Cessation of Smoking By Nicotine Replacement Therapy

Transcription

1 Review Article ISSN: Mamatha. J et al / Journal of Pharmacy Research 2017,11(5), Available online through Cessation of Smoking By Nicotine Replacement Therapy Mamatha. J*, K.V. Ratnamala R.B.V.R.R. Women s college of pharmacy, Barkatpura, Hyderabad,Andhra Pradesh,India. Received on: ; Revised on: ; Accepted on: ABSTRACT The nicotine in cigarettes and tobacco leads to actual physical dependence which can cause unpleasant withdrawal symptoms when a person tries to quit. Nicotine replacement therapy (NRT) is a medically-approved way to take nicotine by means other than tobacco. It is the most commonly used family of quit smoking medications. It is helpful for quitting smoking or stopping chewing tobacco. NRT can help relieve some of the physical withdrawal symptoms so that one can focus on the psychological (emotional) aspects of quitting. It uses products that supply low doses of nicotine. These products do not contain many of the toxins found in cigarette. The goal of therapy is to cut down cravings for nicotine and ease the symptoms of nicotine withdrawal. People may notice that nicotine withdrawal symptoms and cravings are not so strong when using NRT, therefore reduces the risk of smoking. Clinical trials show that NRT can increase the chance of quitting smoking by 50-70% when compared to quitting without help making it a good option to include in their quit smoking plan. All forms of nicotine replacement products appear to be about equally effective when used properly. KEY WORDS: Quitting smoking, Nicotine withdrawal, Nicotine replacement therapy. 1. INTRODUCTION Smoking has become one of the greatest causes of illness and premature death in developed as well as developing countries, but giving up smoking can prevent most of the harm. Although nearly half of the smokers try to stop every year, only 2-3% succeeds. One reason for the low success is that many of the quit attempts are unplanned, so that the most effective cessation aids may not be used. The most widely used cessation aid is nicotine replacement therapy. [1] Smokers who are significantly dependent on nicotine should consider nicotine replacement therapy or drug therapy to help them quit. Some of the signs of severe dependence are: Smoking more than a pack in a day Smoking within 5 minutes of waking up from bed Smoking while sick Waking up at night exclusively to smoke Smoking to ease symptoms of withdrawal The more of these that apply, the more serious the dependence is [2] *Corresponding author Mamatha. J R.B.V.R.R. Women s college of pharmacy, Barkatpura, Hyderabad, Andhra Pradesh,India. What is NRT? The nicotine found in cigarettes makes smoking addictive and causes withdrawal symptoms, like cravings, headaches and irritability when you stop smoking. Nicotine replacement therapy (NRT) can be helpful to fight against these symptoms by releasing low levels of nicotine into your body, without the carbon monoxide, tar and other chemicals which are generally found in cigarettes. NRT can be used for people who want to stop smoking straightaway or those who want to gradually cut down before stopping. [1] Evidence shows one can double, and sometimes even triple the chances of stopping smoking by using NRT. All forms of NRT are equally effective, so one can choose a product based on their feel. The idea is to reduce the amount of NRT gradually. [2] Who can use it? Most people are able to use NRT, including: Adults and children over 12 years of age although children under 18 shouldn t use the lozenges without getting medical advice first Pregnant women doctor may suggest NRT if they think it would help to quit Breastfeeding women doctor can advise, how to do this safely People who are still smoking or using any other form of tobacco should not use NRT

2 Mamatha. J et al / Journal of Pharmacy Research 2017,11(5), Always read the packet or leaflet before using NRT to check whether it s suitable. Sometimes it may be advisable to get medical advice first, for example if anyone have kidney or liver problems or recently had a heart attack or stroke. [3] weaker patch (5-14 mg of nicotine) for another four weeks. The patch should be applied in the morning to a clean, dry area of the skin. Patch should be placed below the neck and above the waist, for example, on the arm. The FDA recommends using the patch for 3-5 months. However, some studies have shown that using it for eight weeks or less is just as effective as using it for longer. [15] NRT has