The Ultimate Guide to Smoking Cessation Products

Gum, Patches, and Lozenges... Oh, My!

I'm not here to convince, persuade, or pass judgement on those who do or do not wish to continue smoking. Rather, I'm here to provide pharmacologic information regarding the available products on the market, the dosages available, and proper usage of said products. I'm also going to illustrate and compare the pricing of said products, to give my audience and other consumers the full picture; the benefits and the risks associated with various smoking cessation tools.

Understanding Smoking Cessation

• Tobacco dependence is both physiological and behavioral. The physiological addiction to nicotine is corrected using medications for cessation, while the behavioral aspect is treated with prolonged implementation of behavior changes.

  • A combination of medication and psychological intervention is most effective from a treatment perspective, but neither are required for patients to sustain tobacco cessation. The most important thing patients require is the willingness to change their behaviors.

• All patients (smokers) qualify for medication

  • EXCEPT: pregnant patients, those using smokeless tobacco, light smokers (less than 10/day), and/or teenagers.

• Alternative Treatments are available. Their efficacy in comparison to traditional smoking cessation products is not well studied. We will not dive into these in our discussion, but we can if you are interested. Leave a comment and let us know! Alternatives include:

  • Acupuncture

  • Hypnosis

With so many options and products available to purchase, how do we know where to begin with quitting smoking?

Some of the most important considerations in choosing a product include: cost, adherence/preference, presence of dentures, history/risk of dermatitis, a patient's preexisting comorbidities, and previous use/success. Patient should be involved in decision making if NRT therapy is being started under a doctor's care. Having a strong support system and the willingness to push through cravings, while staying adherent on NRT can all greatly improve smoking cessation success.

We will briefly discuss the current NRT products available on the market. Listed below you'll find dosing, safety, and counseling information specific to each product.

Note: Pricing is based on current Nicorette manufacturer website listing at the time of publishing. A direct link to purchase can be found below images. Pricing is subject to change and may not be accurately reflect current pricing and availability of medication from different sources. This article is not a promotion or advertisement of any kind for Nicorette. Many generic products exist and may be cheaper for patients, please check your local pharmacy for generic pricing information.

Nicotine Gum

Product Information: “Nicorette” (NRT) gum is a resin complex, sugar-free chewing gum base. Nicotine gum products contains buffering agents which enhance buccal absorption.

**Will not provide the quick relief of a cigarette.

• Doses Available: 2 mg, 4 mg

  • Nicotine Gum 2 mg – for patients who smoke less than 25 cigarettes per day

  • Nicotine Gum 4mg – for patients who smoke more than 25 cigarettes per day
    

• Dosing Schedule:
  

  • Weeks 1-6: Chew 1 piece every 1 to 2 hours when awake

  • Weeks 7-9: 1 piece every 2 to 4 hours when awake

  • Weeks 10-12: 1 piece every 4 to 8 hours when awake

• Side Effects/ADR

  • Chewing the gum too quickly can cause lightheadedness, nausea/vomiting, irritation of the throat and mouth, hiccups, and indigestion.

  • Caution: patients with dental issues

• Advantages of Nicotine Gum:

  • serves as an oral substitute (keeps the mouth "busy)", might delay weight gain, can be titrated to avoid withdrawal effects, can be used in combo with other agents (not approved method, but seen in practice)

• Disadvantages of Nicotine Gum:

  • frequent dosing makes adherence difficult. Not recommended in certain dental conditions.

• Counseling Information:

  • Patients taking any kind of NRT should stop using all forms of tobacco upon starting NRT regimen.

  • Do not use more than 24 pieces of gum in 1 day

  • “Chew and Park”. Chew each piece slowly. Stop chewing when you taste a peppery taste or have a slight tingling. “Park” the product between the cheek and your gums to allow for absorption of nicotine across the buccal mucosa and into the bloodstream. Resume slow chewing when the tingle fades. Repeat this until most of the nicotine is gone – about 30 minutes, when the taste or tingle does not return.

  • Do not eat or drink anything 15 minute prior or during chewing, especially anything acidic – reduces effects.

  • Best not used PRN (as needed), using NRT gum on the proper schedule improves success.

• Brand Pricing
  

Source: https://www.nicorette.com/shop/

• Generic NRT Gum

  • YES - check your local pharmacy for savings. Generic products provide the same active ingredient and dosing. Product choice is based solely on preference, not efficacy.

Nicotine Lozenges

Product Information: Nicorette Lozenges are described as a Nicotine Polacrilex Formulation. Nicorette lozenges are sugar-free, and come in mint and cherry flavors. Buffering agents are present in the formula to enhance absorption.

