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OTC PRODUCTS: Smoking cessation Smoking cessation Catherine Whittaker (B. Pharm)
Abstract
Cigarette smoking is estimated to cause over five million deaths worldwide each year.1 Unfortunately, tobacco addiction is one of the most difficult addictions to overcome. Many of our patients are smokers and as healthcare providers we are uniquely positioned to ask our patients about their smoking status, to encourage them to quit and to provide support. We will review the currently available smoking cessation medications so that we can assist patients with the selection of a safe, effective and appropriate smoking cessation medication to ease the symptoms of nicotine withdrawal and improve the likelihood of successfully quitting smoking.
Table 1: Symptoms of nicotine withdrawal1
South Africa is a leader in tobacco control in Africa and in 1999 banned all tobacco advertising and smoking in public places. Cigarettes are highly taxed and clear health warnings now appear on each pack of Irritability, frustration or anger cigarettes. However, despite these changes and an increased public Difficulty in concentrating awareness regarding the health risks associated with smoking, it remains a huge public health problem in South Africa.
Decreased heart rate Cigarette smoking is estimated to cause over five mil ion deaths Increased appetite or weight gain worldwide each year, making it the leading preventable cause of death.1 The three major causes of smoking related mortality are atherosclerotic cardiovascular disease, lung cancer and chronic obstructive pulmonary Benefits of quitting
disease.1 We need to encourage smokers that stopping smoking reduces their risk of developing and dying of tobacco related diseases, even if they The risk of premature death in smokers is double that of non- quit after they develop cardiovascular or chronic pulmonary disease.1 It smokers.4 On average, non-smokers live six to eight years longer real y is never too late to quit.
than smokers.4 Even a 60 year old smoker could gain at least three years of life expectancy by stopping smoking.4 It may be helpful to It is quoted that around 70% of smokers want to stop their addiction.1 remind people about the numerous other short, medium and long In the pharmacy, we can provide a useful service in this area by term health benefits of quitting. (See table 2) conducting frank discussions of personal health risks, the benefits of smoking cessation, and provide expertise regarding the products available.
Table 2: Short, medium and long term benefits of quitting4
Within eight hours carbon monoxide levels return to normal Barriers to quitting
and oxygen levels return to normal Within 48 hours taste and smell become stronger The primary barrier is nicotine, which is a highly addictive drug. It Within one to three months circulation and lung function is a potent psychoactive drug that is capable of causing physical dependence and tolerance.1 In the absence of nicotine, a smoker Within a few years the risk of heart attack decreases develops cravings for cigarettes and symptoms of nicotine withdrawal Within 5 years the risk of stroke and lung cancer decreases syndrome.1 (See table 1) Secondly, smokers become conditioned to associate the pleasurable effects of tobacco use with environmental triggers such as their morning coffee, an alcoholic drink or the end of a meal.1 These events become triggers to smoke and contribute to the difficulty in Giving up smoking is a difficult challenge and it may be useful to give remaining abstinent from nicotine.1 people practical tips to assist them. (See table 3) SA Pharmacist's Assistant OTC PRODUCTS: Smoking cessation Table 3: Ten useful tips to quit smoking3, 4
detectable levels of carcinogens and toxic chemicals to which users could potentially be exposed.6 Decide on a date to quit smoking. Don't let anything to change that date In South Africa, the SA Pharmacy Council has informed pharmacists Make a list of reasons, including health benefits, social and financial advantages that it cannot endorse the sale of e-cigarettes. The matter has been referred to the Medicines Control Council for consideration.