not yet been proven to help people who smoke fewer than 10 cigarettes a day. The people can talk with their health care provider about a lower dose of NRT if they smoke less than that but feel they need nicotine replacement. [3] Types of NRT: NRT How to How to Use Them Types Get Them Patch Over the Counter To be placed on the skin Gives a small and steady amount of nicotine Gum Over the Counter Chew to release nicotine, chew until you get a tingling feeling and then place between cheek and gums Lozenge Over the Counter To be placed in the mouth like hard candy Releases nicotine as it slowly dissolves in the mouth Inhaler Prescription Cartridge is attached to a mouthpiece. Inhaling through the mouthpiece releases a specific amount of nicotine Nasal Spray Prescription Pump bottle containing nicotine Put into the nose and spray Nicotine patches (transdermal nicotine system): These patches provide a measured dose of nicotine through the skin. As the nicotine dose is lowered over a course of weeks, the smoker is weaned away from nicotine. These patches can be purchased without a prescription. Several types and different strengths are available in this. Package inserts describes how to use the product as well as special considerations and the possible side effects. [4] Side effects are related to the dose of nicotine, the brand of patch, individual skin characteristics, duration of the patch used, and how it is applied. Trying a different brand sometimes solves the problem. Dizziness, racing heartbeat, headache, nausea, vomiting and muscle aches are related to the dose of nicotine. Reducing the dose of nicotine will often relieve these effects. Sleep problems may be temporary and pass within 3 to 4 days or switching to a 16-hour patch may help. Trying a different form of nicotine replacement is another option. [4] Available In India Nicotinell Tts - Novartis (Transdermal patches) 17.5 mg - 30 Approximate cost Rs mg - 30 Rs mg - 30 Rs The 16-hour patch is known to work well for light-to-average smokers and is less likely to cause side effects like skin irritations, racing heart beat and headache. It does not deliver nicotine during the night, thus it is not helpful for early morning withdrawal symptoms. The 24-hour patch is known to provide a steady amount of nicotine, avoiding peaks and troughs. It helps with early morning withdrawal. However, there may be more side effects such as disrupted sleep patterns as well as skin irritation. [12] Depending on body size, smokers should start using a full-strength patch (15-22 mg of nicotine) daily for four weeks, and then use a Nicotine gum: It is a fast-acting form of replacement in which nicotine is absorbed through the mucous membrane of the mouth. It can be bought overthe-counter without a prescription. It comes in 2 mg and 4 mg strengths. For best results, please follow the instructions of the package insert. Chew the gum slowly until you note a peppery taste. Then, place it against the cheek, chewing it and parking it off and on for about minutes. Food and drink can affect how well the nicotine is absorbed. You should avoid acidic foods and drinks such as coffee, juices and soft drinks for at least 15 minutes before the gum use. [13]

3 Mamatha. J et al / Journal of Pharmacy Research 2017,11(5), The smoker who smokes a pack per day and smokes within 30 minutes of waking up may need to start with the higher dose, 4 mg gum. Not more than 20 pieces should be used in a day. Nicotine gum is usually recommended for 1-3 months, with the maximum being six months. Tapering the amount of gum chewed may help to stop using it. [16] One advantage of nicotine gum is that it allows the user to control the nicotine doses. The gum can be chewed as needed and on a fixed schedule during the day. The recent data has shown that scheduled dosing is more effective. A schedule of 1-2 pieces per hour is common. People with sensitive skin may prefer the gum to the patch. [20] Side effects of the gum can include throat irritation, mouth ulcers, hiccups, nausea, jaw discomfort, and racing heartbeat. Symptoms related to the stomach and jaws are usually caused by improper use of the gum, such as swallowing nicotine or chewing too rapidly. Long-term dependence is one disadvantage of nicotine gum. In fact, research has shown that 15%-20% of gum users who successfully quit smoking continue using the gum for a year or longer. Although the maximum recommended length of use is six months, continuing to use the gum is likely to be safer than going back to