Pharm

Nicotine Replacement

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Nicotine Replacement, Nicotine

  • See Also
  1. Tobacco Abuse
  • Indications
  1. Tobacco Cessation
  • Physiology
  • Nicotine
  1. Nicotine is a plant alkaloid extracted from Tobacco, used as an addictive CNS stimulant, as well as an Insecticide
  2. Nicotine Activity
    1. See Nicotinic Acetylcholine Receptor
    2. Binds nicotinic AcetylcholineGanglionic receptors and at Neuromuscular Junctions (stimulatory at low dose, inhibitory at high dose)
    3. Stimulates Epinephrine release from the Adrenal Medulla, and CNS Neurotransmitter release (e.g. Acetylcholine, Dopamine, Norepinephrine)
      1. Results in peripheral Vasoconstriction, Tachycardia, and elevated Blood Pressure
    4. Chemoreceptors may also be stimulated causing Nausea and Vomiting
  • Approach
  1. Eight week course is sufficient with little added benefit to longer use
    1. Schnoll (2015) JAMA Intern Med 175(4): 504-11 [PubMed]
  2. Nicotine Replacement may be used in combination
    1. Controller medication (long-acting): Nicotine Patch
    2. Rescue medication (short acting): Nicotin Gum, Nicotine Lozenge, Nicotine Inhaler
  3. Tobacco and Nicotine Replacement overlap
    1. Best to quit simultaneously with starting Nicotine Replacement
    2. However, now considered safe (although not ideal) to taper Tobacco use while initiating Nicotine Replacement
    3. Simultaneous use was considered a risk for coronary events
      1. Now appears that smokers will self titrate their Nicotine levels
      2. When Tobacco is still being used, Nicotine Replacement is reduced to maintain a constant Nicotine level
  • Preparations
  • Long acting
  1. Nicotine Patch (e.g. Nicoderm, Nicotrol, Habitrol)
    1. Best in white, non-obese with low Nicotine dependence
    2. Lerman (2004) Ann Intern Med 140:426-33 [PubMed]
  • Preparations
  • Short-acting
  1. Nicotine Gum (Nicorette)
    1. Delays weight gain compared with other options
    2. May be preferred in cessation of chewing Tobacco
    3. Consider using in combination with the patch
  2. Nicotine Nasal Spray (Intranasal Nicotine)
    1. Best in obese heavy smokers and non-white patients
    2. Lerman (2004) Ann Intern Med 140:426-33 [PubMed]
  3. Nicotine Inhaler (Nicotrol Inhaler)
  4. Nicotine Lozenge
  • Management
  • Adjunctive medications
  1. See Tobacco Cessation
  2. Varenicline (Chantix)
    1. More effective than Bupropion in Tobacco Cessation
  3. Bupropion
    1. Consider in comorbid Major Depression when not contraindicated (esp. Seizure Disorder)
    2. Use in combination with Nicotine Replacement and other measures
  4. Mecamylamine (Inversine, Vecamyl)
    1. Rarely used in U.S. for Tobacco Cessation
    2. Increases abstinence rates with Nicotine Replacement
    3. Rose (1994) Clin Pharmacol Ther 56:86-99 [PubMed]
  • Adverse Effects
  1. Headache
  2. Nausea
  3. Vomiting
  4. Indigestion
  5. Disturbed sleep
  • Precautions
  1. Avoid Electronic Cigarette (E-Cigarette)
    1. Other standard Nicotine Replacement forms are well studied, regulated and preferred over E-Cigs
    2. Inadequate safety available for e-cig devices
    3. Unknown safety of inhaled vapor (e.g. propylene glycol, lead, Arsenic, formaldehyde, Hydrogen cyanide)
    4. E-cigs are commonly continued indefinitely (and often with continued Tobacco Smoking in up to 50%)
      1. If used, plan a taper schedule and e-cig quit date (e.g. 3 months after starting)
  2. Avoid Hookah Pipe (Tobacco smoke drawn through water before inhalation)
    1. Water does not filter Tobacco-related toxins
    2. Hookah users tend to smoke for longer and have greater exposure
  3. References
    1. (2013) Presc Lett 20(5): 27
    2. Vardavas (2012) Chest 141(6):1400-6 [PubMed]
    3. Trtchounian (2011) Tob Control 20:47-52 [PubMed]
  • Resources
  1. FDA consumer update on Nicotine Replacement
    1. http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm345087.htm
  • References
  1. Wynn (2012) J Pharm Pract 25(6):591-9