Hi, I'm Jessie, Clinical Pharmacy Specialist
at the St. Cloud VA Health Care System
Welcome to Class 2, "Medications Can Help,"
and thanks for taking the time to consider this topic.
There are many different types of medications
that can be helpful in the effort to quit tobacco.
In this class we will cover:
Types of tobacco cessation medications
Nicotine Replacement Medications
Bupropion • Varenicline
Medications affected by smoking
and E-Cigarettes
As was mentioned, there are a variety of medications
that can assist with quitting tobacco use.
Nicotine is typically eliminated from the body
within two weeks of stopping use.
We use medications to make it easier for you
to deal with the behavioral change
and not have to worry about the physical addiction.
This is why you will see that therapy is recommended
for a few months rather than only two weeks.
Some of these medications used in tobacco cessation
provide small doses of nicotine to help you
reduce the nicotine level in your body.
These types of medications are called
nicotine replacement medications.
They reduce your cravings for nicotine and
help reduce the withdrawal symptoms
that accompany the process of quitting.
Nicotine replacement medications include
the nicotine patch, lozenge, and gum.
We will discuss how these work later in class.
In addition, there are two medications
that do not contain nicotine, Bupropion and Varenicline.
These can help you have fewer cravings for nicotine.
Some of these medications can be used together
to help you stop tobacco use.
Studies show that these combinations are effective
and can work better than one medication alone.
The combinations include the nicotine patch
in combination with either the nicotine gum or lozenge
and bupropion in combination with
the nicotine patch, nicotine gum or lozenge.
Varenicline is not used in combination
with any other medications for quitting tobacco.
So you may be wondering, "What works best?"
when it comes to quitting tobacco.
At this time, it appears that combination therapy works best.
This involves using one or more of the medications,
along with behavioral strategies,
for the highest success rates.
You will be learning numerous behavioral strategies throughout
these classes and you can add those strategies
to medications to increase your quitting success.
The medications chosen will be based on your discussion
with your medical provider and determined
by your medical history and preference.
All the medications we will discuss can help
to increase your chances of quitting for good
and are available through the VA.
You can contact your tobacco cessation team,
primary care provider, or mental health provider
if you are interested in using medications
to help you quit tobacco.
Let's talk some more about
nicotine replacement medications.
First, let's review the patch.
The patch provides steady nicotine to your body
but not at a level to cause addiction.
It's job is to make you feel more comfortable
during the process of quitting, so you can focus on
changing habits and behaviors.
It works as a step down process to slowly reduce your body's
need for nicotine as you develop those new behaviors.
The patch delivers nicotine into the body through the skin.
It is typically applied to the skin on the upper arm,
upper chest, or upper back.
The patch is placed down firmly
so that it will stick to your skin.
It's best not to use lotion on your skin
before using the patch.
If your skin tends to be oily, you may want to first use
rubbing alcohol to clean the area.
Then when the skin is dry you can apply the patch.
You may be wondering how much of this medication to use.
If you smoke 10 cigarettes or more a day,
you would begin with a 21 mg patch daily for 4-6 weeks;
then you would step down to a 14 mg patch for about 2 weeks
and finally a 7 mg patch for 2 weeks.
If you smoke less than 10 cigarettes a day,
you would begin with a 14 mg patch daily for 6-8 weeks
and then step down to a 7 mg patch daily for 2 weeks.
People often ask if they can still smoke
when using the nicotine patch.
You should try to stop smoking when wearing the patch.
If you slip and smoke a few cigarettes,
continue to use the nicotine patch.
It helps to use the nicotine gum or lozenge for cravings
rather than smoking.
Other strategies may help you with cravings such as
chewing gum, eating carrot sticks, deep breathing,
going for a walk, or drinking water.
But we'll focus more on these types of behavioral strategies
in our upcoming classes.
If you do have a relapse and you are back
to your original smoking habit,
it is typically best to stop using the nicotine patch
and contact the person who prescribed the patch.
They can discuss the best steps for setting another quit day and
restarting the patch when you are ready to quit completely.
As you think about this option,
it's important to review the possible side effects.
The patch can cause itching or rash in the area
where it is applied.
If that occurs you could put the patch on a different area
of skin each day.
Some people experience nausea or dizziness
if the dose is too high and this should be discussed
with your tobacco cessation team.
Another possible side effect is difficulties with
sleep or nightmares.
If this happens it may help to remove the patch before
you go to sleep and place a new patch upon waking.
The patch is a good option to use
when you need a gradual decrease in nicotine levels in your body,
however it is not good during situations where you
utilize behavioral strategies already
and you still have cravings and urges.
This is where the nicotine lozenges or gum comes in
and helps with those additional behavioral triggers
as well as nicotine withdrawal symptoms you may experience.
