Nicotine Replacement

Aka: Nicotine Replacement

1. See Also
   1. Tobacco Abuse
2. Indications
   1. Tobacco Cessation
3. 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
4. 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]
5. 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
6. Management: Adjunctive medications
   1. Bupropion
      1. Significantly increases Tobacco Cessation efficacy
      2. See Tobacco Cessation
   2. Varenicline (Chantix)
      1. Not recommended due to increased cardiovascular risk
   3. Mecamylamine (Inversine)
      1. Increases abstinence rates with Nicotine Replacement
      2. Rose (1994) Clin Pharmacol Ther 56:86-99 [PubMed]
7. Precautions
   1. Avoid Electronic Cigarette (E-Cigarette)
      1. Inadequate safety available for these devices and the inhaled vapor
      2. Other standard Nicotine Replacement forms are well studied and regulated
   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]
8. Resources
   1. FDA consumer update on Nicotine Replacement
      1. http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm345087.htm
9. References
   1. Wynn (2012) J Pharm Pract 25(6):591-9