**Will not provide the quick relief of a cigarette.

• Doses Available: 2 mg, 4 mg

  • Based on the “time to first cigarette” (TTFC) as an indicator of nicotine dependency

  • 2mg if you smoke more than 30 mins after waking up

  • 4mg if you smoke less than 30 mins after waking up

• Dosing Schedule:

  • Weeks 1-6: 1 lozenge every 1 to 2 hours when awake

  • Weeks 7-9: 1 lozenge every 2 to 4 hours when awake

  • Weeks 10-12: 1 lozenge every 4 to 8 hours when awake

• Side Effects/ADR: Nausea, hiccups, cough, heartburn, headache, flatulence (gas, bloating), insomnia

• Advantages of Nicotine Lozenge:

  • serves as an oral substitute (keeps the mouth "busy)", might delay weight gain, can be titrated to avoid withdrawal effects, can be used in combo with other agents (not approved method, but seen in practice)

• Disadvantages of Nicotine Lozenge:

  • Gastrointestinal side effects can be bothersome, frequent dosing can make it difficult for patients to maintain scheduled dosing (adherence issues). NRT Lozenges are most effective when utilized according to the recommended dosing schedule.

• Counseling Information:

  • Users should use at least 9 lozenges per day during the first 6 weeks of treatment

    • Do NOT use more than 20 lozenges per day during the first 6 weeks

  • Directions for Use: place in mouth and allow to dissolve slowly (nicotine may cause a warm, tingling sensation). Rotate through the mouth. Do NOT chew or swallow lozenges.

  • Nicorette lozenge usually dissolves within 20-30 mins

  • Nicorette Mini Lozenge will dissolve in 10 minutes.

• Brand Pricing:
  

Source: https://www.nicorette.com/shop/

• Generic NRT Lozenges 

  • YES - check your local pharmacy for savings. Generic products provide the same active ingredient and dosing. Product choice is based solely on preference, not efficacy.

Nicotine Patches

Product Information: NicoDerm CQ is a transdermal (through the skin) preparation. Nicotine is well absorbed across the skin. Delivery through the skin avoids hepatic metabolism, and therefore avoids certain metabolic drug interactions. Plasma (blood) nicotine levels are lower and fluctuate less as compared to smoking cigarettes.

• Doses Available: 7 mg, 14 mg, 21 mg

• Dosing Schedule: ONE patch per day

  • If you smoke more than 10 cigarettes a day:

    • Weeks 1-6: 21 mg

    • Weeks 7-8: 14 mg

    • Weeks 9-10: 7 mg

  • If you smoke 10 or less cigarettes per day:

    • Skip step 1, start at step 2

    • Weeks 1-6: 14 mg

    • Weeks 7-8: 7 mg

    • *8 weeks of treatment may be just as efficacious as longer periods

• Side Effects/ADR:

  • In the first hour: mild itching, burning, tingling.

  • Others: vivid dreams or sleep disturbances, headaches

  • After patch removal: skin may be red for 24 hours.

    • **If more than 4 days of redness, speak to a doctor before next patch use.

  • Local skin reactions are very common – usually caused by the adhesive.

    • Up to 50% of patients have a skin reaction.

    • DO NOT USE in patients with dermatologic conditions: psoriasis, eczema, etc.

• Advantages of Nicotine Patches

  • Once daily dosing (easy to adhere)

  • Use is discrete and not obvious to others (consider workplace, places of education, or presence of stigma)

  • Can be used in combination with Bupropion (FDA approved).

• Disadvantages of Nicotine

  • When NRT patches are used as monotherapy (without any other NRT products), the dose cannot be easily titrated to acutely manage withdrawal symptoms. In other words, NRT patches do not provide the withdrawal relief that may be associated with oral products which are shorter acting.

  • Not for patients with skin conditions or history of allergies to adhesives. Check the individual product packaging for more information.

• Counseling Information:

  • Directions for use:

    • Choose an area on the upper body or upper outer part of the arm (between head and waist). Make sure the skin is clean, dry, hairless, and not irritated. Wash hands prior to application.

    • Do not cut the patch – less effective and nicotine can evaporate out.

    • Apply the patch to a different area every day. Do not use the same area again for at LEAST 1 week.

      • Water will not harm the patch as long as it is applied correctly. All daily activities are OK to continue as normal.

    • Wash hands after applying the patch. Residual nicotine on the hands can get into the eyes or nose and cause stinging and redness.

    • Remove the patch before any MRI is performed.

  • Discarding of the patch:

    • Fold the patch in half, making sure to to cover all of the adhesive area. Discard in trash. Keep all patches away from children and pets to avoid contamination or unintentional poisoning.

    • Any adhesive remaining on the skin after patch removal can be removed with acetone or rubbing alcohol.
      

• Brand Pricing:

Source: https://www.nicorette.com/shop/

• Generic NRT Patches 

  • YES - check your local pharmacy for savings. Generic products provide the same active ingredient and dosing. Product choice is based solely on preference, not efficacy.

