+--------+-----------+---------+-----------+-----------+-----------+
| **VA   |           |         |           |           |           |
| For    |           |         |           |           |           |
| mulary |           |         |           |           |           |
| C      |           |         |           |           |           |
| hoices |           |         |           |           |           |
| for    |           |         |           |           |           |
| Pha    |           |         |           |           |           |
| rmacot |           |         |           |           |           |
| herapy |           |         |           |           |           |
| of     |           |         |           |           |           |
| S      |           |         |           |           |           |
| moking |           |         |           |           |           |
| Cessa  |           |         |           |           |           |
| tion** |           |         |           |           |           |
+--------+-----------+---------+-----------+-----------+-----------+
|        | ***Bup    | ***N    | **        | **        | ***Varen  |
|        | ropion*** | icotine | *Nicotine | *Nicotine | icline*** |
|        |           | Tran    | p         | p         |           |
|        |           | sdermal | olacrilex | olacrilex |           |
|        |           | P       | gum***    | l         |           |
|        |           | atch*** |           | ozenge*** |           |
+--------+-----------+---------+-----------+-----------+-----------+
| *      | Bupropion | Nic     | Nicorette | Commit    | Chantix   |
| *Trade | SR        | oderm/H | Gum       | Lozenge   |           |
| Name   | (Zyban)   | abitrol |           |           | 0.5mg,    |
| and    |           | 21mg/1  | 2mg, 4mg  | 2mg, 4mg  | 1mg       |
| Dose   | 150mg,    | 4mg/7mg |           |           | tablet    |
| av     | 300mg tab |         |           |           |           |
| ailabi |           | Nic     |           |           |           |
| lity** | Bupropion | otrol\* |           |           |           |
|        | IR 100mg  |         |           |           |           |
|        | tab       | 15mg/1  |           |           |           |
|        |           | 0mg/5mg |           |           |           |
+--------+-----------+---------+-----------+-----------+-----------+
| *      | *         | High    | High      | High      | Initial:  |
| *Recom | Bupropion | Depe    | De        | De        | 0.5 mg qd |
| mended | SR        | ndence† | pendence† | pendence† | for days  |
| Reg    | (Zyban)*  |         |           |           | 1- 3,     |
| imen** |           | 21mg x  | 4mg       | 4mg       | then 0.5  |
|        | 150mg qd  | 4-6wks, | q1-2hrs   |           | mg bid    |
|        | x 3d then |         | x6wks,    | Low       | for days  |
|        | 150mg bid | then    |           | D         | 4 -7,     |
|        | (8 hrs    | 14mg x  | then      | ependence | then 1 mg |
|        | apart)    | 2wks,   | q2-4hrs   |           | bid for   |
|        |           |         | x4wks,    | 2mg       | total of  |
|        | patients  | then    |           |           | 12 weeks  |
|        | with      | 7mg x   | then      | -Suck 1   | duration  |
|        | cirrhosis | 2wks    | q4-6hrs   | lozenge   |           |
|        | need      |         | x2wks     | q1-2hrs   | \- Dose   |
|        | adjusted  | Low     |           | x6wks,    | adjust    |
|        | dose:     | Dep     | Low       | then 1    | for       |
|        | 150mg qod | endence | D         | q2-4hrs   | CrCl\<30: |
|        |           |         | ependence | x3wks,    | max dose  |
|        | *         | 14mg x  |           | then 1    | is 0.5mg  |
|        | Bupropion | 6-8wks, | 2mg       | q4-8hrs   | bid;      |
|        | IR*       |         | q1-2hrs   | x3wks     |           |
|        |           | then    | x6wks     |           | ESRD or   |
|        | 100mg qd  | 7mg x   |           | -No more  | HD: 0.5mg |
|        | x3d,      | 2wks    | then      | than 20   | qd.       |
|        |           |         | q2-4hrs   | lozen     |           |
|        | then      |         | x3wks     | ges/24hrs |           |
|        | 100mg tid |         |           | or 5      |           |
|        |           |         | then      | loze      |           |
|        | patients  |         | q4-6hrs   | nges/6hrs |           |
|        | with      |         | x3wks     |           |           |
|        | cirrhosis |         |           |           |           |
|        | need      |         | -No more  |           |           |
|        | adjusted  |         | than 24   |           |           |
|        | dose:     |         | pie       |           |           |
|        | 75mg qd   |         | ces/24hrs |           |           |
+--------+-----------+---------+-----------+-----------+-----------+
| **Ad   | -start    | -       | -Chew     | -Allow    | -Start 1  |
| minist | 1-2 wks   | Usually | slowly    | lozenge   | week      |
| ration | prior to  | worn    | (about 10 | to        | prior to  |
| comm   | quitting  | for     | chews)    | dissolve  | quit date |
| ents** | smoking   | 16 -    | until     | slowly    |           |
|        | (to       | 24hrs   | peppery   | over      | -Take     |
|        | achieve   |         | taste     | 20-30     | drug      |
|        | ste       | -Apply  | then      | minutes   | after     |
|        | ady-state | from    | "park"    | shifting  | eating    |
|        | levels)   | neck to | between   | in mouth  | and with  |
|        |           | waist   | teeth and | occa      | 8 ounces  |
|        | -continue |         | gums till | sionally. | of water  |
|        | treatment | -Rotate | taste     |           |           |