If you choose to use nicotine gum or lozenge,
nicotine is delivered to the body
through the lining of your mouth,
similar to the area where chewing tobacco is placed.
So the question is how much do we use?
When using these products by themselves
the recommendations are as follows:
If you smoke your first cigarette with 30 minutes
of waking, use the 4 mg strength of the gum or lozenge.
It is recommended to use these medications every 1-2 hours
and at least 10 times a day when first initiating.
From there it would be recommended
to try and decrease the number of times
you are using the gum or lozenge each week.
For example use 10 pieces of gum or lozenges daily
for the first week, use it 9 time daily the second week,
8 times daily the third week and so on.
The goal would be to taper off within 3-4 months of use.
If you are smoking less than one pack a day you would start with
the 2 mg gum or lozenge and follow the same schedule we just
reviewed, however using the 2 mg dose instead of the 4mg dose.
As noted above, a combination of two medications
may be more effective than one medication alone.
If you are using the nicotine gum or lozenge in combination
with nicotine patches or Bupropion,
you should follow the following guidelines.
• Use the 2 mg gum or lozenge when you have a craving for
tobacco or at a time you know you will have a strong craving.
Often these types of cravings occur in the morning
so you should use the gum or lozenge right when you wake.
• Try to use no more than 6-10 pieces a day
when you are using the nicotine gum or lozenge
in combination with the nicotine patch.
The longer you've been off tobacco,
the less you need the breakthrough gum or lozenge.
You can also begin using substitutes like sugar-free gum,
mints, or candy between doses of nicotine gum or lozenge.
• It is important to note that when your nicotine patch is
titrated down to the next dose, it is possible that your use of
the nicotine gum or lozenge may increase as the background
nicotine dose from your patch is decreased.
If this occurs, slowly taper down on the gum or lozenge
thereafter as you are able.
Using the gum or lozenge involves
some specific strategies to remember.
The first thing to remember is that you don't chew nicotine gum
like you would regular gum.
Instead you use the "bite and park" method.
This means you place a piece of gum in your mouth and bite it
two or three times until you get a peppery taste
or feel a tingling sensation.
Then you park the gum in the inside of your cheek
and leave it there until you no longer have
that peppery taste or tingling.
Then repeat the bite-and-park method several times
until there is no longer any peppery taste to the gum.
At this time you would throw the gum out.
Remember I said you should avoid using nicotine gum
like you would use chewing gum.
The reason for this is that if you use it like chewing gum,
it will not allow the nicotine to be absorbed
through the lining of your mouth.
You will swallow the nicotine, which may cause you
to feel sick to your stomach and have heartburn.
In addition, your nicotine craving will not go away since
the nicotine will not be absorbed from your stomach.
It's also important to not combine chewing gum
with nicotine gum since this will reduce the absorption
of the nicotine.
Similarly, when using the lozenge you simply place it
in your mouth and put it in the inside of your cheek
and leave it there.
You may rotate the place in your cheek where you put the lozenge
in order to reduce irritation in your mouth.
It's important to not chew or bite the lozenge.
It must dissolve completely
to release the entire dose of the nicotine.
With both the nicotine gum and the nicotine lozenge, it is important
that you do not eat or drink for 15 minutes before, while using
and for 15 minutes after using the products.
It's important to avoid acidic beverages like coffee,
juices, soda, and alcohol
during these times since this will reduce the absorption
of the nicotine from the gum or the lozenge.
There are a couple of possible side effects
from the nicotine gum.
These include irritation of the mouth and
nausea and heartburn if the gum is chewed quickly
or the lozenge is chewed or swallowed
We've just reviewed the nicotine replacement medications,
now I'd like to review some other medications
that can aide in tobacco cessation.
Bupropion is a medication that reduces nicotine cravings
by increasing the dopamine in the brain.
Dopamine is involved in the addiction to nicotine.
Remember, Bupropion does not include nicotine so you may
still have some nicotine withdrawal symptoms.
Bupropion is also an antidepressant,
which can be beneficial for some people who use tobacco
and have a history of depression.
Your medical provider will specify the correct dosage
but here are some things to consider.
First, Bupropion is a tablet that is swallowed whole.
So do not crush or break the tablet
unless instructed to do so by your provider.
This medication is started about 7-14 days before your quit date
so it's important to set your quit date about a week
or so after you start taking Bupropion.
This medication is typically taken for 8-12 weeks
but can be used longer if needed.
I'd like to wrap up this section by talking about
who should not use Bupropion and possible side effects.
Let's start with who should not use Bupropion.
Bupropion can increase your risk of seizures so individuals
should avoid this medication if they have a history of seizures,
a current eating disorder, or if they are drinking
more than two servings of alcohol a day.