smoking. [4] nose, watery eyes, throat irritation and coughing. There is also the danger of using more than it is needed. If the patient has asthma, allergies, nasal polyps or sinus problems, doctor may suggest another form of nicotine replacement. [19] Not Available As Yet In India Nicotine inhalers: Inhalers are available only by prescription. The nicotine inhaler is a thin plastic tube with a nicotine cartridge inside. Unlike the other inhalers, which deliver most of the medicine to the lungs, the nicotine inhaler delivers most of the nicotine vapor to the mouth where it gets absorbed into the bloodstream. Nicotine inhalers are the FDAapproved nicotine replacement method that is most like smoking a cigarette, which some smokers find helpful. [21] At this time, inhalers are the most expensive form of NRT available. These are not the same as electronic cigarettes, which are not approved by the FDA to help people quit smoking. [5] How to use the nicotine oral inhaler: You puff on the inhaler and the cartridge sends the nicotine vapor into your mouth. You may use the cartridge all at once over about 20 minutes, or puff on it only a few minutes at a time. The recommended dose is between 4 and 20 cartridges a day, slowly tapering off over 6 months. [23] Side effects: The most common side effects, especially when first using the inhaler include coughing, mouth or throat irritation, runny nose, upset stomach [5] Available in India Nicorette - Pharmacia & Upjohn Gum 2mg Approximate cost: 15 pieces Rs. 150=00 Nicotine nasal spray: Nicotine nasal spray delivers nicotine quickly to the bloodstream as it is absorbed through the nose. It is available by prescription itself. Nasal spray gives immediate relief of withdrawal symptoms and offers the smoker a sense of control over nicotine cravings. As the spray is easy to use, smokers report great satisfaction. Generally, it should not be used for longer than six months. The most common side effects which last about 1-2 weeks include nasal irritation, runny Nicotine lozenges Nicotine lozenges can be bought without a prescription. The lozenges are available in 2 strengths: 2 mg and 4 mg. Smokers choose their dose based on how long they can wait to have their first cigarette after waking up. [6] If a person smokes his first cigarette within 30 minutes of waking up, then it is better to use 4 mg nicotine lozenges for him. If the same person smokes his first cigarette more than 30 minutes after waking up, he can use 2 mg-nicotine lozenges. [10] How to use nicotine lozenges: The recommended dose is 1 lozenge per every 1 to 2 hours for 6 weeks, then 1 lozenge per every 2 to 4 hours for weeks 7 to 9, and finally, 1 lozenge per every 4 to 8 hours for weeks 10 to 12. [7] The lozenge makers also recommend:

4 Mamatha. J et al / Journal of Pharmacy Research 2017,11(5), One should not eat or drink for at least 15 minutes before using a lozenge. (Some drinks can reduce how well the lozenge works) One should not use more than 1 lozenge at a time and do not use one right after another [24] Suck on the lozenge until it is fully dissolved, about 20 to 30 minutes. Move it from side to side in the mouth. Do not bite or chew it and don t swallow it. The nicotine absorbs through the mucous membranes of the mouth [8] Do not use more than 5 lozenges in 6 hours and more than 20 lozenges per day [27] Stop using the lozenge after 12 weeks. Possible side effects of the nicotine lozenge include nausea, hiccups, sore throat, coughing, and heartburn [5] Combination NRT: Combining two forms of NRT (patch plus oral form) has been shown to be more efficacious than a single form of nicotine replacement. The patches provide a steady background nicotine level and the oral forms provide relief for breakthrough cravings. [9] There is evidence from nine trials that the combination NRT is more effective than a single type. Health professionals should encourage smokers to use combined NRT if they are unable to quit using one NRT product alone or experience cravings using only one form of NRT. Combination NRT can also be recommended as first line treatment. [10] In Australia, the combination of NRT patch and 2 mg gum, 2 mg lozenge or 1.5 mg mini lozenge is licensed for smokers who have relapsed in the past or who experience cravings using only one form of NRT. Some experts recommend combination therapy for all dependent smokers using NRT, rather than monotherapy, including use of the stronger forms of oral products for those who need them. [11] Side Effects of NRT: Since all NRTs appear