialysis.
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