Savvy Psychopharmacology

Smoking cessation: What to tell patients about over-the-counter treatments

Current Psychiatry. 2012 January;11(1):43-47

References

1. Centers for Disease Control and Prevention Smoking and Tobacco Use. Adult cigarette smoking in the United States: current estimate. http://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm. Accessed November 29 2011.

2. Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update Panel, Liaisons, and Staff. A clinical practice guideline for treating tobacco use and dependence: 2008 update. A U.S. Public Health Service report. Am J Prev Med. 2008;35(2):158-176.

3. Physicians’ Desk Reference. 64th ed. Montvale, NJ: Thomson PDR; 2010.

4. Kroon LA, Hudmon KS, Corelli RL. Smoking cessation. In: Berardi RR Ferreri SP, Hume AL, et al, eds. Handbook of nonprescription drugs: an interactive approach to self-care. 16^th ed. Washington, DC: American Pharmacists Association; 2009:883–916.

5. Doering PL, Kennedy WK, Boothby LA. Substance-related disorders: alcohol nicotine, and caffeine. In: DiPiro JT, Talbert RL, Yee GC, et al, eds. Pharmacotherapy: a pathophysiologic approach. 7th ed. New York, NY: McGraw-Hill; 2008:1083–1098.

6. U.S. Food and Drug Administration. Electronic cigarettes. http://www.fda.gov/NewsEvents/PublicHealthFocus/ucm172906.htm. Accessed November 29, 2011.

7. Prokhorov AV, Hudmon KS, Marani S, et al. Engaging physicians and pharmacists in providing smoking cessation counseling. Arch Intern Med. 2010;170(18):1640-1646.

Disclosure

Dr. Ellingrod receives grant/research support from the National Institute of Mental Health.

Dr. Burghardt reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Table 2

Prescription smoking cessation products^a

Product	Dosage	Side effects	Amount of nicotine	Cost^b	Notes
Nicotine inhaler	6 to 16 cartridges/d	Throat/mouth irritation and cough	10 mg cartridges deliver 4 mg of nicotine	10 mg inhaler with 168 cartridges: $213	Vapor, not smoke, is released and deposited in mouth. Similar mechanism of action to nicotine gum. Continuously puff for ~20 minutes. Gradually reduce dosage over 12 weeks. Helps with patients who need the “action” of smoking. Caution in patients who have a history of bronchospastic disease because of potential airway irritation
Nicotine nasal spray	10 mg/ml bottle 8 to 40 doses/d One dose is a spray to each nostril	Initial (~10 week) watery eyes, coughing, and nasal and throat irritation	0.5 mg/spray	10 ml bottle: $186	Fastest delivery of nicotine vs other products. Tilt head back slightly when delivering spray. Do not sniff, swallow, or inhale through the nose. Continue treatment for 3 to 6 months with an individualized reduction in usage
Bupropion SR	150 mg/d for 3 days, then 300 mg/d for 7 to 12 weeks or longer	Weight change, constipation, confusion, headache, and insomnia	N/A	60 tablets: $106	Patients should stop smoking during the second week of treatment. Combination treatment has achieved higher cessation rates. Avoid bedtime dosing to minimize insomnia (eg, 7 AM and 3 PM dosing strategy). Avoid in patients with seizure disorders
Varenicline	Days 1 to 3: 0.5 mg/d Days 4 to 7: 1 mg/d Day 8 to end of treatment: 2 mg/d Start treatment 1 week before quitting and continue for 3 to 6 months	Constipation, flatulence, nausea, vomiting, insomnia, and headache	N/A	Starting pack: $179 Continuing pack: $177	Partial agonist of nicotinic acetylcholine receptor. Superiority to placebo has been shown but more studies are needed to show superiority to NRT. Safety and efficacy of combination therapy has not been established. Pack titrates dosage to 2 mg/d to decrease nausea. Take with water and food. Has a “black-box” warning for serious neuropsychiatric events, including suicidal ideations and behavior

Smoking cessation: What to tell patients about over-the-counter treatments

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