OTCs Today

Mary Warner

Despite numerous campaigns to decrease tobacco use, smoking remains the leading preventable cause of death in the United States, responsible for over 450,000 deaths each year. The negative effects of tobacco use are well-publicized, and most cigarette smokers want to quit smoking, but the addictive effects of nicotine make quitting extraordinarily difficult. In fact, quitting without treatment decreases the likelihood of a successful quit attempt, making appropriate treatment for tobacco dependence essential. Pharmacists can help patients in their quest to quit smoking through counseling, advice about nonprescription treatment options, and—in some states—through use of prescription medication.

Nonpharmacologic therapy, such as motivational interviewing, cognitive behavioral therapy, and comprehensive counseling has been shown to be essential to successful smoking cessation. The Agency for Healthcare Research and Quality’s “5 A’s Approach” to comprehensive counseling can be particularly useful for pharmacists helping patients quit smoking. The five key components are asking patients whether they use tobacco, advising tobacco users to quit, assessing patients’ readiness to quit, assisting patients with quitting, and arranging follow-up care. Patients should be advised that using nicotine replacement products without nonpharmacologic therapy is unlikely to result in their goal of quitting smoking.

Nonprescription therapies

Nonprescription nicotine replacement therapy (NRT) is commonly used for smoking cessation and is particularly helpful in mitigating withdrawal symptoms that a patient may experience when quitting smoking. The 2018 American College of Cardiology Expert Consensus Decision Pathway on Tobacco Cession Treatment includes seven first-line treatment options, including five NRT and two non-nicotine–containing oral medications, varenicline and bupropion, both of which are available only by prescription. However, only six first-line treatment options, including four NRT therapies, are commercially available. The nicotine inhaler (previously a first-line option) was removed from the market in 2023 after the manufacturer discontinued production. One of the NRT therapies, the nicotine nasal spray, is available only by prescription.

Nicotine replacement options include patches, gum, lozenges, and sprays. All of these products can help reduce nicotine cravings and withdrawal symptoms when used appropriately. Electronic cigarettes (e-cigarettes) have received attention as an alternative way to quit smoking, but they are not FDA-approved and haven’t been shown to help people stop smoking. In fact, research has shown that many people who use e-cigarettes to stop smoking end up using both products rather than quitting.

Nicotine patches, lozenges, and gum are readily available in pharmacies and online. All provide a source of nicotine to reduce withdrawal symptoms. Patches are available in 7 mg, 14 mg, and 21 mg strengths, which release a slow, steady amount of nicotine through the skin. They have a time-to-peak of approximately 2 to 8 hours and can control nicotine cravings and withdrawal symptoms for up to 24 hours. However, they may cause insomnia or vivid dreams.

Nicotine lozenges are available in 2 mg and 4 mg strengths, with nicotine absorbed through the buccal mucosa. Their time-to-peak is approximately 30 minutes, and they can be used repeatedly throughout the day to control cravings or withdrawal symptoms. They may, however, cause mouth irritation, hiccups, heartburn, or nausea and are not a good choice for patients with breathing conditions such as asthma.

Nicotine gum, also absorbed through the buccal mucosa, is available in 2 mg or 4 mg strengths and can be used every 1 to 2 hours, up to 24 pieces per day. A specific biting technique, involving biting the gum until it has a peppery taste or causes a tingly sensation in the mouth, holding the gum between the gumline and cheek until the taste or sensation stops, and repeating the process for about 30 minutes, is required for nicotine gum to work effectively. It can control sudden nicotine cravings and withdrawal symptoms but often must be used repeatedly throughout the day to avoid withdrawal symptoms. It can also cause mouth irritation, jaw soreness, heartburn, hiccups, or nausea and may stick to or damage dental appliances.

Prescription NRT and medications

Prescription NRT products, bupropion, and varenicline are often used along with nicotine patches, lozenges, or gum to help patients quit smoking. Various combinations of nonprescription and prescription treatments have been tested and are recommended for various patient populations. Regulations for pharmacists prescribing prescription medications for smoking cessation vary by state. In some cases, the use of varenicline or bupropion requires collaboration with the patient’s physician.

Nicotine nasal spray works faster than other nicotine replacement products and allows dose control by using the spray as needed throughout the day. The recommended dose is one to two sprays in each nostril once or twice an hour. It may cause nasal and throat irritation, rhinitis, sneezing, coughing, or watery eyes and isn’t a good choice for patients with sinus or nasal conditions.

Bupropion, an antidepressant often used to treat major depression and seasonal affective disorder, also supports smoking cessation. While the exact mechanism of its action is not entirely understood, bupropion is thought to mimic the nicotine effects on dopamine and noradrenaline. It takes several days for bupropion to achieve effective levels in the blood, so it should be taken at least a week before the patient intends to quit smoking. After starting treatment, bupropion must be taken twice a day and may cause dry mouth, headache, or insomnia.

Varenicline can also help reduce cravings for tobacco and control nicotine withdrawal symptoms. It is thought to work by blocking nicotine from binding at the receptor, decreasing the reward from nicotine use while simultaneously reducing or relieving nicotine withdrawal. As with bupropion, it takes several days for varenicline to reach effective levels in the blood. It must be taken twice a day and may cause nausea, insomnia, and vivid or strange dreams.

What to tell your patients

Remind patients that tobacco dependence is a chronic condition and that, on average, it takes five to seven attempts to successfully quit long-term, so they should remain positive and keep trying even if an attempt fails. Advise patients that it is never too late to quit and that quitting smoking at any age has immediate as well as long-term benefits by reducing the risk for smoking-related diseases and improving health in general. Instruct patients on how to use the various nicotine replacement products, including application of the nicotine patch and the special bite technique for nicotine gum. Finally, ensure that patients understand that self-treatment is not recommended for those under 18 years, individuals who are pregnant or breastfeeding, and those with serious heart disease.

For more information, particularly on patient counseling for smoking cessation, see the chapter on “Tobacco Cessation” in APhA’s Handbook of Nonprescription Drugs, available in the bookstore on pharmacist.com or in APhA OTC on PharmacyLibrary (www.pharmacylibrary.com). ■