Nicotine Replacement

Aka: Nicotine Replacement, Nicotine

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II. Indications

  1. Tobacco Cessation

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. Avoid Nicotine pouch products (e.g. Zyn) for Nicotine Replacement
    1. Product placed between the gum and lip
    2. Risk of toxin exposure and secondary cancers (none are considered safe)
  4. 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

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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
FPNotebook does not benefit financially from showing this medication data or their pharmacy links. This information is provided only to help medical providers and their patients see relative costs. Insurance plans negotiate lower medication prices with suppliers. Prices shown here are out of pocket, non-negotiated rates. See Needy Meds for financial assistance information. GoodRx is another tool for finding lower drug prices.

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