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Chapter: Essentials of Psychiatry: Substance Abuse: Nicotine Dependence

Specific Medication and Psychosocial Treatment Interventions - Nicotine Dependence

It should be noted that even brief face-to-face intervention by a physician or other medical staff increase the likelihood of cessa-tion two- to tenfold.

Specific Medication and Psychosocial Treatment Interventions


It should be noted that even brief face-to-face intervention by a physician or other medical staff increase the likelihood of cessa-tion two- to tenfold. There are now numerous effective psychoso-cial and pharmacological approaches that can be used in nicotine dependence treatment. Psychosocial intervention alone, pharma-cotherapy alone, or combined approaches may be used. Given pa-tients’ preferences and current concerns with cost-effectiveness, less costly single-modality interventions are often used initially, whereas more costly multimodal interventions are often reserved for persons for whom cessation attempts have failed. This may not be the wisest strategy, but it is the most common.


Pharmacological interventions have become an important component of treating nicotine dependence. Approaches used par-allel other addictions in treating acute withdrawal (detoxification), protracted withdrawal and even maintenance for harm reduction. The primary medications are NRT and bupropion. All six of these modalities are FDA approved and have demonstrated efficacy.

Nicotine replacement therapy (NRT) is the most widely used medication option and is available over-the-counter (patch and gum) or by prescription (patch, gum, spray and inhaler). The principle behind nicotine replacement is that nicotine is the de-pendence producing constituent of cigarette smoking, and that smoking cessation and abstinence can be achieved by replacing nicotine without the harmful impurities in cigarette smoke. The abuse liability of nicotine replacement appears to be minimal. The substituted nicotine initially prevents significant withdrawal symptoms that may lead to relapse during the early period of smoking cessation. The substituted nicotine is then gradually ta-pered and discontinued.


Nicotine gum was the first NRT approved and it slowly releases nicotine from an ion exchange resin when chewed. The nicotine released is absorbed through the buccal mucous mem-branes. The NRT gum is available in doses of 2 and 4 mg, and the recommended dosing is in the range of nine to 16 pieces per day. Nicotine gum is more effective when used in conjunction with some type of psychosocial intervention, particularly BT. Outcome is more positive when a definite schedule for gum use is prescribed – for example, one piece of gum per hour while awake – than when used on an as-needed basis. (Tapering may be necessary after 4 to 6 months of use, especially for individu-als using higher total daily doses of gum. Nicotine gum is often not effectively utilized in patients with temporomandibular joint problems, dental problems and dentures. Nicotine gum requires a highly motivated patient and a good deal of time in instructing the patient in proper use of the gum. Many individuals find the gum difficult to learn to use properly. Patients must be instructed that nicotine gum is not like bubble gum and that the gum is crunched a few times and “parked” between the gum and cheek. It should not be used soon after drinking acidic substances such as coffee, soda, or orange juice because the acidic environment in the mouth interferes with its release and absorption.


The nicotine patch transdermal delivery system pro-vides continual sustained release of nicotine, which is absorbed through the skin. This form of nicotine replacement more than doubles the 1-year cessation rate (Hughes, 1994). There is a dose–response relationship, with patients receiving higher doses attaining higher cessation rates. The nicotine patch eliminates the conditioning of repeated nicotine use, which remains present with the use of other NRT products. Compliance rates are higher because it involves once-daily dosing and its administration is simple and discreet. The typical starting dose of NRT patch is 21 or 15 mg patch, however, in some cases multiple patches are used. Lower dose patches available at 7 and 14 mg are used to taper after smoking cessation. The patch delivers approximately 0.9 mg of nicotine/hour. Steady-state nicotine levels are 13 to 25 ng/mL and the highest levels are seen soon after patch application. The nicotine patch is often used for a total of 6 to 12 weeks but can be used for much longer (American Psychiatric Association, 1996). The transdermal patch does not allow for self-titrated dosing, craving and nicotine withdrawal symptoms like the other NRT routes (gum, spray, inhaler); however, the nicotine blood levels are significantly less than with smoking. The patch can be used more discreetly and can be used despite dental or temporoman-dibular joint problems.


Although the nicotine patch is well tolerated, about 25% of patients have significant local skin irritation or erythema and 10% discontinue the patch because of intolerable side effects. Other side effects include sleep problems with the 24-hour patches.

Some experts suggest using nicotine gum concurrently with transdermal nicotine on an as-needed basis to cover emer-gent withdrawal symptoms or craving not controlled by replace-ment from the transdermal patch, whereas others suggest simply increasing the dose of the transdermal patch or using gum ini-tially and then switching to the patch (Gourley, 1994; Fagerstrom et al., 1993). Combining transdermal nicotine and nicotine gum increases the potential for significant side effects.


The nicotine nasal spray is rapidly absorbed and produces a higher nicotine blood level than does transdermal nicotine or gum. A single dose of the spray delivers 0.5 mg to each nostril and it can be used one to three times/hour. It has been suggested that the effective daily dose in nicotine dependent smokers is 15 to 20 sprays (8–10 mg).


The nicotine inhaler provides nicotine through a car-tridge that must be “puffed”. It mimics the upper airway stimula-tion experienced with smoking; however, absorption is primarily through the oropharyngeal mucosa. Although the blood level of nicotine is lower than with other forms of nicotine replacement (8–10 ng/mL), the inhaler has been shown to be effective. Side effects of the inhaler and spray include local irritation, cough, headache, nausea, dyspepsia, the need for multiple dosing and the impossibility of discreet use.


Bupropion, the non-nicotine pill FDA-approved medica-tion option, is a heterocyclic, atypical antidepressant that blocks the re-uptake of both dopamine and norepinephrine. Its efficacy as an aid to smoking cessation was first demonstrated in threedouble-blind placebo-controlled trials. Smoking cessation rates appear to improve further when bupropion is combined with the nicotine patch (Nides, 1997).


Combined NRTs/bupropion or serial pharmacotherapeutic approaches may also be beneficial, especially in more difficult to treat cases of nicotine dependence. For example, combining the patch with other nicotine replacement medications like nicotine gum or the spray allows for both more rapid onset of action and reduction of withdrawal symptoms through steady levels of nico-tine released by the patch. Combining nicotine replacement with non-nicotine replacement strategies (e.g., bupropion and nicotine patch) has been beneficial in further improving outcomes in some studies and is common in clinical practice. The combination ap-proach offers the advantage of multiple neurobiological mecha-nisms of action.


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