II. Indications

III. Physiology: Nicotine

  1. Nicotine is a plant alkaloid extracted from Tobacco, used as an addictive CNS stimulant, as well as an Insecticide
  2. Nicotine Activity
    1. See Nicotinic Acetylcholine Receptor
    2. Binds nicotinic AcetylcholineGanglionic receptors and at Neuromuscular Junctions (stimulatory at low dose, inhibitory at high dose)
    3. Stimulates Epinephrine release from the Adrenal Medulla, and CNS Neurotransmitter release (e.g. Acetylcholine, Dopamine, Norepinephrine)
      1. Results in peripheral Vasoconstriction, Tachycardia, and elevated Blood Pressure
    4. Chemoreceptors may also be stimulated causing Nausea and Vomiting

IV. Approach

  1. Eight week course is sufficient with little added benefit to longer use
    1. Schnoll (2015) JAMA Intern Med 175(4): 504-11 [PubMed]
  2. Nicotine Replacement may be used in combination
    1. Controller medication (long-acting): Nicotine Patch
    2. Rescue medication (short acting): Nicotin Gum, Nicotine Lozenge, Nicotine Inhaler
  3. Tobacco and Nicotine Replacement overlap
    1. Best to quit simultaneously with starting Nicotine Replacement
    2. However, now considered safe (although not ideal) to taper Tobacco use while initiating Nicotine Replacement
    3. Simultaneous use was considered a risk for coronary events
      1. Now appears that smokers will self titrate their Nicotine levels
      2. When Tobacco is still being used, Nicotine Replacement is reduced to maintain a constant Nicotine level

V. Preparations: Long acting

  1. Nicotine Patch (e.g. Nicoderm, Nicotrol, Habitrol)
    1. Best in white, non-obese with low Nicotine dependence
    2. Lerman (2004) Ann Intern Med 140:426-33 [PubMed]

VI. Preparations: Short-acting

  1. Nicotine Gum (Nicorette)
    1. Delays weight gain compared with other options
    2. May be preferred in cessation of chewing Tobacco
    3. Consider using in combination with the patch
  2. Nicotine Nasal Spray (Intranasal Nicotine)
    1. Best in obese heavy smokers and non-white patients
    2. Lerman (2004) Ann Intern Med 140:426-33 [PubMed]
  3. Nicotine Inhaler (Nicotrol Inhaler)
  4. Nicotine Lozenge

VII. Management: Adjunctive medications

  1. See Tobacco Cessation
  2. Varenicline (Chantix)
    1. More effective than Bupropion in Tobacco Cessation
  3. Bupropion
    1. Consider in comorbid Major Depression when not contraindicated (esp. Seizure Disorder)
    2. Use in combination with Nicotine Replacement and other measures
  4. Mecamylamine (Inversine, Vecamyl)
    1. Rarely used in U.S. for Tobacco Cessation
    2. Increases abstinence rates with Nicotine Replacement
    3. Rose (1994) Clin Pharmacol Ther 56:86-99 [PubMed]

VIII. Adverse Effects

  1. Headache
  2. Nausea
  3. Vomiting
  4. Indigestion
  5. Disturbed sleep

IX. Precautions

  1. Avoid Electronic Cigarette (E-Cigarette)
    1. Other standard Nicotine Replacement forms are well studied, regulated and preferred over E-Cigs
    2. Inadequate safety available for e-cig devices
    3. Unknown safety of inhaled vapor (e.g. propylene glycol, lead, Arsenic, formaldehyde, Hydrogen cyanide)
    4. E-cigs are commonly continued indefinitely (and often with continued Tobacco Smoking in up to 50%)
      1. If used, plan a taper schedule and e-cig quit date (e.g. 3 months after starting)
  2. Avoid Hookah Pipe (Tobacco smoke drawn through water before inhalation)
    1. Water does not filter Tobacco-related toxins
    2. Hookah users tend to smoke for longer and have greater exposure
  3. References
    1. (2013) Presc Lett 20(5): 27
    2. Vardavas (2012) Chest 141(6):1400-6 [PubMed]
    3. Trtchounian (2011) Tob Control 20:47-52 [PubMed]

X. Resources

  1. FDA consumer update on Nicotine Replacement
    1. http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm345087.htm

XI. References

  1. Wynn (2012) J Pharm Pract 25(6):591-9

Images: Related links to external sites (from Bing)

Related Studies

Cost: Medications

nicotine (on 12/21/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
NICOTINE 14 MG/24HR PATCH Generic OTC $1.54 each
NICOTINE 2 MG CHEWING GUM Generic OTC $0.21 each
NICOTINE 2 MG LOZENGE Generic OTC $0.37 each
NICOTINE 2 MG MINI LOZENGE Generic OTC $0.40 each
NICOTINE 21 MG/24HR PATCH Generic OTC $1.57 each
NICOTINE 4 MG CHEWING GUM Generic OTC $0.27 each
NICOTINE 4 MG LOZENGE Generic OTC $0.34 each
NICOTINE 4 MG MINI LOZENGE Generic OTC $0.40 each
NICOTINE 7 MG/24HR PATCH Generic OTC $1.65 each
NICOTINE TRANSDERMAL SYSTEM Generic OTC $1.46 each