|        | for 7-12  | sites   | di        | -Do not   | \-        |
|        | wks (if   |         | ssipates. | chew or   | Instruct  |
|        | no        | -Takes  | Repeat    | swallow   | patient   |
|        | progress  | 2-3d    | process   | (         | or        |
|        | is made   | for     | on and    | increased | caregiver |
|        | by week   | effect  | off for   | risk of   | to report |
|        | 7,        | after   | 30m       | GI side   | de        |
|        | consider  | appl    | ins/piece | effects)  | pression, |
|        |           | ication |           |           | suicidal  |
|        | disc      | of      | -Has been |           | ideation, |
|        | ontinuing | first   | studied   |           | unusual   |
|        | therapy)  | patch   | in        |           | changes   |
|        |           |         | co        |           | in        |
|        | -if       |         | mbination |           | behavior, |
|        | insomnia, |         | with      |           | or        |
|        | take PM   |         | patch     |           | worsening |
|        | dose in   |         |           |           | of        |
|        | afternoon |         |           |           | pre       |
|        |           |         |           |           | -existing |
|        |           |         |           |           | ps        |
|        |           |         |           |           | ychiatric |
|        |           |         |           |           | illness   |
|        |           |         |           |           |           |
|        |           |         |           |           | \- An     |
|        |           |         |           |           | a         |
|        |           |         |           |           | dditional |
|        |           |         |           |           | 12 wks of |
|        |           |         |           |           | treatment |
|        |           |         |           |           | in        |
|        |           |         |           |           | patients  |
|        |           |         |           |           | who have  |
|        |           |         |           |           | suc       |
|        |           |         |           |           | cessfully |
|        |           |         |           |           | stopped   |
|        |           |         |           |           | smoking   |
|        |           |         |           |           | may       |
|        |           |         |           |           | increase  |
|        |           |         |           |           | the       |
|        |           |         |           |           | l         |
|        |           |         |           |           | ikelihood |
|        |           |         |           |           | of        |
|        |           |         |           |           | long-term |
|        |           |         |           |           | a         |
|        |           |         |           |           | bstinence |
+--------+-----------+---------+-----------+-----------+-----------+
| **     | 10-30%    | 16-30%  | 20-30%    | 15-20%    | 18.5% -   |
| 1-year |           |         |           |           | 23% (12   |
| Abst   | (up to    | (dose   |           |           | wk        |
| inence | 35% when  | depe    |           |           | course)   |
| ra     | combined  | ndent); |           |           | vs 4-10%  |
| tes**‡ | with      |         |           |           | with      |
|        | patch)    | high    |           |           | placebo   |
|        |           | dose    |           |           |           |
|        |           | patch:  |           |           | 43.6%     |
|        |           | 30%     |           |           | (with     |
|        |           |         |           |           | a         |
|        |           |         |           |           | dditional |
|        |           |         |           |           | 12 wk     |
|        |           |         |           |           | course)   |
|        |           |         |           |           | vs 37%    |
|        |           |         |           |           | with      |
|        |           |         |           |           | placebo   |
+--------+-----------+---------+-----------+-----------+-----------+
| **Time | 3 hours   | 4-10hrs | 15-30     | No data   | 3-4 Hours |
| to     |           |         | mins      | on *time* |           |
| Peak   | (         |         |           | to peak   |           |
| blood  | half-life |         |           | conc      |           |
| conc   | = 21 hrs) |         |           | entration |           |
| entrat |           |         |           |           |           |
| ions** |           |         |           |           |           |
+--------+-----------+---------+-----------+-----------+-----------+
| **     | 20%       | 75-90%  | 30%       | 30%       | High;     |
| Absorp |           |         |           |           | virtually |
| tion** |           |         |           |           | c         |
|        |           |         |           |           | ompletely |
|        |           |         |           |           | absorbed  |
+--------+-----------+---------+-----------+-----------+-----------+
| **Adva | (+)       | (+)best | (+) helps | (+)easy   | (+)       |
| ntages | better    | adh     | prevent   | to use;   | better    |
| (+)    | co        | erence; | sudden    | discreet; | co        |
| and**  | mpliance; | easy to | urges;    | higher    | mpliance; |
|        | ease of   | use;    | can       | immediate | ease of   |
| **D    | use; can  | con     | titrate   | levels;   | use;      |
| isadva | be        | sistent | to adjust | can       | c         |
| ntages | combined  | rate of | for       | titrate   | onsistent |
