Treatment and Dosage Nicotine
smokeddailyseeTable 11.3
. Figure11.1
summarisestheeficacyofthevariousnicotine products,basedonpublishedreportsfromtheliterature,witha6-monthperiodofabsti-
nencefromsmokingbeingthecriterionforsuccess. NRTistheappropriateinstrumentforhelpingthedependentsmokertoachievesmok-
ingcessation.Itseffectivenessisincreased2–3-foldifthesmokerwantstostop.While
Table 11.3
Stepwisescheduleforsmokingcessationwithnicotineproductspatchwithtransdermal releaseof0.9mgh,4mgchewinggum,nasalspraycontaining0.5mgsprayandsublingualtablets
containing2mg Level
Diagnosticcriteria Therapeuticscheduledailydoses
1Mild FTND1–2,5–10cigarettes
day,CO:10–15ppm Medicalconsultationtoeducatethesmoker
abouttheharmfuleffectsofsmokingon healthandabouthisherpersonalsituation
basedonindividualindings,
a
onepieceof chewinggum,asrequired,whentheurgeto
smokeacigaretteisstrong 2Moderate
FTND³3;15cigarettes day;CO:10–20ppm
Initially,upto12piecesofnicotinechewing gumoronenicotinepatch,plusafewpieces
ofnicotinegumonlyintheinitialdaysof treatment;dependinghowtheex-smoker
feels,continuethetreatmentfor2–3weeks, thenreducethedoseasappropriate
3Severe FTND³5;15–25ciga-
rettesday;CO:15–35 ppm
Onenicotinepatchplus6–12piecesofnicotine gum,dependingonurgetosmoke,or
nicotinenasalsprayonesprayintoeach nostrileverytimethereisanurgetosmoke;
notmorethantwoapplicationsh;continue thetreatmentfor3–6weeks,thenreducethe
doseasappropriate;supplytheex-smoker withaproductnicotinechewinggumor
nasalsprayasreliefforcravingorstrong urgetosmokeduringtheensuingmonths
4Verysevere FTND
b
³7;25–40 cigarettesday;CO
c
: 30–45ppm
Onenicotinepatchplus10–12piecesof nicotinechewinggum
d
plusnicotinenasal sprayonesprayintoeachnostrilas
required,untilcravingortheurgetosmoke isrelieved;continuetreatmentfor2–4
weeksandthendiscontinueonenicotine productchewinggum;laterhalvethedose
administeredbypatch,retainthenasalspray torelievecravingforupto6monthsthis
willnotberequiredatallonvariousdays FTNDFagerströmTestforNicotineDependence;COcarbonmonoxideconcentration
[1] .The
levelofdependenceisclassiiedinfourgrades
a
Theseconsultationsarealsocompulsoryathigherdependencelevels
b
AninternalcorrelationbetweentheFTNDandCOvalueshasnotbeenconirmed.Thetwovalues areonlyapproximatelylinkedwitheachother
c
TheCOlevelsmeasuredareinluencedbythetimewhensmokingtookplace.Anintervalof30 minshouldbeobservedbetweenthelastcigaretteandthemeasurementofCO
d
Insteadofthe4mgchewinggum,the2mgsublingualtabletmayalsobeused
patchesaremoreconvenienttousethanchewinggumornasalspray,theyarelesseffective forthereliefofcravingswhencomparedwithnasalspray,inparticular.Althoughonlya
fewstudieshavebeenpublishedonthecombineduseoftwodifferentnicotineformula- tionspatch+chewinggumornasalspray,andchewinggum+nasalsprayorpatch+
inhaler,thesuppressionofcravingsisthecrucialissuewithregardtofailureinmanydis- sonantex-smokersoncesmokingcessationtherapyhasbegun.Medicalmanagementhasa
pivotalroletoplayduringsmokingcessationtherapy [5]
. Ourownexperienceswiththetreatmentofseveralhundredsmokersaresetoutsche-
maticallyinTable 11.3
.Theschedulecannotbedeinedrigidlybecausewhilethelevelof dependencecanbeidentiied–itissoshapedbythepatient’spersonalitystructure,includ-
inghisherownwillpower–thetherapistmustrepeatedlyexpecttheunexpected. Wherethegoaloftherapyistotalsmokingcessation,itisimportanttowarnpatients
emphaticallytostopsmokingcompletelywhiletakingnicotineproducts.Iftheobjective is reduced smoking “harm reduction”, the number of cigarettes smoked should not
exceed10day.Inthiscase,nicotinetherapyshouldbetailoredaccordingly. GenderdifferencesmayplayaroleintheeficacyofNRTs.Thiswasanalysedina
meta-analyticalreviewof90effectsizesobtainedfromasampleof21double-blind,pla- cebo-controlledrandomizedstudies
[55] .ItwasshownthatalthoughNRTwasmoreeffec-
tive for men than placebo at 3-, 6- and 12-month follow-ups, the beneits of NRT for womenwereclearlyevidentonlyatthe3-and6-monthfollow-ups.Also,givingNRTin
conjunction with high-intensity nonpharmacological support was more important for womenthanmen.Itwasconcludedthatlong-termmaintenanceofNRTtreatmentgains
decreasemorerapidlyforwomenthanmen [55]
.