to work equally well, many smokers choose a treatment based on how easy it is to use and what possible side effects it may cause. All forms of nicotine replacement have side effects, but the types of side effects differ. Very few people (less than 5%) have to stop using a nicotine replacement product because of side effects. Stopping nicotine replacement therapy abruptly may cause some of the same withdrawal symptoms that occur when the person stops smoking. It is possible for a person to become dependent on a nicotine replacement product, although this is rare. [12] CONCLUSION: The dose of nicotine in NRT is not as high as in cigarettes; the nicotine from smoking is absorbed quickly and has a quicker effect than NRT. The risk of becoming addicted to (dependent on) NRT is small. About 1 in 20 people who stop smoking with the help of NRT continue to use NRT in the longer term. Apart from causing addiction, nicotine is not thought to cause disease when taken for a few months. The health problems from cigarettes, such as lung and heart diseases, are due to the tar and other chemicals in cigarettes. So, taking NRT instead of smoking is one step towards a healthier life. REFERENCES: 1. BMJ 2009, Effectiveness and safety of nicotine replacement therapy assisted reduction to stop smoking: systematic review and meta-analysis, Published 02 April 2009, Centers for Disease Control and prevention, Learn About Nicotine Replacement Therapy, reviewed: February 22, 2017, guide/explore-medications.html 3. Mills EJ et al, Adverse events associated with nicotine replacement therapy (NRT) for smoking cessation. A systematic review and meta-analysis of one hundred and twenty studies involving 177,390 individuals, NCBI, published: 13 July 2010, pubmed/ Indiacancer.org, Nicotine Replacement therapy, &view=article&id=91 5. American Cancer Society 2016, Nicotine Replacement Therapy to Quit Smoking stay-away-from-tobacco/guide-quitting-smoking/nicotinereplacement-therapy.html 6. NHS Choices, Stop smoking treatments, reviewed: 19/07/ 2016, Pages/Treatment.aspx# 7. Quit Smoking Community, The Problem with Nicotine Replacement Therapy, June 16, 2014, smoking community.org/problem-with-nicotine-replacementtherapy/ 8. Patient, Nicotine Replacement Therapy, in/health/nicotine-replacement-therapy 9. Ministry of Health, Guide to Prescribing Nicotine Replacement Therapy (NRT), system/files/documents/publications/guide-to-prescribingnicotine-replacement-therapy-nrtv2.pdf 10. Smokefree, NHS stop smoking medicines RACGP, Nicotine replacement therapy, nicotine-replacement-therapy/

5 Mamatha. J et al / Journal of Pharmacy Research 2017,11(5), 12. WebMD, Nicotine Replacement Therapy for Quitting Tobacco, nicotine-replacement-therapy-for-quitting-tobacco 13. U.S. Food & Drug Administration, Nicotine Replacement Therapy Labels May change, U.S. Department of Health and Human Services, published: April 1, 2013, ucm htm 14. NHS Choices, Stop smoking treatments, reviewed: 19/07/ 2016, Pages/Treatment.aspx# 15. National Cancer Institute, NCI Dictionary of Cancer Terms, GP Notebook, nicotine replacement therapy, Smokefree, NHS stop smoking medicines Mills EJ et al, Adverse events associated with nicotine replacement therapy (NRT) for smoking cessation. A systematic review and meta-analysis of one hundred and twenty studies involving 177,390 individuals, NCBI, published: 13 July 2010, pubmed/ PubMed Health, Can nicotine replacement therapy (NRT) help people quit smoking?, U.S. National Library of Medicine, reviewed: 19 September 2012, ASHLine, Medications to Help You Quit Smoking, ashline.org/about-quit-coaching/medications-and-nrts/ 21. Quitline, NRT and Quitcards, helping-others-quit/research/nrt-and-quitcards 22. Ministry of Health, Guide to Prescribing Nicotine Replacement Therapy (NRT), system/files/documents/publications/guide-to-prescribingnicotine-replacement-therapy-nrtv2.pdf 23. Silagy C et al, Nicotine replacement therapy for smoking cessation, NCBI, 2002 ;( 4):CD Quit, Nicotine replacement therapy, Want-to-Quit/Support-Treatment/Nicotine-replacementtherapy.html 25. Lisa J et al, What is the most effective nicotine replacement therapy?, The Journal of Family Practice, 2003 June; 52(6): Quit Smoking Community, The Problem with Nicotine Replacement Therapy, June 16, 2014, quitsmokingcommunity.org/problem-with-nicotinereplacement-therapy/ 27. Quit, Nicotine replacement products, /preparing-to-quit/choosing-best-way-to-quit/nicotinereplacement-products Source of support: Nil, Conflict of interest: None Declared