Nicotine: Progress stalled, threats loom

Helping people quit

Nicotine has always been a tough addiction to break, but tobacco opponents had one reliable strategy: get young people not to take up the habit. Today, with an explosion in devices for getting the drug into the body—especially the popular electronic cigarettes that mimic smoking so well—pharmacists and other health professionals must seek new and different ways of countering both advertising strategies and peer pressure when it comes to producing progress in stalled tobacco use rates.

Some professionals—and even the American Heart Association—are turning to e-cigarettes as the answer when other methods of getting people off tobacco don’t work. With the safety of these new devices unclear, not everyone is on board with that approach.

“It’s frustrating to start somebody on effective cessation therapy only to lose them to the e-cig marketplace,” Karla Lodge, a physician assistant in the Phoenix area, told Pharmacy Today. “Competent providers know that long-term success is much more likely when there is lasting behavior modification that results in a patient [who] is no longer dependent on nicotine.”

Pharmacists are undoubtedly well positioned to help people stop using tobacco and nicotine, with high visibility, trust, and availability of nonprescription options. It takes some effort, though, and perseverance.

Nicotine as you like it

Smoking rates are at historic lows but are stalled after decades of decline. The explosion in availability of nicotine-delivery systems—and their popularity among teenagers and young adults, as reported in the 2013 National Youth Tobacco Survey—suggests the need for prescription and OTC cessation products won’t subside any time soon.

Constant vigilance and continuing education are required for pharmacists to maintain their credibility regarding all the new nicotine delivery systems. E-cigarettes, vapor devices, strips, orbs, and snus are all marketed as cleaner versions of tobacco products and even hailed by some as tools for smoking cessation.

How you can help

Nicotine replacement therapy (NRT) products have been available for more than 30 years. The products produce higher quit rates than many other cessation techniques, are safe to use without a prescription, and are readily available to consumers. 

Used as monotherapy or in combination, OTC nicotine patches, gum, and lozenges can triple quit rates, compared with placebo, according to the new edition of APhA’s Handbook of Nonprescription Drugs. While about 14% of patients can achieve smoking abstinence with placebo, rates jump to 19% with gum, 23% with lozenges, and 27% with patches. Combining the patches with nonprescription gum or lozenges, or with prescription nicotine inhalers, enables 37% of patients to quit.

If NRT products are designed to put nicotine into patients’ circulation, can the same end result be achieved through use of vaporized nicotine? Most health-related professional organizations, including APhA, want to see more research. The American Heart Association encourages “clinicians to use proven smoking cessation strategies as the first line of treatment for any patient,” but “when repeated efforts with conventional treatment fail, [are] intolerant, or rejected by a patient, clinicians may support the patient’s attempt to quit using e-cigarettes.” 

The American Lung Association (ALA) takes a different tack. Even though 51 years have passed since smoking was linked to lung cancer by the U.S. Surgeon General, nearly half a million Americans die from smoking-related causes each year, and the habit costs society $333 billion for health care and lost productivity, ALA said. In calling for action by the federal government, the association emphasized the following three goals for the nation as a whole:

  • Reduce smoking rates, currently at about 18%, to less than 10% by 2024.

  • Protect all Americans from secondhand smoke by 2019.

  • Ultimately eliminate the death and disease caused by tobacco use.

Old drug offers new option

Thanks to a recent article in the New England Journal of Medicine, pharmacists may be getting questions about a plant extract from Eastern Europe, cytisine, for smoking cessation. Chemically similar to nicotine and varenicline, cytosine is currently manufactured as Tabex by a Bulgarian company, Sopharma, and marketed in Europe.

Compared with 8 weeks of NRT in 1,310 smokers, cytosine administered orally for 25 days produced significantly higher quit rates: 40% versus 31%. Adverse effects were more common in the cytisine group and included gastrointestinal problems and sleep disturbances. 

Earlier studies have shown similar short-term results with cytisine, and one study stated a 12-month quit rate for cytisine as 8.4% versus 2.4% for NRT. Most of these studies provided minimal behavioral counseling.

Tabex is being shipped into the United States and is currently unregulated by FDA.

Another new tool would enable personalization of therapy by identifying slow metabolizers of nicotine. Slow metabolizers achieve higher quit rates with NRT patches, a Pfizer-sponsored study of 1,200 smokers showed, while normal metabolizers responded better to varenicline.

APhA policy on the use and sale of electronic cigarettes (e-cigarettes) (2014)
  1. APhA opposes the sale of e‐cigarettes and other vaporized nicotine products in pharmacies until such time that scientific data support the health and environmental safety of these products.
  2. APhA opposes the use of e‐cigarettes and other vaporized nicotine products in areas subject to current clean air regulations for combustible tobacco products until such time that scientific data support the health and environmental safety of these products.
  3. APhA urges pharmacists to become more knowledgeable about e‐cigarettes and other vaporized nicotine products.
  4. APhA urges FDA to require the full disclosure of all ingredients in e‐cigarettes and other vaporized nicotine products in both the pre‐use and vapor states.
Source: J Am Pharm Assoc. 2014;54:358


1. MMWR. 2014;63(45):1021
3. N Engl J Med. 2014; 371:2353–62