| (-)**  | with      | ex      | cravings; | to adjust | rate of   |
|        | patch;    | posure; | oral      | for       | exposure; |
|        | c         | unob    | s         | cravings; | superior  |
|        | onsistent | trusive | ubstitute | reduces   | rate of   |
|        | rate of   |         | for       | self      | a         |
|        | exposure; | (-)less | c         | -reported | bstinence |
|        | helps     | ef      | igarettes | w         | compared  |
|        | with      | fective |           | ithdrawal | to        |
|        | w         | for     | (-)       | symptoms  | bupropion |
|        | ithdrawal | cr      | difficult |           | and       |
|        | symptoms  | avings; | for those | (-)must   | placebo   |
|        |           | di      | with poor | abstain   |           |
|        | (-) many  | fficult | dentition | from      | (-)       |
|        | drug      | to      | or        | drinki    | potential |
|        | int       | control | dentures; | ng/eating | for       |
|        | eractions | tit     | must      | during    | serious   |
|        | due to    | ration; | learn     | lozenge   | n         |
|        | m         | abs     | proper    | use       | eurologic |
|        | etabolism | orption | chewing   |           | and       |
|        | by        | in      | t         |           | ps        |
|        | CYP2B6;   | creased | echnique; |           | ychiatric |
|        | CNS side  | at      | must      |           | side      |
|        | effects;  | e       | abstain   |           | effects   |
|        | must be   | levated | from      |           | par       |
|        | adjusted  | tempe   | drinki    |           | ticularly |
|        | for       | ratures | ng/eating |           | in those  |
|        | hepatic   |         | during    |           | with      |
|        | insuf     |         | gum use   |           | u         |
|        | ficiency; |         |           |           | nderlying |
|        | increased |         |           |           | ps        |
|        | risk of   |         |           |           | ychiatric |
|        | seizures  |         |           |           | disease;  |
|        |           |         |           |           | dose      |
|        |           |         |           |           | adjust    |
|        |           |         |           |           | for renal |
|        |           |         |           |           | insuf     |
|        |           |         |           |           | (CrCl     |
|        |           |         |           |           | \<30);    |
|        |           |         |           |           | high      |
|        |           |         |           |           | incidence |
|        |           |         |           |           | of        |
|        |           |         |           |           | nausea;   |
|        |           |         |           |           | not       |
|        |           |         |           |           | studied   |
|        |           |         |           |           | in those  |
|        |           |         |           |           | with      |
|        |           |         |           |           | u         |
|        |           |         |           |           | nderlying |
|        |           |         |           |           | mental    |
|        |           |         |           |           | illness   |
+--------+-----------+---------+-----------+-----------+-----------+
| **A    | -anxiety  | -sleep  | -local    | -local    | -dream    |
| dverse |           | distu   | mouth     | mouth     | disorders |
| Eff    | -         | rbances | i         | i         |           |
| ects** | disturbed |         | rritation | rritation | \-        |
|        | conc      | -local  |           | /tingling | headache  |
|        | entration | skin    | -jaw pain |           |           |
|        |           | irr     |           | -h        | \-        |
|        | -         | itation | -hiccups  | eartburn, | insomnia  |
|        | dizziness |         |           | ind       |           |
|        |           | -bone   | -         | igestion, | -abnormal |
|        | -insomnia | pain    | dyspepsia | nausea    | behavior  |
|        |           |         |           | (if       |           |
|        | -con      | -h      | -rhinitis | chewed)   | -         |
|        | stipation | eadache |           |           | agitation |
|        |           |         | -nausea   | -headache |           |
|        | -dry      | -nausea |           |           | -         |
|        | mouth     |         |           | -nausea,  | depressed |
|        |           |         |           | diarrhea  | mood      |
|        | -nausea   |         |           |           |           |
|        |           |         |           | -f        | \-        |
|        | -seizures |         |           | latulence | suicidal  |
|        | (risk     |         |           |           | thoughts  |
|        | 1:1000)   |         |           |           |           |
|        |           |         |           |           | -con      |
|        |           |         |           |           | stipation |
|        |           |         |           |           |           |
|        |           |         |           |           | -f        |
|        |           |         |           |           | latulence |
|        |           |         |           |           |           |
|        |           |         |           |           | -nausea   |
|        |           |         |           |           | and       |
|        |           |         |           |           | vomiting  |
|        |           |         |           |           |           |
|        |           |         |           |           | -Consider |
|        |           |         |           |           | dose      |
