Each option has drawbacks. Bottom line: The ideal choice is the one the patient will actually use.
Not long ago, Robin Corelli, PharmD, stepped into a taxi with a chatty driver. Instead of pondering the weather, the driver told her he’d been addicted to cocaine and cigarettes. Corelli asked him which habit was tougher to kick. No contest, the man replied. “By far, it was the smoking.”
Robin CorelliThis news did not surprise Corelli, professor of clinical pharmacy at the University of California, San Francisco, who specializes in tobacco cessation.
“People tend to think smokers are weak in character,” Corelli told an audience recently at the annual meeting of the American Pharmacists Association in San Diego. “But it’s a physiological addiction. Nicotine is one of the most addictive substances that we know about.”
Fortunately, pharmacists are in a position to help smokers quit, said Corelli and fellow speaker Karen S. Hudmon, DrPH, MS, RPh, professor of pharmacy practice at Purdue University.
“Patients expect us to be able to address this, according to studies,” said Hudmon, after questioning the audience and finding that several attendees had helped patients try to quit smoking. “Eight years ago, no one raised their hand,” she said. Now, “our graduates are equipped to help patients quit.”
The first step, she said, is to ask patients whether they smoke tobacco or other nicotine products, such as electronic cigarettes. If they want to quit, options include going cold turkey - which works less than 5% of the time - tapering use, and formal cessation programs.
Medications do help smokers quit, and most people will benefit from nicotine replacement therapy, Corelli said. The reason is simple: Tobacco withdrawal is extremely difficult for addicts to tolerate. In just 24 hours, it causes symptoms such as restlessness, anxiety, irritability, and difficulty concentrating.
But if patients manage to stay the course, in most cases withdrawal symptoms lessen after two to four weeks, Corelli said, adding that familiar nicotine replacement products such as nicotine gum and patches can help patients get through the withdrawal symptoms and focus on behavioral aspects.
Corelli provided several tips on use of these medications.
• Nicotine replacement products have not been proven to help people who use smokeless tobacco and electronic cigarettes. Nor are they shown to help teens or people who smoke fewer than 10 cigarettes a day, for whom behavioral treatments probably would be more helpful.
• People with serious cardiac issues should only use nicotine replacement therapy under medical supervision.
• Nicotine gum should not be chewed like normal gum. Patients need to follow the product labeling instructions on the box.
• Three-quarters of patients who decide to quit smoking use the nicotine patch, but this product cannot be titrated to treat varying levels of withdrawal symptoms.
• Nicotine nasal sprays are highly effective, but many Americans don’t like to use nasal sprays. Pharmacists should warn patients who are willing that they may experience a peppery burning sensation. Adjustment to the product may take a week or two.
• Nicotine inhalers, which look like plastic cigarettes instead of asthma inhalers, are also not commonly used. Because they mimic the hand-to-mouth ritual of smoking, they can be helpful; however, their effectiveness appears to be compromised in temperatures at or under 60° F.
• Other options include bupropion (Zyban), an antidepressant, and varenicline (Chantix), but these products come with a number of serious warnings. Researchers have linked them to neuropsychiatric symptoms and suicide risk.
Which of all these medication options is ideal? “The best one,” Corelli said, “is really the one that patient can take and will take.”
Cost is an issue. Brand-name tobacco cessation products cost from $3.70 to $8.24 a day. Generics, which are not always available, range in price from $1.52 to $2.72. In some cases, cessation treatment costs more than a pack-a-day habit.
A common problem that patients may encounter is suboptimal dosing, Corelli said, so pharmacists need to ask patients how they use the medication.
“If the patient is using an insufficient dose, maybe the patient would be a candidate for combination therapy. Combining medications has been shown to be effective,” she said.
Randy Dotinga is a healthcare writer based in San Diego, Calif.