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Nicotine Replacement Therapy: Administration and Overview Barbara Hart, MPA and Claudia Lechuga, MS Bronx BREATHES T: (718)430-2601 E: [email protected] / [email protected] www.bronxbreathes.org June 15, 2009 Smoker Assessment • History of usage • Previous quit attempts – Withdrawal/abstinence symptoms • Motivational level for quit attempt • Current social environment – – – – Stressors Triggers Biological/medical assessment Family and friend support/sabotage Previous Quit Attempts • Dates • Age • Method used to quit – Medications or counseling used (if any) • • • • Duration of that method Problems and successes experienced Reason for relapse Withdrawal/Abstinence Symptoms Current Quit Attempt • Motivational Level – Confidence • Main reason for considering/wanting to stop • Concerns about quitting – Weight gain concerns Use of NRT Reasons for using NRT • Doubles the success rate • Treats nicotine withdrawal – Helps patient feel more comfortable • Safe – Patient receiving same drug (nicotine) in a less addictive form over a relatively short period Reasons for NOT using NRT • Medical conditions requiring caution/physician input – i.e. recent MI, pregnancy, current arrythmia • Age – Under 18s require physician/parental input • Specific issues – Allergy to patches – Personal aversion to medication • Questionable efficacy – i.e. those smoking less than 10pd Tobacco Cessation Medications Nicotine Replacement • Patch * • Gum * • Lozenge * • Oral Inhaler ^ • Nasal Spray ^ * Available OTC Non-nicotine medication • Bupropion ^ – (Zyban/Wellburtrin) • Varenicline ^ – (Chantix) ^ prescription only Nicotine Delivery Comparison Nicotine Delivery Device Nicotine in Product Approx Amount of Nicotine Delivered to User Comments Tobacco Products Marlboro Red Marlboro Light Cigars 13 mg 13 mg 10-40 mg Moist Snuff 3-12 mg 1-3 mg 1-3 mg Highly Variable Varies depending on pH and other characteristics Also delivers a wide range of carcinogens and other toxins Nicotine Replacement Products Nicotine Gum Nicotine Gum Nicotrol Patch (Pharmacia) Nicoderm CQ Step 3 (Glaxo Smith Kline) Nicoderm CQ Step 2 (Glaxo Smith Kline) Nicoderm CQ Step 1 (Glaxo Smith Kline) 2 mg piece 4 mg piece Up to 0.8 mg Up to 1.5 mg 15 mg / 16 hours 7 mg / 24 hours 14 mg / 24 hours 21 mg / 24 hours Only delivers nicotine to the consumer Medication Overview Product Use Advantage s Disadvantage s Pre cautions Nicotine Patch Apply each day to clean, dry , hairless skin. Start 21 mg patch if .10 cig per day ; can taper to 14 mg in 4-6 weeks, then 7 mg in 2 weeks if no crav ings Place and f orget; Passiv e - no actions ov er the counter; to take when can decrease crav ing occurs morning crav ings if worn at night Not recommended to use while smoking; caution within 6 weeks of heart attack Nicotine Gum Chew ev ery 1-2 hours as needed; chew and park; 2 and 4 mg strength (4mg if around 1 ppd) Use as needed; can Dif f icult to chew self -dose; Ov er the counter Av oid f ood and acidic drinks 15 minutes bef ore and while using (decreases absorption) Side Effe cts Skin reaction (50% of patients; usually mild and can use hy drocortisone cream); Rotate sites; v iv id dreams or sleep disturbances possible at night Jaw pain; nausea if swallowing saliv a Cos t $45/2 week supply (generics av ailable and ef f ectiv e) $35-50/2 week supply Use and Efficacy of combination therapy • Multiple patch therapy (42 vs 21mg) – 20% increased abstinence – No significant increased sleep disturbances – (Dale 1995; Jorenby 1995) • Patch + Gum – Kornitzer 1995; Puska 1995 • Early better rates – 7% increase at 6 months • Not sustained at 1 year • No increase in adverse events – 2008 OHS Guidelines Meta-analysis • Path + Gum/Spray OR = 1.9 – Compared to patch alone (OR=1) – Fiore 2008 • Abstinence rates – Nicotine Patch = 23.4% – Nicotine Gum = 19.0% – Long term Patch + Gum = 36.5% Important Points about NRT • Nicotine is the addictive part of tobacco smoke but NOT the most dangerous part • People do NOT generally become addicted to medication • People DON’T use enough medication or stop TOO EARLY – Medications are SAFE and EFFECTIVE – Plan on minimum of 2 months of medication • Combinations – Work better than single medications • Use Long acting + Short acting NRT Kits Available Moderate Smokers • Smoke 10-20 per day • Includes: – Novartis Step 1 • 28 count 21 mg patches Heavy Smokers • Smoke 20+ per day • Includes: – Nicorelief Gum • 110 pieces of 4mg gum – Novartis Step 1 • 28 count of 21mg patches NRT Enrollment Forms Necessary for each course distributed Full information required Fax or email back to Bronx BREATHES NRT Enrollment Forms (cont’d 1) NRT Enrollment Forms (cont’d 1) NRT Enrollment Forms (cont’d 1)