by encouraging and instructing unwilling smokers to substantially and persistently reduce their daily smoking
as much as possible while they are receiving nicotine- replacement therapy. 62
Nicotine gum Use and dosage
Patient instructions Nicotine gum should be used regularly by chewing one piece of gum every 1-2 hours or chewing one piece of gum when the patient has the urge to smoke. It should be chewed slowly until there is a slight tingling in the mouth. The patient should stop chewing and place (park) the chewing gum between the cheek and gum. When the tingling subsides (after about one minute), the patient should resume chewing and the cycle repeated for about 30 minutes. Tapering the use of nicotine gum can be accomplished by reducing the daily dose by one piece every 4-7 days or by decreasing the chewing time for each piece from 30 minutes to 10-15 minutes. Patients may substitute one or more pieces of sugarless gum for an equal number of pieces of nicotine gum. The nicotine gum should be discontinued when the craving for nicotine is satisfied by one or two pieces of gum per day. Prescribing information recommends use for a period of 12 weeks. However, patients may extend use to prevent relapse. According to the prescribing literature, the use of nicotine gum is discouraged for longer than 6 months due to the potential for dependence. Although use of nicotine gum is preferable to tobacco use because the gum contains no carcinogens, physiologic effects such as elevated blood pressure can occur with prolonged use of NRT. Nicotine gum should not be used within 15 minutes of eating or drinking, as the acidic pH of the mouth will interfere with the absorption of the nicotine through the buccal mucosa. Chewing the gum too rapidly might precipitate lightheadedness, nausea and vomiting, irritation of the throat and mouth, hiccups, and indigestion. 63 by increasing the time between dosing until the patient is comfortable. 64 However, the standard recommended duration of use is 3 to 6 months. Precautions The nicotine lozenge should be used with caution in patients with active peptic ulcer disease or a severe sore throat. 64 Side effects Possible side effects associated with the nicotine lozenge may include heartburn, nausea, mouth or throat irritation, headache, hiccups, and dizziness. 64 Patient instructions The lozenge should be allowed to dissolve in the mouth over 20 to 30 minutes and should not be chewed or swallowed, as this will decrease nicotine delivery and increase the possibility of side effects. The lozenge should not be used within 15 minutes of eating or drinking as the acidic pH of the mouth will interfere with the absorption of the nicotine through the buccal mucosa. 64 a nicotine reservoir, an adhesive layer, and a removable protective liner. Nicotine concentrations from the patch are lower and fluctuate less than those achieved with tobacco products: Plasma nicotine levels obtained via transdermal delivery are approximately 50% lower than those achieved with cigarette smoking. 61 Lower levels of nicotine still alleviate the symptoms of withdrawal but are far less likely to lead to dependence when compared to tobacco or other forms of NRT. Patches are available in three strengths: 21 mg, 14 mg, and 7 mg.
Nicotine gum needs to be used in a very specific manner to be effective and, like chewing gum, should not be swallowed. The gum is available over the counter in both brand-name and generic forms. The package insert describes appropriate use but clinicians should provide brief instructions on use and dosage. The gum is available in two strengths, 2-mg and 4-mg. For individuals who smoke more than 25 cigarettes per day, the 4-mg strength is recommended: In highly-dependent smokers there was a significant benefit of 4-mg gum compared with 2-mg gum. 60 The 2-mg strength is recommended for patients who smoke fewer than 25 cigarettes per day. It may be necessary to increase the dosage from 2-mg to 4-mg in patients whose withdrawal symptoms are not alleviated with the lower dose. When using the 2-mg dose, the total daily use should be limited to no more than 30 pieces a day. When using the 4-mg dose, individuals should limit use to no more than 24 pieces a day. Nicotine from the gum is absorbed through the buccal mucosa. 63 One advantage of the gum is that patients can use the gum as needed in combination with a steady-state nicotine delivery system such as the nicotine patch. 63 Contraindications The use of nicotine gum is contraindicated in patients with temporomandibular joint disease (TMJD) or chronic TMJ pain. 63 Side effects Side effects of nicotine gum may include mouth ulcers, jaw muscle aches, dizziness, headaches, and nausea. 63 The lozenge is available over the counter in both brand- name and generic forms. As with the nicotine gum, the package insert describes appropriate use, but clinicians should provide brief instructions on dosage and use. The dose equivalent of the lozenge delivers approximately 25% more nicotine than the gum. 64 If the patient smokes the first cigarette of the day within 30 minutes of waking up in the morning, the 4-mg lozenge is indicated. If the patient smokes the first cigarette more than 30 minutes after waking, the 2-mg nicotine lozenge is recommended. 64 The recommended regimen for use of the lozenge is one lozenge every 1-2 hours for weeks 1-6 of treatment. Using at least nine lozenges per day will increase the chances of successful cessation. One lozenge every 2-4 hours is recommend for weeks 7-9 of treatment, then one lozenge every 4-8 hours for weeks 10-12. Patients should not use more than five lozenges in a 6-hour time period or more than 20 lozenges per day. If complete abstinence is not achieved at 12 weeks, lozenge use may be extended The primary advantages of the patch include steady-state nicotine levels throughout the day and better compliance compared to other nicotine replacement medications that are used at specified intervals. The patch is available over the counter in both brand-name and generic forms. As with the other forms of nicotine replacements, the package insert describes appropriate use, but clinicians should provide brief instructions on dosage and use. Transdermal nicotine delivery systems consist of an impermeable surface layer, Nicotine lozenge Use and dosage Nicotine transdermal patch Use and dosage
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