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Pharmacotherapy Options for Tobacco Cessation in Nonpregnant Patients

Pharmacotherapy Options for Tobacco Cessation in Nonpregnant Patients - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Alcohol and Tobacco, Related


1
Table 1. Pharmacotherapy Options for Tobacco Cessation in Nonpregnant Patients1-5
Medication Contraindications/ Precautions Adverse Effects Dosage Initiation, Use, & Monitoring
Varenicline
(Chantix)
Prescription only
(HHS Strength of
Evidence A)
Use with caution in patients:
- With serious psychiatric illness
- With significant renal impairment
- Unstable psychiatric status
- History of suicidal ideation
- Nausea
- Insomnia
- Abnormal,
strange dreams
0.5 mg every morning (Days 1-3)
0.5 mg twice daily (Days 4-7)
1 mg twice daily (Days 8-end)
Start 1 week before quit date and
use 3-6 months OR
Begin and then quit smoking
between day 8 and 36
Monitor for neuropsychiatric
symptoms including changes in
behavior, hostility, agitation,
depressed mood, and suicide-
related events, including ideation,
behavior, and attempted suicide
Combination
Therapy:
Nicotine Patch +
short-acting
nicotine products
(e.g., lozenge, gum)
(HHS Strength of
Evidence A)
Only patch + bupropion is currently
FDA-approved Reference individual medications
Follow instructions for individual
medications
Follow instructions for individual
medications
Bupropion
SR 150
(Generic, Zyban,
Wellbutrin SR)
Prescription only
(HHS Strength of
Evidence A)
Avoid use in patients with:
- History of seizures or risk for
seizures
- Use of monoamine oxidase inhibitor
(MAOI)
- Use of bupropion in any other form
- History of eating disorders
- Insomnia
- Agitation
- Dry mouth
150 mg each morning (Days 1-3)
150 mg twice daily (at least 8 hours
apart) (Days 4-end)
Start 1-2 weeks before quit date;
use 2-6 months
Monitor for neuropsychiatric
symptoms including changes in
behavior, hostility, agitation,
depressed mood, and suicide-
related events, including ideation,
behavior, and attempted suicide
Appendix to UW Health Tobacco Cessation Guideline
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2017CCKM@uwhealth.org

2


Medication Contraindications/ Precautions Adverse Effects Dosage Initiation, Use, & Monitoring
Nicotine Patch
(Generic,
Nicoderm CQ)

Prescription or OTC

(HHS Strength of
Evidence A)
Do not use in patients with severe
eczema or psoriasis
- Local skin
reaction
- Insomnia
- Vivid dreams
One patch per day
If > 10 cigarettes/day: 21 mg for 4
weeks, 14 mg for 2-4 weeks, 7 mg
for 2-4 weeks
Pre-quit: Up to 6 months prior to
quit date
Post-quit: 12 weeks

Rotate sites of application with
each new patch to minimize skin
irritation

If removed, takes 0.5-3 hrs. after
reapplication to reach effective
levels

If cigarette cravings occur upon
awakening, wear for 24 hours; if
vivid dreams or other sleep
disturbances occur, remove the
patch at bedtime and apply a new
patch in the morning
Nicotine Gum
(Generic, Nicorette)

Prescription or OTC

(HHS Strength of
Evidence A)
- Caution with dentures
- Can worsen dental problems
- Do not eat or drink 15 minutes
before or during use
- Mouth soreness
- Stomach ache
- Heartburn
- Unpleasant taste
2 mg (smoking > 30 min. after
waking)
4 mg (smoking < 30 min. after
waking)

Maximum 24 pieces/day

(HHS Strength of Evidence B)
1 piece every 1-2 hrs.
(6-15 pieces/day) for the first 6
weeks, every 2-4 hours for the
next 3 weeks, every 4-8 hours for
the final 2 weeks; use for 3 months

Requires proper chewing
technique (chew and park)

GI side effects are usually due to
overly vigorous chewing

Oral substitute for cigarettes

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

3


Medication Contraindications/ Precautions Adverse Effects Dosage Initiation, Use, & Monitoring
Nicotine Inhaler
(Nicotrol inhaler)

Prescription only

(HHS Strength of
Evidence A)
- May irritate mouth/throat at first
(improves with use)
- Use with caution in patients with
bronchospastic disease
- Local irritation of
mouth & throat
6-16 cartridges/day
Inhale 80 times/cartridge
May save partially-used cartridge
for next day

Maximum 16 cartridges/day
Pre-quit: Up to 6 months before
quit date
Post-quit: Up to 6 months; taper at
end

Requires frequent puffing

Oral substitute for cigarettes

Nicotine
Lozenge
(Generic, Commit)

Prescription or OTC

(HHS Strength of
Evidence B)
- Do not eat or drink 15 minutes
before or during use
- One lozenge at a time
- Limit 20 in 24 hrs.
- Unpleasant taste
- Hiccups
- Cough
- Heartburn
- Mouth irritation
2 mg (smoking > 30 min. after
waking)
4 mg (smoking < 30 min. after
waking)

Maximum 20 lozenges/day

Use 3-6 months

Weeks 1-6: 1 every 1-2 hrs.
Weeks 7-9: 1 every 2-4 hrs.
Weeks 10-12: 1 every 4-8 hrs.

Oral substitute for cigarettes

Can be used in patients with poor
dentition
Nicotine Nasal
Spray
(Nicotrol NS)

Prescription only

(HHS Strength of
Evidence A)
- Do not use in patients with severe
reactive airway disease
- Avoid use in patients with chronic
allergic rhinitis, nasal polyps, or
sinusitis
- May irritate nose (improves with
use)
- May cause dependence
- Nasal and throat
irritation
- Rhinitis
- Sneezing,
coughing
0.5 mg/spray
1 “dose” = 2 sprays (1 in each nostril)

1-2 doses/hour (2-4 sprays/hour)
8-40 doses/day (16-80 sprays/day)

Maximum 5 doses/hr (10 sprays/hr)
and 40 doses/day (80 sprays/day)
Use 3-6 months; taper at end
DO NOT inhale

Local irritation to nasal mucosa is
difficult for many patients to
tolerate

References
1. Fiore M, Jaen CR, Baker T, et al. Treating Tobacco Use and Dependence: 2008 Update. Rockville, MD: U.S. Department of Health and Human Services Public Health Service; 2008.
2. Cahill K, Stevens S, Perera R, Lancaster T. Pharmacological interventions for smoking cessation: an overview and network meta-analysis. Cochrane Database Syst Rev. 2013;5:CD009329.
3. Koegelenberg CF, Noor F, Bateman ED, et al. Efficacy of varenicline combined with nicotine replacement therapy vs varenicline alone for smoking cessation: a randomized clinical trial. JAMA.
2014;312(2):155-161.
4. Rigotti NA. Strategies to help a smoker who is struggling to quit. JAMA. 2012;308(15):1573-1580.
5. Shahab L, Brose LS, West R. Novel delivery systems for nicotine replacement therapy as an aid to smoking cessation and for harm reduction: rationale, and evidence for advantages over
existing systems. CNS Drugs. 2013;27(12):1007-1019.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org