Nicotine Replacement Therapy

Before starting the nicotine replacement therapy the user has to quit smoking. Nicotine replacement therapy provides an alternative form of nicotine to relieve symptoms of withdrawal in a smoker who is abstaining from tobacco use.8 The pharmacokinetic properties of available products differ, but none deliver nicotine as fast as does inhaling nicotine. The patch provides a relatively stable, fixed dose of nicotine over a period of 16 or 24 hours. The other products have a more rapid onset and a shorter duration of action, allowing the user to adjust the dose of nicotine. Blood nicotine levels peak 5 to 10 minutes after the adminis-

Table 29-2. The five As: intended for every smoker who wants to stop


Implementation strategy

"Ask": systematically ask (preferably every year) whether he/she is a smoker

Design a department-wide/organization-wide manner in which, for every patient, it is established (preferably yearly) whether he/she smokes and record this. Exception: adults who have not smoked for a considerable period of time, and for whom the status is clearly established.

"Advise": emphatically advise him or her to stop smoking

Advise the smoker to stop smoking, in a clear, strong, and person-specific manner.

"Assess": establish the willingness to stop smoking

Establish whether the smoker is willing to undertake an attempt to stop at this moment (e.g. within the next 30 days)

"Assist": help him/her in undertaking the attempt to stop

Make a 'stop plan' together with the smoker.

Give practical support

Implement prompts for health professionals to systematically inquire about smoking behavior, for example stickers on the status or by placing a reminder in the patient's electronic record.

Smoking status: smoker, has stopped, never smoked.

Clear: I think that it is important that you stop and I think that I can help you.

Emphatic: You should know that giving up smoking is the best way of keeping your health in the future.

Specific to the person: Look at personal motives for the smoker: relationship with disease, cost-savings, in the children's interest, etc.

Prepared to stop now; proceed to assistance.

Needs intensive support; offer this or refer. Not prepared to stop now; intervene at the motivation level.

Special circumstances (child, pregnant, etc.) consider giving additional information.

Agree on a stop date.

Arrange social support from others (tell everybody).

Anticipate difficult moments (withdrawal symptoms).

Remove tobacco products from places (home and work) where the smoker might be.

Stop completely; do not even smoke half a cigarette.

Evaluate previous failed attempts.

Establish how the person can recognize a difficult moment.

Suggest avoiding difficult moments (e.g. whilst having an alcoholic drink).

Try to get partners, relatives, and friends to stop at the same time.

Table 29-2. Continued


Offer support

Try to arrange support from others

Advise pharmacotherapy, except in special situations

Obtain additional information

"Arrange": care for follow-up as a form of preventing relapse

Determine dates for follow-up contact, in person or over the telephone.

Implementation strategy

Where can the smoker always go to in the event of questions and problems?

Ask partners, parents, and colleagues to support the smoker in the attempt to stop.

Consider advising pharmacotherapy if a smoker smokes more than 10 cigarettes per day.

Explain why this increases the chances of stopping.

Timing: follow-up contact must take place soon after the planned stop date, preferably within one week, and a within second one month.

Actions in follow-up: celebrate the success; if the person has still smoked, evaluate why and try to once more obtain a commitment for a complete stop; remind the smoker that failure can be seen as a learning step; discuss difficult moments and anticipate future ones; evaluate pharmacotherapy and consider more intensive treatment.

Table 29-3. Guidelines for relapse prevention

Problem: lack of support


• make agreements for follow-up (if need be by telephone)

• try to find sources of support in the neighborhood of the stopped smoker

• refer to a relevant organization which can provide support

Problem: negative mood/depression


• provide support, see if medication can help and refer to a relevant health professional

Problem: strong withdrawal symptoms


• see if medication or an adjustment to the medication is needed

Problem: weight increase


• emphasize the importance of a good diet, discourage strict dieting and try to encourage extra physical activity. State that an increase in weight is normal, but that after a while the weight no longer increases

• consider continuing to use medication which postpones the weight increase, for example bupropion

