An Introduction to Tobacco Cessation2: Nicotine Replacement Therapy

Trainers: Ray Croucher, Faraz Siddiqui,

Heather Thomson

2

Tobacco cessation 2

1. To introduce the intake, dependence scores and nicotine levels found in tobacco users.

2. To list the Nicotine Replacement Therapy (NRT) options available.

3. To describe the process of prescribing NRT gum, including measuring dependency, dosage, chewing technique & possible side effects.

Evidence Based Treatments to support tobacco cessation

3

Behavioural support

Nicotine replacement

Smo

kele

ss • 200 ST users (Bangladesh)

• Avg. intake: 11.7 dips/day

• mean FTND-ST: 4.7

• Avg. cotinine: 361 ng/ml

Smo

kin

g • 207 cigarette users (Europe)

• Avg. intake: 10.7/day

• mean FTND: 1.7

• Avg. cotinine: 113 ng/ml

Intake, dependence scores & nicotine levels in tobacco users(Huque et al 2016 & Etter J-F et al , 2000)(

Treatment to support tobacco cessation: Nicotine Replacement Therapy (NRT)

- Relieves cravings by providing low levels of nicotine.- Treatment lasts up to 8-12 weeks.- Available in different forms and strengthsGumSkin Patch Lozenge, oral strips and filmsOral/nasal spraysInhalator

- Minimal side effects.• .

Is Nicotine Replacement Therapy effective?

Quitting smoked tobacco

136 trials (64,640 participants)

Typical daily intake: 15 cigarettes

All NRT types improve quitting success – 50-60% improved chance

Some side effects reported e.g. mouth irritation, no evidence of any increased risk of heart attacks

[Hartmann-Boyce J et al (2018)]

Quitting smokeless tobacco

12 trials (3,000+ participants)

NRT can help with a quit attempt

Success rate vs placebo - RR: 1.24 (1.11-1.39)

All studies conducted in European or North American samples

Need for further research to generate more evidence

[Ebbert JO et al (2015)]

Nicotine gum

• Available throughout the Region.

• 2mg and 4mg dose – to suit low and high dependence tobacco users.

• Chewing can provide a small level of behavioural substitution for ST users.

• Some acidic beverages (e.g. orange juice, coffee and cola) reduce nicotine absorption – avoid for 15 minutes before and during chewing.

Changes in blood nicotine concentrations

(Molyneux, 2004)

How quickly does gum deliver nicotine?

2

4

0

6

8

10

12

14

5 10 15 20 25 30

Minutes

Gum 4mg

Gum 2mg

Ng/ml

Nicotine dependence and NRT dosage in tobacco users

10

NRT gum dosage (2, 4 or 6 mg) will be determined by responses to the following Heaviness of Tobacco Use questions:

1. How soon after waking do you have your first tobacco intake of the day?

2. How many times a day do you take a tobacco intake?

Those reporting tobacco use within 30 mins of waking up AND / OR more than 10 tobacco intakes per day should receive a higher dose (6mg). Other clients should receive a lower dose (2 or 4 mg).

Participants should take the prescribed dose hourly to a maximum of 15 per day. Reducing frequency in the later weeks of a quit attempt should be considered. (Users frequently self titrate.)

The NRT will be provided for a total duration of 8 weeks.

Participants should receive no more than a

two week supply at any one time.

NRT gum - the chewing technique • Use a ‘chew and park’ technique for about 30 minutes.

• Incorrect chewing may reduce nicotine absorption or result in gastrointestinal effects such as hiccups.

• Important to chew sufficient pieces of gum to maintain cessation success. Gum should be chewed every hour.

• https://youtu.be/ysLLlnz_Y5M

Nicotine Gum chewing technique

Chew gum slowly

until taste becomes

strong (approx.1

min)

1

Rest gum

between cheek

and gum

2Chew gum

again when

taste has

faded

3

Side effects of NRT gum use

Side effects of a quit attempt (nicotine withdrawal): irritability, anxiety, restlessness, increased appetite, poor concentration, urges to use tobacco.Side effects of too much nicotine: feeling faint, nausea, headache, hiccupping.

Very common side-effects

(may affect more than 1 in 10)

Headache, cough, nausea,

hiccups, sore mouth

Common side-effects

(may affect up to 1 in 10)

Dizziness, loss of taste, stomach

pain, dry or sore mouth, excess gas

or wind, vomiting, burning

sensation in the mouth

Uncommon side-effects

(may affect up to 1 in 100)

Abnormal dreams, belching,

swollen tongue, mouth ulcers, rash,

chest discomfort, jaw ache, high

blood pressure, shortness of breath

Advise your clients: That NRT is very safe – in most cases NRT use is better than continuing tobacco use. That some side effects may occur when it is used. That clients should contact you if they are worried by any side-effects.

Important points to rememberwhen prescribing NRT gum

1. Client effort and determination are essential.

2. It provides nicotine more slowly and in smaller amounts than either smoked or smokeless tobacco.

3. It reduces any discomfort (withdrawal symptoms) in quitting.

SUMMARY

• Client collaboration offers a higher chance of a successful quit attempt.

• NRT is available in a range of formats.

• Dependency defines NRT dosage.

• Daily dosage limits.

• Users should be advised of possible side effects e.g. mouth irritation.

• Can be combined with behavioural support.

Thank you for listening!