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NRT: sustained releaseNicotine transdermal patch (Habitrol, Nicoderm, generics) |
>20 cigarettes/day: 1 patch (21 mg/24 h) for 4–6 weeks, then taper to 14 mg/day for 2–4 weeks, then 7 mg per day for 2–4 weeks.If patient has cardiovascular disease, weighs less than 45 kg or smokes <½ pack/day begin with 14 mg/24 h×6 weeks then ↓ to 7 mg/24 h × 2 weeksNB: 16-h patches are available in some countries |
Side effects:Skin sensitivity and irritation (most common); abnormal dreams; insomnia; nausea, dyspepsia |
Start patch on quit date. Advise not to smoke cigarettes while using the patch, though this is generally safe and does not indicate treatment failure. Educate users on the signs and symptoms of nicotine toxicity |
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NRT: immediate releaseNicorette inhaler (nicotine inhaler) |
Available in 4 mg strength.Encourage patient to use at least six doses/day for the ?rst 3–6 weeks.Max 12/day.Tapering: gradual reduction in use over next 6–12 weeks, stopping when reduced to 1–2/day |
Side effects:Mild local irritation of mouth and throat, coughing, rhinitis that may decline with continued use |
Not a true inhaler—the nicotine is delivered and absorbed buccally.“Hand-mouth” activity from using the inhaler is preferred by some quitters while others ?nd it to be a trigger. Useful in those with poor oral health or dentures and in those who cannot chew gum |
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NRT: immediate releaseNicotine polacrilex gum (Nicorette Gum) |
10–12 pieces per day initially (2 mg or 4 mg pieces) to maximum of 20 pieces per day, for 12 weeks.Tapering: 1 piece/day each week, as withdrawal symptoms allow |
Side effects:Mouth soreness, hiccups, dyspepsia, jaw ache |
Use 4 mg in heavily dependent smokers. May be used for temporary abstinence—eg, to comply with smoking restrictions on aeroplanes |
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NRT: immediate releaseNicotine lozenge |
1 lozenge (2 mg or 4 mg lozenges) every 1–2 h up to 6 weeks; weeks 7–9, every 2–4 h; weeks 10–12, every 4–8 h |
Side effects:Nausea, hiccups, heartburn, headache, coughing |
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NRT: immediate releaseNicotine nasal spray |
1.0 mg of nicotine per spray (10-ml bottle contains 100 mg nicotine) 1–2 doses/h up to 40 doses per day; for 3 months |
Side effects:Mild nasal/throat irritation |
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Antidepressant:Bupropion (Zyban, generics) |
150 mg daily × 3 days then 150 mg twice daily × 7–12 weeks. Begin 1–2 weeks before the selected quit date |
Side effects:Insomnia, dry mouthDrug interactions:Clearance of bupropion may be ↓ by inhibitors (for example, ticlopidine) or ↑ by inducers (for example, phenobarbital, phenytoin, primidone) of CYP2B6. May ↓ clearance of other substrates of CYP2B6 (for example, cyclophosphamide, ketamine, promethazine, propofol, selegiline). MAOIs, levodopa, amantadine may ↑ toxicity. May be safely combined with NRT (monitor for treatment-emergent hypertension) |
Not recommended in patients with conditions predisposing to seizures, history of seizures, current eating disorder or severe hepatic impairment.Least expensive of oral medications indicated for smoking cessation |
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Nicotine receptor partial agonistsVarenicline (Champix, Chantix) |
0.5 mg daily for 3 days, then twice daily for 4 days then 1 mg by mouth twice daily for 12 weeks.Patient should quit smoking 1–2 weeks after starting the medication. Reassess if patient is still smoking 4 weeks after starting medication; can be continued for an additional 12 weeks if patient has bene?ted. No tapering necessary |
Side effects: nausea, sleep disturbance, abnormal/vivid/strange dreams.Drug interactions: should not be combined with NRT therapy because of increased risk of adverse effects |
Does not induce cytochrome P450 enzymes; excreted renally unchanged.Smokers considering use of varenicline should be screened for a history of psychiatric disorders, have close monitoring, and be advised to report any adverse effects they might experience. Care and close surveillance needs to be taken if prescribing to patients with psychiatric disorders |