Throw away all reminders of smoking such as cigarettes and ashtrays Drink lots of water - it will help to flush the nicotine from Become more active - exercise Over the counter preparations
Change your routine. Avoid smokers and things that make you want to smoke for the first few days Nicotine Replacement Therapy (NRT) Tell family and friends so they can offer support NRT provides nicotine to a smoker without using tobacco, thereby Do not use a crisis or special occasion as an excuse for "just relieving nicotine withdrawal symptoms while the smoker breaks the behaviour of cigarette smoking.1 NRT is available in skin patches The first 2-3 days are the most difficult, after that it gets that deliver nicotine slowly through the skin, chewing gum, mouth spray, inhalers and tablets which deliver nicotine via the mucous Be prepared - know the withdrawal symptoms and how to membrane of the mouth more quickly than skin patches, but less rapidly than from smoking cigarettes.7 Efficacy: Clinical trials have found evidence that all forms of NRT
Alternatives to cigarettes
made it more likely that a persons' attempt to quit smoking would succeed.7 The chances of stopping smoking were increased by 50- 1. Hubbly Bubbly
70%.7 Most of the studies were performed in people smoking more than 15 cigarettes a day.7 All products had a higher cessation rates when used in combination with a behavioural smoking counselling Contrary to the popular myth, smoking a hubbly bubbly (also known programme.1 The limited evidence available suggests no overall as a hookah, waterpipe or narghile), is not a safe alternative to
smoking and is associated with many of the same risks as
difference in effectiveness of different forms of NRT.7 smoking.3 A typical one hour long hubbly bubbly smoking session
Safety: Adverse effects from using NRT are related to the type of product
involves inhaling 100-200 times the volume of smoke inhaled with a and include skin irritation from patches and irritation to the inside of the single cigarette.3 Even after the smoke has passed through the water, mouth from gum, sprays and tablets.7 Common adverse events that are it still contains high levels of toxic compounds, including carbon common to al NRT products include dizziness, nausea and headache.2 monoxide, metals and cancer-causing chemicals.3 We need to There is no evidence that NRT increases the risk of heart attacks.7 educate the population, particularly the youth, regarding the serious health risks associated with the use of a hubbly bubbly.
Smokers often worry that they will remain dependent on nicotine if they use these products when they stop smoking. This may occur, 2. Electronic cigarettes
although it is not common; it is extremely rare with the patch, presumably because of slower absorption.1 However, experts Electronic cigarettes are now sold in many pharmacies, but what do recommend NRT use for a longer period if the alternative would be to we actually know about them? They typically look like a real cigarette return to cigarette smoking.1 and users puff on it like a real cigarette, but it is made of stainless steel and is powered by a rechargeable battery.5 It has a chamber for 1. Transdermal nicotine patches: (e.g. Nicorette Patch®) delivers
storing liquid nicotine in different concentrations and flavours.5 They nicotine through the skin at a relatively steady state.2 Compliance are marketed as therapy for smokers trying to quit as users do not with the patch is higher than with other NRT products but the user light it and it produces no smoke.5 Rather, it produces a fine heated has no control of nicotine dose to respond to nicotine cravings and mist which is absorbed into the lungs.
withdrawal symptoms during the day.1, 2 For breakthrough cravings not adequately controlled by transdermal nicotine alone, acute The World Health Organization has voiced concerns regarding therapies (such as the gum or spray) may be added.2 electronic cigarettes stating that they are not a proven nicotine replacement therapy as no rigorous peer reviewed studies have been Administration: a patch should be applied once daily and left on the
conducted showing that they are safe and effective.5 The US Food skin for 16 hours.9 Most smokers should start with the highest dose and Drug Administration (FDA) is also concerned about the safety (15 mg/day) for twelve weeks and then gradually taper to lower dose of these products as they are not regulated and have therefore not patches (10 mg/day and 5 mg/day).9 undergone formal testing of the levels of nicotine or the amounts of other chemicals that the various brands deliver to the user. An 2. Nicotine gum: (e.g. Nicorette Gum®) provides a short acting