In addition, if you are taking medications for depression,
bipolar disorder or other mental health disorder,
you should discuss this with your medical provider
whether Bupropion will work with your current medications.
Possible side effects of Bupropion include
difficulty sleeping, nervousness, and dry mouth,
and less commonly rash and swelling.
Some people can experience mood changes, depression,
or suicidal or homicidal thoughts.
If you experience any of these types of mood changes
or thoughts contact your doctor immediately.
If you are in crisis,
call 1-800-273-TALK or (1-800-273-8255)
and press 1 to talk with someone immediately.
You may also seek help online at
www.veteranscrisisline .net
One additional medication we'll cover today is
Varenicline or Chantix®.
Varenicline works by blocking the receptor in the brain
where nicotine binds.
This blocks the effect of nicotine when you smoke
or chew tobacco.
This medication also acts like a weak form of nicotine,
which can help reduce nicotine withdrawal symptoms.
Varenicline is not used in combination with
nicotine replacement medications
because it blocks the nicotine receptors,
making the nicotine replacement medication less effective.
Varenicline is a tablet which can be split if necessary and
your medical provider will specify the correct dosage.
It is important to always take Varenicline
with a full glass of water and with food
to decrease the risk of an upset stomach and vomiting.
This medication is started 7-14 days before your quit date
so it's important to set your quit date
about a week or so after you start taking it.
This medication is typically taken for 12 weeks but can be
used for an additional 12 weeks if you have successfully quit
tobacco and feel you need longer use of the medication.
Your provider will assist you with this as you move forward.
With this medication we also need to review who should not
take it and what the possible side effects may be.
Please consult with your doctor about taking Varenicline if you
have a history of depression, bipolar disorder, PTSD or other
mental health disorder since it may not be safe for you.
If you have had a history of suicidal or homicidal thoughts
or acts in the past 12 months,
Varenicline would not be appropriate for you.
Common side effects of Varenicline include
upset stomach, nausea, vomiting, headache,
difficulty sleeping and dream disturbances.
Some individuals experience depression, anger, irritability,
suicidal thoughts or homicidal thoughts.
If any of these side effects happen after starting
Varenicline, stop taking it and contact your medical provider
or go to the ER.
Again, remember if you are in a crisis,
call 1-800-273-TALK or 1-800-273-8255
and press 1 to talk speak with someone immediately.
You may also seek assistance online at
www.veteranscrisisline.net
We have discussed a number of options for medications
that can assist you in your efforts to quit tobacco.
As you consider your options with tobacco cessation
medications, it is also important to know that
your current tobacco habit can affect some of the medications
you may be taking for other health conditions.
Tobacco smoke affects how some medications are used
and removed from your body.
This means there may be lower amounts of medicine in your body
when you are smoking so they might not work as well.
As a result, your doctor may need to increase
the dosage of certain medications.
However, just the opposite could be the case
as well when you stop using tobacco.
This may also result in a need for an adjustment
in your dosage.
The best plan is to talk with your medical provider
about any side effects you may experience
from your medications after you quit smoking.
Some types of medications that can be affected by smoking
include antidepressants,
anti-anxiety medications, antipsychotic medications,
blood thinners such as Warfarin,
high blood pressure medications,
and medications for heart rhythm problems.
Caffeine is also removed from your body faster
when you smoke so you might need less caffeinated coffee
or other beverages after you quit.
Typically it is good to reduce your caffeine intake
by half when you quit tobacco.
There is one more topic that is important to discuss
when planning to quit tobacco.
Some people look at using e-cigarettes as an option and
think this may be a good way to get rid of their smoking habit.
E-cigarettes have health risks as well
and I'd like to review a few of them.
An e-cigarette or electronic cigarette uses a metal tube
with an atomizer and a cartridge of liquid nicotine.
When the user inhales, the atomizer converts
liquid nicotine into a vapor that is inhaled.
There are concerns about this delivery system.
Nicotine concentration can vary by brand and the e-cigarettes
are not regulated E-cigarettes expose users to harmful
chemicals other than nicotine including many of the same
toxic carcinogenic compounds found in regular cigarettes.
The nicotine goes right into the lungs
through an inhaler that is absorbed in the oral membrane.
One question stands out,
"Do electronic cigarettes help people quit smoking?"
Research studies have not shown an improvement
in cessation rates.
Other studies show that there is a potential for increase
in nicotine addiction and cigarette use in adolescents.
There is a lack of safety information available
to know the long term risks with E-cigarette use.
The best advice is to quit for good.
We have covered a lot of information in this class and
I'm sure you have a great deal to think about.
At the VA, we are committed to your success
in your efforts to quit using tobacco.
Your facility has clinicians on your tobacco cessation team
that can help you with your individual medication needs.
Please feel free to contact a member of your health care team
via Secure Messaging or telephone to ask your questions
and find the support you need.