Kick Smoking to the Curb with Nicotine Replacement Therapy

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Did you know that it takes an average of 6 to 7 quit attempts before someone successfully becomes smoke-free for life?


Did you also know that your pharmacist can help initiate an individualized smoking cessation therapy plan for you?


I am sure you have heard numerous time that “smoking is bad for you,” but let’s dive a little deeper…



Impacts of Smoking On Your Health


Smoking has many negative health consequences including an increased risk for heart disease, high blood pressure, diabetes, osteoporosis, COPD, and various cancers. It also increases the risk of complications from surgeries and increases the time to full recovery. Further, tobacco smoke interacts with many drugs including corticosteroids, hormonal contraceptives, warfarin, and insulin, complicating certain drug therapy treatments. The nicotine component is teratogenic, meaning it has many negative effects on pregnancy such as decreased fertility, stillbirth, ectopic pregnancy, birth defects, and ADHD in children. Unfortunately, 15% of Canadians over the age of 15 still smoke according to the 2017 Canadian Tobacco, Alcohol and Drugs Survey.



Benefits of Smoking Cessation


Smoking is the number 1 cause of preventable deaths and diseases in both Canada and the U.S. – emphasis on “preventable.” Even if you have smoked for a number of years, it is never too late to quit! Studies have shown that after just 1 year of quitting, a smoker’s excess risk of heart disease above a non-smoker is reduced by 50%. After 15 years, the risk of heart disease becomes similar to people who have never smoked in their life. Quitting smoking is also cost-effective, not only in terms of the amount spent on cigarettes but also in terms of health care costs and lost productivity as a result of smoking-related illnesses.


It can be very difficult to quit smoking right away due to the highly-addictive nicotine component; it often takes multiple quit attempts to become successful. Your approach to smoking cessation can play a large role in how successful the quit attempt is, and your pharmacist can help with that!



Nicotine Replacement Therapy Options


Nicotine replacement therapy (NRT) has been shown to increase abstinence rates by 50-70%. You might be thinking, “Why would I want to intake more nicotine if I’m trying to quit?” The addictive nature of nicotine can cause your body to become physically dependent on it. If you abruptly stop your consumption of nicotine, your body may experience withdrawal symptoms such as irritability, concentration difficulties, insomnia, headaches, and the urge to smoke again. NRT can help you quit smoking by replacing cigarettes (and its many harmful components) with nicotine-only substitutes. Slowly decreasing the amount of nicotine intake overtime helps to reduce the severity of the withdrawal symptoms. There are a variety of over-the-counter NRT products to fit your personal preferences, from lozenges to sprays to patches!


Gum (Nicorette, Thrive, Nic-Hit)

  • Available in 1, 2, or 4 mg

  • Peak effect is achieved after 20-30 minutes of chewing

  • Absorption occurs through the mucosa (inner lining) of the cheek, not the stomach

  • Use the “chew and park” technique for maximum effectiveness (chew until the you feel a tingling sensation, then move the gum between your cheek and gums until the sensation is gone, and repeat)

  • Avoid eating or drinking 15 minutes before or while chewing the gum, as it can impair nicotine absorption


Lozenge (Nicorette, Thrive, Nic-Hit)

  • Similar to gum

  • Available in 1, 2, or 4 mg

  • Peak effect is achieved in 20-60 minutes

  • Use the “suck and park” technique for maximum effectiveness (suck until the nicotine flavour is strong, then rest the lozenge in your cheek until the taste fades and repeat)

  • Avoid swallowing to avoid an upset stomach

  • Avoid eating or drinking 15 minutes before or while using the lozenge, as it can impair nicotine absorption


Inhaler (Nicorette)

  • Available as 4 mg of nicotine per cartridge

  • Peak effect is achieved in 15 minutes

  • Mimics the hand-to-mouth action of smoking a cigarette

  • Absorption occurs through the mucosa of the mouth, not the lungs

  • Inhale short puffs into the cheek or deep into the back of the throat

  • Each cartridge allows for ~20 mins of continuous puffing over 24 hours


Quick Mist Spray (Nicorette, Nic-Hit)

  • Each spray contains 1-2 mg of nicotine

  • Peak effect is achieved in 16 minutes

  • Prime the spray pump if using for the first time or if it has not been used in over 2 days

  • Use 1-2 sprays on the inside of the cheek every 30-60 minutes as needed

  • Avoid getting the spray down the throat, do not inhale, and refrain from swallowing for a few seconds to avoid nausea

  • Avoid eating or drinking 15 minutes before or while using the spray, as it can impair nicotine absorption


Transdermal Patch (NicoDerm, Habitrol)

  • Provides continuous nicotine replacement

  • Peak effect is achieved in 2-6 hours

  • Apply the patch in the morning to a clean, dry, non-hairy area of the skin on the upper arm, hip, or top of the foot

  • For better adhesion, ensure the area of skin is free from any creams, lotions, oils, or sweat and hold the patch for 3 minutes. You may also use adhesive tape on top of the patch such as Tegaderm.