(Rx Required) Nicotine Nasal Spray

Product Information: Nicotrol NS is an aqueous (water-containing) solution of nicotine in a 10mL nasal spray bottle. Nicotine is absorbed rapidly across the nasal mucosa. Quicker physiologic response as compared to oral and transdermal options.

Caution: DEPENDENCY. Nicotrol NS provides the highest peak of nicotine levels. Many patients use the nasal spray for longer than recommended due to these effects.

• Doses Available: E ach metered spray provides 0.5 mg nicotine.

  • 1 spray = 1 dose.

• Dosing Schedule:

  • Initially: 1 to 2 doses (sprays) per hour

    • Increase as directed by MD/prescriber based on patient symptoms and cravings.

    • Maximum Dosage: 5 doses per hour or 40 mg of nicotine daily

  • For the best results: patients should use at least 8 doses daily for the first 6-8 weeks.

    • To discontinue use, gradual tapering down of daily use over an additional 4-6 weeks is recommended.

  • Recommended total duration of therapy is 3-6 months

• Side Effects/ADR

  • In the first week: hot, peppery sensation in the back of throat or nose. Sneezing, coughing, watery eyes, runny nose.(cold, allergy-like symptoms). Should self resolve after the first few days of use. If these side effects do not subside after 1 week, contact your prescriber.

  • Long term: spray may cause tearing, coughing, and sneezing immediately after use.

• Advantages of Nicotine Nasal Spray

  • can be titrated based on patient needs

  • can be used with other products (off-label)

• Disadvantages of Nicotine

  • Frequent dosing complicates treatment adherence, nasal administration may not be the most desirable for patients, and dependency is common. Nicotine nasal sprays may not be the most effective option for complete cessation of smoking.

• Counseling Information:

  • Prime the pump before the first use. Re-prime if not used in 24 hours Blow nose, tilt head back slightly and insert tip into nostril as far as comfortableBreathe through the mouth and spray onceDo not swallow, sniff, or inhale to avoid irritation.

  • Gently sniff if nose starts to run. Wait 2-3 mins before blowing nose.

  • Wait 5 minutes before operating heavy machinery.

  • Avoid contact with eyes, skin, and mouth

  • AVOID USE in patients with chronic nasal disorders or severe reactive airway disease.

• Brand Pricing: may be covered by insurance.  If no insurance, patients may use discount cards at the pharmacy's discretion. Call your prescription insurance company for further information about rx costs.

(Rx Required) Nicotine Oral Inhaler

Product Information: Nicotrol Inhaler is a nicotine inhalation system which consists of: a mouthpiece, and a cartridge containing 10mg nicotine and 1mg menthol. 1 cartridge delivers 4mg of nicotine via vapor, absorbed across the buccal mucosa.

• Doses Available: Each cartridge delivers 4 mg of nicotine over 40 inhalations

• Dosing Schedule:

  • In general, use 1 cartridge every 1-2 hours for 12 weeks
    

    • Total of 6-16 cartridges per day for up to 6 months duration.

    • Tapering dose downwards during the last 3 months

• Side Effects/ADR:

  • Mild irritation of the mouth/throat, cough, headache, rhinitis, dyspepsia (stomach upset). Severity is usually mild, and symptoms can resolve with continued use.

• Advantages of Nicotine Inhaler

  •  Oral substitute. Titrated for symptom severity (adjustable dosing), mimics the oral fixation of smoking

• Disadvantages of Nicotine Inhaler

  • Delivery of nicotine decreases at temps below 40 F (dosing outside/in cold may be an issue)

  • Delivery of nicotine can be decreased by certain food/drinks which alter the mouth's typical environment.

  • Frequent dosing makes adherence more difficult than other options (ex: patch).

• Counseling Information:

• Directions for Use:

  • Use continuous puffing for 20 minutes for best results, or puff in short breaths.

  • The cartridge does NOT have to be used all at once – experiment with different schedules to find what works best. (at first, use it to control cravings)

  • Reusable mouthpiece, clean regularly with soap and water.

  • DO NOT eat or drink 15 mins BEFORE or WHILE USING

• Brand Pricing: may be covered by insurance.  If no insurance, patients may use discount cards at the pharmacy's discretion. Call your prescription insurance company for further information about rx costs.

(Rx Required) Bupropion SR (Zyban) Tablets

• Product Information: Bupropion SR is an atypical antidepressant that affects the neurotransmitters norepinephrine and dopamine. Clinical Effects in smoking cessation include decreased craving for cigarettes, and decreased symptoms of nicotine withdrawal.

• Caution: consider other options in patients who have had any head trauma, take other antidepressants, have severe hepatic impairment, or seizure history.

