What are the recommendations for when you should take medication in order to quit smoking?
The general recommendation is that all smokers trying to quit should be offered medication. There is compelling evidence that medication aids in abstinence. The evidence is even stronger that medication and counseling are more effective than either alone. For that reason, medication is strongly encouraged. All seven of the FDA-approved medications for treating tobacco use are recommended, including bupropion SR, nicotine gum, nicotine inhaler, nicotine lozenge, nicotine nasal spray, nicotine patch, and varenicline. Additionally, the use of these medications for up to six months does not present a known health risk, and developing dependence on these medications is rare. The higher-dose preparations have been shown to be effective in highly dependent smokers.
NRT combinations are especially helpful for highly dependent smokers or those with a history of severe withdrawal. Combining the nicotine patch long-term with nicotine gum, nicotine nasal spray, nicotine inhaler, or bupropion SR, also increases long-term abstinence rates relative to placebo treatments.
However, combining varenicline with NRT agents has been associated with higher rates of side effects (such as nausea and headaches). Unfortunately, there are no well-accepted
algorithms to guide optimal selection among the first-line medications. Data show that bupropion SR and nicotine replacement therapies, in particular the 4-mg nicotine gum and 4-mg nicotine lozenge, bupropion SR, and nortriptyline appear to be especially effective in treating tobacco-dependent patients diagnosed with depression, but nicotine replacement medications also appear to help individuals with a past history of depression.
That being said, there are some exceptions to that general recommendation.
These exceptions are:
1. Women: Evidence is mixed as to whether NRT is less effective in women than men. The clinician should consider the use of another type of medication with women, such as bupropion or varenicline.
2. Pregnant women: These smokers should be encouraged to quit without medication. The studies of medication use are far too small. Bupropion has not been found to be effective at all in pregnant smokers. That being said, one may still recommend medication to this group if, in the clinician’s opinion, the benefits outweigh the risks.
In pregnant women, for example, the risks of nicotine alone on the mother and the fetus must be weighed against the risks of nicotine, tar and carbon monoxide should the pregnant woman be unable to stop smoking without the benefit of an NRT.
3. Cardiac patients: NRT should be used with caution among particular cardiovascular patient groups: those who have had a heart attack within two weeks, those with serious arrhythmias, and those with unstable angina pectoris.
4. Light smokers, smokeless tobacco users, and adolescents: Few studies have been done on these populations to conclude any significant benefit, nor suggest any potential risk. Again, the clinician should weigh the risks against the benefits when considering medications in these populations.
Terms:
Arrhythmias – Abnormal heart rhythm.
Angina Pectoris (Also known as angina.) – Severe chest pain due to a blockage of blood flow in the arteries of the heart. It is a symptom of an impending heart attack.
There is compelling evidence that medication aids in abstinence
What are the success rates of the five nicotine replacement therapies alone and in combination with other forms?
Recent studies have examined the combination of some of the nicotine replacement products and the smoking cessation aids. The FDA has not approved these medications incombination because of the limited number of efficacy and safety studies. Nevertheless, it is frequently done in practice. Using the patch alone, there is an estimated abstinence rate of 17.4%. By combining the nicotine gum or nicotine lozenge with the patch, the abstinence rate can increase to 28.6%. Therefore, combining the patch with other self-titrating nicotine replacement therapies may be more effective than just using the nicotine patch alone. There is less evidence to support doubling the nicotine patch. In fact, there are warnings against doing so. Combining medications is one of the recommended treatments for those heavy smokers who have difficulty quitting with just the patch and who are being closely monitored by a physician.
Can I become addicted to any of the drugs used to assist a person to quit smoking?
It is estimated that 1.5 to 2 million Americans try the nicotine gum each year. Thanks to the gum, many people have successfully kicked the cigarette habit. However, some ex-smokers have weaned themselves from one nicotine habit only to pick up a new addiction, but a less risky one. GlaxoSmithKline, manufacturers of Nicorette gum, advises people to stop using the nicotine gum at the end of 12 weeks, and to talk to a doctor if you need to continue to use the gum. But these guidelines haven’t stopped some people from using the gum for many months and even years.
In a recent report evaluating data collected by A.C. Nielsen, researchers concluded that 5% to 9% of nicotine gum users relied on nicotine gum longer than the recommended three months. About half of the people in the study used it for six months or longer. In published studies at the Mayo Clinic Nicotine Dependence Center, people have used nicotine gum up to five years without heart or vascular problems. By chewing the gum, the nicotine is delivered slowly through the mucous membranes in the mouth, at much lower levels than the quick-hit surge of nicotine when puffing on cigarettes.
At the same time, the gum does not contain any of the cancer-causing substances present in cigarettes. The cancers and vascular diseases associated with smoking develop from the carcinogens, tars, and the carbon monoxide in cigarettes.
What is Bupropion SR?
Bupropion is also known as Zyban or Wellbutrin. Zyban is the trade name for the medication when it is prescribed for smoking cessation and Wellbutrin is the trade name for the medication when it is prescribed for depression. It is therefore classified as an antidepressant. Bupropion works by blocking the dopamine transporter pump preventing the transport of dopamine back into the neuron, and thereby increasing the amount of dopamine in the synaptic cleft. Dopamine is a neurotransmitter found in the brain that is involved in attention, decision making, motor activity, mood, and the generation of psychoses. It is also the major reward chemical thought to be involved in all forms of addiction. Bupropion comes in two forms of tablets to be taken by mouth: a regular tablet and a sustained-release or extended-release (long-acting) tablet. The regular tablet (Wellbutrin) is usually taken three or four times a day, with doses at least six hours apart. The sustained-release tablet (Wellbutrin SR or Zyban) is usually taken once or twice daily in the morning and afternoon.
Directions:
• Your doctor will probably start you on a low dose of bupropion and gradually increase the dose over time.
• It may take four weeks or longer before you feel the full benefit of bupropion.
• Continue to take bupropion even if you feel well. Do not stop taking bupropion without talking to your doctor.
• Your doctor will probably decrease the dose gradually over a period of two weeks prior to stopping the medication.
• If you forget, skip, or miss a dose, then continue your regular dosing schedule. Do not take a double dose to make up for a missed dose.
• Always allow the full scheduled amount of time to pass between doses of bupropion.
Your doctor may need to change the doses of your medications or monitor you carefully for any pre-existing conditions.
There are a number of conditions for which you should not be taking this medication, including if you have a seizure disorder.
If you have anorexia or if you have liver disease you should let your doctor know, as these are general contraindications to taking this medication If you experience a serious side effect, you or your doctor should send a report to the Food and Drug Administration’s (FDA) Med watch Adverse Event Reporting program online (at http://www.fda.gov/MedWatch/report.htm).
If you are taking the sustained or extended-release tablet, you may notice something that looks like a tablet in your stool. This is just the empty tablet casing and does not mean that you did not get your complete dose of medication.
Term:
Contraindications – A condition or factor that increases the risk of an adverse event when taking a particular medication or receiving a particular treatment.