Ontology: Tobacco Use Disorder (C0040336)

Definition (MSHCZE) Tabák užívaný na úkor zdraví člověka nebo jeho fungování ve společnosti. Deskriptor zahrnuje i závislost na tabáku. R
Definition (CCC) Excessive use of tobacco products
Definition (MSH) Tobacco used to the detriment of a person's health or social functioning. Tobacco dependence is included.
Definition (CSP) tobacco used to the detriment of a person's health or social functioning; tobacco dependence is included.
Concepts Finding (T033)
MSH D014029
ICD9 305.1
SnomedCT 110483000, 89765005
LNC LP36308-2, MTHU019365
English TOBACCO ABUSE, Disorder, Tobacco Use, Disorder, Tobacco-Use, Tobacco Use Disorders, Tobacco-Use Disorder, Tobacco use disorder, Tobacco Use Disorder, tobacco use disorder, TOBACCO USE DIS, Tobacco Abuse, Tobacco Use Disorder [Disease/Finding], rndx tobacco abuse, rndx tobacco abuse (diagnosis), Abuse;tobacco, tobacco user, tobacco users, tobacco abuse, abuse tobacco, Tobacco use, tobacco abuse (diagnosis), Tobacco abuse, Tobacco user, Tobacco user (finding), abuse; tobacco, tobacco; abuse, Tobacco user (life style)
Italian Abuso di tabacco, Utilizzatore di tabacco, Disturbi da uso di tabacco
Dutch tabakgebruiksstoornis, Tabaksmisbruik, misbruik; tabak, tabak; misbruik, tabaksgebruiker, tabaksmisbruik, Aandoening ten gevolge van tabaksgebruik, Tabaksgebruik, aandoening ten gevolge van
Portuguese Afecção pelo consumo de tabaco, Abuso de tabaco, Consumidor de tabaco, Transtorno por Uso de Tabaco
Spanish Trastorno por consumo de tabaco, abuso de tabaco, consumidor de tabaco (estilo de vida) (estilo de vida), consumidor de tabaco (estilo de vida), consumidor de tabaco (hallazgo), consumidor de tabaco, Abuso de tabaco, Usuario de tabaco, Trastorno por Uso de Tabaco
Japanese タバコ乱用, タバコ使用者, タバコランヨウ, タバコシヨウシャ, ニコチン依存, 喫煙性人格障害, 人格障害-喫煙性, ニコチン障害, タバコ使用障害, タバコシヨウショウガイ, タバコ依存, 異常喫煙
Swedish Tobaksberoende
Czech nikotinismus, otrava tabákem, Zneužívání tabáku, Porucha užívání tabáku, Uživatel tabáku, poruchy vyvolané užíváním tabáku, tabakismus
Finnish Tupakkariippuvuus
Russian KURENIE TABAKA, RASSTROISTVA ZDOROV'IA, TABAKA UPOTREBLENIE, RASSTROISTVA ZDOROV'IA, TABAK, ZAVISIMOST', NIKOTINOVAIA ZAVISIMOST', КУРЕНИЕ ТАБАКА, РАССТРОЙСТВА ЗДОРОВЬЯ, НИКОТИНОВАЯ ЗАВИСИМОСТЬ, ТАБАКА УПОТРЕБЛЕНИЕ, РАССТРОЙСТВА ЗДОРОВЬЯ, ТАБАК, ЗАВИСИМОСТЬ
Croatian DUHAN, UPORABA, POREMEĆAJ
Polish Nikotynizm
Hungarian Dohányzási betegség, Dohányzó, Dohány abúzus
Norwegian Skadelig tobakksbruk, Psykiske forstyrrelser og atferdsforstyrrelser som skyldes bruk av tobakk
German Stoerung durch Tabakgenuss, Störung durch Tabakgenuß, Tabakkonsument, Tabakmissbrauch
French Consommateur de tabac, Abus tabagique, Trouble lié à la consommation de tabac, Trouble lié au tabac, Trouble lié au tabagisme

Ontology: Nicotine replacement therapy (C1278444)

Definition (NCI) Therapy to help control nicotine withdrawal symptoms during tobacco cessation
Definition (NCI_NCI-GLOSS) A type of treatment that uses special products to give small, steady doses of nicotine to help stop cravings and relieve symptoms that occur when a person is trying to quit smoking. These products include nicotine gum, nicotine inhaler, nicotine nasal spray, nicotine lozenges, and nicotine patch. They do not contain any of the other chemicals found in tobacco products.
Definition (CSP) nicotine complexed with polymers for the controlled release of nicotine as deterrent for the eventual cessation of abusing tobacco products.
Concepts Therapeutic or Preventive Procedure (T061)
SnomedCT 313396002, 182828001, 151159008
English Nicotine replacement therapy (context-dependent category), Nicotine replacement therapy (situation), nicotine replacement therapy, nicotine replacements, nicotine replacement, nicotine replacement therapies, Nicotine replacement therapy (procedure), Nicotine replacement therapy, NRT, Nicotine Replacement Therapy, Nicotine Replacement
Spanish terapia sustitutiva de nicotina (situación), terapia sustitutiva de nicotina (categoría dependiente del contexto), terapia de reemplazo con nicotina, terapia sustitutiva de nicotina