• Doses Available: 150 mg, 300 mg

• Dosing Schedule:

  • Initial: 150mg by mouth every morning for 3 days

    • Then 150mg by mouth twice daily for 7-12 weeks

      • Give doses earlier in the afternoon, administered at least 8 hours apart

  • Max: 300mg daily

  • Patients should consider Bupropion as a longer term treatment, lasting up to 6 months post-quitting.

• Side Effects/ADR

  •  Insomnia (avoid giving at bedtime), dry mouth. Less common: rash, tremor

• Advantages of Bupropion SR

• oral dosing with simple adherence requirements. Bupropion also delays weight gain and supports weight loss.
  

  • an excellent option for patients who also suffer with depression.

  • Can be used safely in combination with other NRT.

• Disadvantages of Bupropion SR

  •  Increased seizure risk and potential for interactions with other psychiatric medications. Monitor for psych symptoms - it's possible for antidepressants to cause worsening symptoms and suicidality, especially under the age of 25. Discontinue Bupropion SR in the event of new or worsening negative moods, suicidal/homicidal thoughts or actions. Call MD or seek emergency care immediately if this occurs.

• Counseling Information:

  • CONTRAINDICATED in patients with a history of bulimia or anorexia nervosa, patients undergoing abrupt d/c of benzos, sedatives, or alcohol (due to increased seizure risk).

  • CONTRAINDICATED in patients with a seizure disorder, patients taking Wellbutrin, or taking any MAO inhibitor within the last 2 weeks.
    

  • Discontinue treatment if no improvement is seen in 7 weeks. Can re-evaluate and restart at a later date.

• Pricing: may be covered by insurance. If no insurance, patients may use discount cards at the pharmacy's discretion. Call your prescription insurance company for further information about rx costs.

Rx Required: Varenicline (Chantix) Tablets

• Product Information: Varenicline (Chantix) is a partial nicotinic receptor agonist used as an aid in smoking cessation. Like Bupropion SR, Chantix is also a NON-nicotine based cessation aid. Clinical effects include decreased symptoms of nicotine withdrawal. Varenicline blocks the dopaminergic stimulation responsible for the “reward” associated with smoking.

• Doses Available: Chantix is available as Starter Pack and Maintenance Pack (blister packs), with instructions included on how to properly dose medication each day. Apo-varenicline (mentioned below) is available as 0.5 mg tablets and 1 mg tablets as loose tablets in manufacturer bottle.

• When to Stop Smoking

  • Begin varenicline treatment 1 week PRIOR to quitting smoking - OR- begin varenicline treatment and quit smoking between days 8-35.

• Dosing Schedule:

  • dose is gradually increased to limit nausea and insomnia

  • Day 1 to 3: Take 0.5 mg by mouth 3 times per day

  • Day 4 to 7: Take 0.5 mg by mouth 2 times per day

  • Day 8 to end of treatment: Take 1 mg by mouth 2 times per day

  • Take all doses WITH food and water

  • Treatment duration up to 12 weeks.

• Treatment Goals: decrease cigarette use by 50% within the first 4 weeks, and completely stop smoking by 12 weeks.

• Side Effects/ADR

  • Stomach upset, neuropsychiatric effects - caution driving, drinking alcohol, driving until you know how it affects you. Additionally, vivid nightmares are a unique side effect associated with Chantix use

  • Neuropsychiatric symptoms and suicidality (same as Bupropion) - Discontinue Chantix in the event of new or worsening negative moods, suicidal/homicidal thoughts or actions.  Call MD or seek emergency care immediately if this occurs.

• Advantages of Varenicline

  • Most notably, this is the only treatment option in which patients do not have to abstain from smoking prior to use. May be best for severe addiction /high nicotine use.

  • Oral dosing makes adherence easier to maintain, may be desirable for certain patients.

• Disadvantages of Varenicline

  • Caution use in RENAL IMPAIRMENT - adjust dosing if necessary, or consider alternative treatment options.

  • Increased risk of: seizures, enhanced effects of alcohol, accidental injury, cardiovascular events, and angioedema

  • Often not in stock - personally, I've noticed a problem over the past few years in the ability of pharmacies to secure Chantix, specifically in the "packs" form. Some patients may receive apo-varenicline, which is an originally Canadian product that has temporary authorization to replace Chantix brand products in the event of inventory issues.

• Pricing: may be covered by insurance. If no insurance, patients may use discount cards at the pharmacy's discretion. Call your prescription insurance company for further information about rx costs.

Source: the chart below is an all-encompassing look at smoking cessation presented in a chart format. This chart was created by myself and Dr. James Gorman, Pharm.D during our time as student pharmacists. Download the original chart below:

smokingcessationchart.pdf

Download PDF • 131KB