FDA laboratory analysis of two electronic cigarette samples found but rapid onset pattern of nicotine delivery.1 It is available in SA Pharmacist's Assistant OTC PRODUCTS: Smoking cessation 2 mg and 4 mg doses, delivering approximately 1 mg and 2 mg with bupropion and the number of people stopping smoking with of nicotine.2 Nicotine gum contains nicotine bound to a polacrilex varenicline was higher than with buproprion.8 One trial was a resin. Chewing releases nicotine from the gum to be absorbed comparison between varenicline and nicotine patches and showed through the oral mucosa, resulting in a peak blood nicotine level a modest benefit of varenicline over the patches.8 in 20 minutes.1 The gum al ows the user flexibility to respond to acute cravings or withdrawal symptoms as a cigarette smoker Safety: The main adverse event was nausea and this usually
subsided over time.8 There are recent concerns that varenicline may be linked with depressive mood, agitation or suicidal thinking and Administration: Smokers are instructed to chew the gum whenever
behaviour in some smokers.8 they have the urge to smoke.1 To ensure that nicotine is absorbed and not swallowed, chewing technique is important. A "chew and park" technique is recommended where the gum is chewed until nicotine taste, then "parked" between the cheek and gum until the Many smokers are in denial about their addiction. We need to taste disappears.1,2 This cycle is then repeated. become more proactive and initiate conversations with our patients regarding smoking to prompt them to quit. We can educate patients Acidic beverages (e.g. beer, coffee and carbonated drinks) interferes with information regarding the benefits of quitting and the safety and with the buccal absorption of nicotine and patients should avoid efficacy of the currently available smoking cessation medication so acidic beverages for 15 minutes before and during chewing gum.2 they can make an informed decision. Finally, we can provide much Smokers who smoke more than 25 cigarettes per day have a better needed support during the quitting process.
result with the 4 mg gum, whereas the 2 mg gum is recommended for lighter smokers.1 3. Nicotine Spray: (e.g. Quit®) delivers nicotine via the oral mucosa.
Administration: It is available in 1 mg, 0.66 mg and 0.33 mg doses
Rennard SI et al Management of Smoking Cessation September 2009, Up to Date and 1 to 2 doses are sprayed in the mouth when the urge to smoke (last accessed 24-01-2010) is felt.4 The 1 mg dose is recommended in smokers who smoke more Lande RG, Nicotine addiction, October 2009, www.emedicine.medscape.com (last than 20 cigarettes per day. accessed 18-01-20100 www.cansa.org.za (last accessed 19-01-2010) MIMS Guide to OTC Products, Volume 14 2008 World Health Organisation http://www.who.int/mediacentre/news/releases/2008/pr34/en/index.html (lasta ccessed18-01-2010) 1. Bupropion (e.g. Zyban®) is believed to act by enhancing the
Food and Drug Administration http://www.fda.gov/NewsEvents/Newsroom/ central nervous system noradrenergic and dopaminergic release. It PressAnnouncements/ucm173222.htm (last accessed 18-01-2010) may therefore act by alleviating some of the symptoms of nicotine Stead LF et al, Nicotine Replacement Therapy for smoking cessation, November 2007 withdrawal, which includes depression. 1, 2 www.cochrane.org (last accessed 20-01-2010) Stead LF and Lancaster T, Nicotine receptor partial agonists for smoking cessation, Efficacy: Bupropion has been shown to approximately double rates
March 2008, www.cochrane.org (last accessed 20-01-2010) of cessation compared with placebo, and is equally effective in men Nicorette Patch 5mg, 10mg, 15mg package insert and women.1,2 It has also been shown that bupropion combined with NRT may increase cessation rates relative to bupropion alone.2 The recommended dose of bupropion is 300 mg/day, given as 150 mg twice daily.2 Safety: The most common side effects are insomnia, agitation, dry
mouth and headache.1
2. Varenicline is not yet licensed in South Africa. It is a partial
agonist at the alpha4beta2 subunit of the nicotinic acetylcholine
receptor, the receptor that appears to produce the reinforcing
effects of nicotine and thereby produces nicotine dependence.1
It is thought to work in two ways; by reducing the symptoms
of nicotine withdrawal and by blocking the nicotine in tobacco
smoke from binding to the receptor and thereby reducing the
rewarding aspects of cigarette smoking.1
Efficacy: In a number of clinical trails, it was shown that varenicline
increased the chances of quitting between two and three fold
compared with placebo.8 Three trials included a direct comparison
SA Pharmacist's Assistant

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