  • Avoid reapplying to the same area of skin on consecutive days to avoid skin irritation

  • You may bathe, shower, or swim for short periods while wearing the patch

  • You may use the patch for a full 24 hours or remove it before sleeping if it causes insomnia

  • Remove the patch 2 hours before any prolonged, strenuous exercise as it may increase nicotine absorption

  • Products usually come in “3 Steps” and the dosage depends on how many cigarettes you are smoking at the present moment:

-- Step 1 (21 mg): 20--29 cigs/day

-- Step 2 (14 mg): 10--19 cigs/day

-- Step 3 (7 mg): <10 cigs/day


There are a variety of approaches to starting and dosing NRT. Different NRT methods can also be combined to increase effectiveness. To find out which strategy is best for you, speak with your local pharmacist!


*There are some contraindications with nicotine replacement therapy, so always ask your pharmacist before starting any NRT products to ensure it is safe for you (especially patients that are pregnant, breastfeeding, under the age of 18, or who possess other health conditions).



Prescription Options for Smoking Cessation


While NRT is the mainstay of over-the-counter smoking cessation therapy, some patients may opt to try prescription medications to increase their chances of success. This includes Varenicline (Champix) and Bupropion SR (Zyban). Pharmacists in Ontario are certified to conduct assessments and prescribe these medications for you without having to visit your doctor, making smoking cessation services much more accessible!



Pharmacy Smoking Cessation Program


Whether you want to stick with over-the-counter products or are curious about prescription options, your pharmacist is here to help. Ontario residents who are covered under the Ontario Drug Benefit (ODB) Program are eligible for enrolment in the ODB Pharmacy Smoking Cessation Program, which covers the cost of pharmacy counselling services as well as the medications. This program is designed to provide patients with one-on-one support over a one-year period. Your pharmacist will help you create an effective quit plan based on your personal history and lifestyle factors, identify triggers and develop coping skills, and connect you with resources and other community support services. The program consists of 9 pharmacist--patient consultations, each individualized to the patient:

  1. Readiness assessment (10 minutes) to determine the patient’s desire to quit smoking

  2. First consultation meeting (20 minutes) to discuss the patient’s smoking history, medication history, health risks, triggers, and strategies, as well as to set a quit date and assess appropriate pharmacotherapy options

  3. Follow--up counselling sessions (5--10 minutes) to provide ongoing support, review the patient’s progress to-date, and address any issues or concerns with the current pharmacotherapy plan (7 follow-up sessions in total)


If you are not eligible under ODB and do not have private insurance that covers the Pharmacy Smoking Cessation Program, these services may also available for a fee determined by the participating pharmacy. The fee only covers the counselling services provided by the pharmacy, not the medications.


Ask your pharmacist about the Pharmacy Smoking Cessation Program today!


Click here to view our infographic!



 


References

  1. Canadian pharmacist smoking cessation pharmacotherapy algorithm. Pharmacists for a Smoke-Free Canada Network. Updated February 2020. Accessed February 17, 2021. https://psfcnetwork.com/wp-content/uploads/2011/11/Canadian-Pharmacist-SC-Pharmacotherapy-Algorithm-Feb-2020.pdf

  2. Canadian tobacco, alcohol and drug survey (CTADS): summary of results for 2017. Government of Canada. Updated January 4, 2019. Accessed February 17, 2021. https://www.canada.ca/en/health-canada/services/canadian-tobacco-alcohol-drugs-survey/2017-summary.html#n2

  3. Ling J. Smoking cessation training program. Presented as part of Pharmacy 229; July 2020; Waterloo, ON.

  4. Petrasko K, Reeve C. Smoking cessation. In: Compendium of Therapeutics for Minor Ailments. Canadian Pharmacists Association. Updated May 1, 2018. Accessed February 17, 2021. https://myrxtx-ca.proxy.lib.uwaterloo.ca/search

  5. Pharmacy smoking cessation program: The pharmacist’s role in a smoking cessation system. Ontario Ministry of Health and Long-Term Care. Updated June 26, 2019. Accessed February 17, 2021. http://www.health.gov.on.ca/en/pro/programs/drugs/smoking/

  6. Smoking Cessation Leadership Center. Drug interactions with tobacco. University of California San Francisco. Updated 2019. Accessed February 17, 2021. https://smokingcessationleadership.ucsf.edu/sites/smokingcessationleadership.ucsf.edu/files/Documents/FactSheets/Drug%20Interactions%20with%20Tobacco%20Smoke.pdf

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