• refer to a relevant organization which can provide support

Problem: decreased motivation and slackness


• emphasize that this is a normal reaction

• recommend rewarding activities

• discourage temporary tobacco use and emphasize that smoking (even one cigarette) only makes it more difficult to stop tration of the nasal spray, 20 minutes after the user begins the chewing gum, sublingual tablet, sucking tablet or uses a inhaler, and 2 to 4 hours after the application of a nicotine patch. The dose depends on the number of cigarettes smoked a day. If more than two packets of cigarettes are smoked each day, two patches are recommended (twice a day) or one patch combined with some other form of nicotine replacement. Different nicotine forms of replacement therapy can be combined safely. The side-effect of these products varies according to the manner in which nicotine is administrated.9

Although nicotine increases the myocardial workload, nicotine replacement therapy is safe in patients with cardiovascular disease, including stable angina. The risk of cardiac complications should be lower than with smoking. Unlike smoking, nicotine replacement therapy does not increase the coagulability of blood or expose a patient to carbon monoxide or oxidizing gases that damage endothelium. In women who are pregnant or breastfeeding, the risk of smoking can be more severe than nicotine replacement therapy.

In a meta-analysis of placebo-controlled trials, nicotine replacement therapy was found to result in higher rates of smoking cessation, especially when combined with counseling.9

Table 29-4. Drugs used for smoking cessation

Duration of



Daily Dose



Side Effects


Nicothine -

(2) instable angina, serious


cardiac arythmics, recent myocardial

therapy (1) (3)

infarction or cerebrovasculair accidents


7-, 14- or 21 mg for

idem, after 4-6 weeks

6-12 weeks

skin irritation, insomnia

(2) serious eczema, allergic to patches

patch 7-, 14-, 21- or

24 hours or 15 mg

halve the dosage

(remove during the

15mg (1) (3)

for 16 hours



2-4mg each 2 hour

idem, after 4-6 weeks


mouthe irritation,

(2) jaw problems, esophagitis

gum 2-, 4mg


halve the dosage

1 year

sorc jaw, dyspepsia,





2-4mg each

idem, after 2-3 months

6 months

mouthe irritation,


tablets 2-,4mg

1-2 hour

phase out

dyspepsia, hiccups


(maximum 60mg/day)


1-4mg each

idem, after 2-3 months

6 months

mouthe irritation,



1-2 hour

phase out

dyspepsia, hiccups

1-, 2-,4mg



25 mg/day)

Vapor inhalor

6-12 cartridges/day

idem, after 2-3 months

6 months

mouthe irritation,

(2) asthma, rhinitis, nose polyps,

4-, 10mg

phase out

dyspepsia, hiccups

allergic to menthol


Nasal spray

1-2 doses each hour

idem, after 2-3 month

6 month

nasal irritation,


0.5 mg

in each nostril

phase out

sneezing, cough ,teary


(maximum 40 mg/day)




after 6 days 150 mg

7-9 weeks

insomnia, dray mouth,

allergic to bupropion, epilepsy or


(6 days)

twice a day 4) when


seizures in the past, tumor of the

(3) (6)

predisposed to seizures: maintain 150mg/day

central nerve system, abrupt cessation of benzodiazepines or alcohol, anorexia nervosa, boulimia, serious livercirrose


25 mg/day (3 days)

after 7 days

7-12 weeks

dry mouth, sedation,

see bupropion except the


50 mg/day (4 days)

75mg/day 4)


(1) Different nicotine-replacement products can be combined safely.

(2) Contraindication for all nicotine-replacement therapy is instable angina, serious cardiac arytmics, recent myocard infarction or cerebrovascular accidents.

(3) Bupropion and nortriptyline can be combined with nicotine-replacement therapy.

(4) Smoking cessation 10 days after start medication.

(5) Nortriptyline has not been approved by the Food and drug Amministration as a smoking-cessation aid. The Public Health Service clinical guidelines recommend it as a second-line drug for smoking cessation.

(6) Bupropion and nortriptyline should not be combined with MOA-inhibitors.

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