|        |           |         |           |           | reduction |
|        |           |         |           |           | in        |
|        |           |         |           |           | patients  |
|        |           |         |           |           | sensitive |
|        |           |         |           |           | to        |
|        |           |         |           |           | adverse   |
|        |           |         |           |           | effects   |
|        |           |         |           |           | (eg,      |
|        |           |         |           |           | nausea,   |
|        |           |         |           |           | headache, |
|        |           |         |           |           | insomnia) |
+--------+-----------+---------+-----------+-----------+-----------+
| **VA   | None      | None    | None      | Yes -     | Yes --    |
| Na     |           |         |           | r         | Must meet |
| tional |           |         |           | estricted | criteria  |
| For    |           |         |           | to        | for use.  |
| mulary |           |         |           | patients  | Available |
| Re     |           |         |           | who       | at        |
| strict |           |         |           | cannot    | [         |
| ions** |           |         |           | tolerate  | http://ww |
|        |           |         |           | gum (i.e. | w.pbm.va. |
|        |           |         |           | dentures, | gov/guide |
|        |           |         |           | missing   | lines/Var |
|        |           |         |           | teeth,    | enicline% |
|        |           |         |           | TMJ, s/p  | 20Prelimi |
|        |           |         |           | head and  | nary%20Pr |
|        |           |         |           | neck      | escribing |
|        |           |         |           | surgery)  | %20Guidan |
|        |           |         |           |           | ce.doc](h |
|        |           |         |           |           | ttp://www |
|        |           |         |           |           | .pbm.va.g |
|        |           |         |           |           | ov/guidel |
|        |           |         |           |           | ines/Vare |
|        |           |         |           |           | nicline P |
|        |           |         |           |           | reliminar |
|        |           |         |           |           | y Prescri |
|        |           |         |           |           | bing Guid |
|        |           |         |           |           | ance.doc) |
|        |           |         |           |           |           |
|        |           |         |           |           | \-        |
|        |           |         |           |           | Available |
|        |           |         |           |           | to        |
|        |           |         |           |           | patients  |
|        |           |         |           |           | without   |
|        |           |         |           |           | active    |
|        |           |         |           |           | mental    |
|        |           |         |           |           | health    |
|        |           |         |           |           | disorders |
|        |           |         |           |           | or with   |
|        |           |         |           |           | c         |
|        |           |         |           |           | linically |
|        |           |         |           |           | stable    |
|        |           |         |           |           | mental    |
|        |           |         |           |           | health    |
|        |           |         |           |           | disorders |
|        |           |         |           |           | who have  |
|        |           |         |           |           | had \>1   |
|        |           |         |           |           | relapse   |
|        |           |         |           |           | on NRT or |
|        |           |         |           |           | bupropion |
+--------+-----------+---------+-----------+-----------+-----------+
| **VA   | SR:       | All     | 2mg gum:  | 2mg or    | 0.5mg and |
| Cost║  |           | str     |           | 4mg       | 1mg       |
| and    | \         | engths: | \         | lozenge:  | tablets:  |
| A      | $0.48/tab |         | $12.62/50 |           |           |
| verage |           | \$35.07 | pieces    | \         | \         |
| cost   | \         | /       |           | $29.45/72 | $1.17/tab |
| per    | $0.96/day | 14      | \$        | lozenges  |           |
| day    |           | patches | 20.12/110 |           | \         |
| based  | IR:       |         | pieces    | \$0.4     | $2.34/day |
| on     |           | \$2.5   |           | 1/lozenge |           |
| above  | \         | 0/patch | \$0.1     |           |           |
| re     | $0.28/tab |         | 8-\$0.25/ | avg       |           |
| gimens |           | avg     | piece     | \$        |           |
| (      | \         | \$2     |           | 5-\$8/day |           |
| avg)** | $0.84/day | .50/day | avg       |           |           |
|        |           |         | \$2.2     |           |           |
|        |           |         | 0-\$6/day |           |           |
|        |           |         |           |           |           |
|        |           |         | 4mg gum   |           |           |
|        |           |         |           |           |           |
|        |           |         | \         |           |           |
|        |           |         | $13.70/50 |           |           |
|        |           |         | pieces    |           |           |
|        |           |         |           |           |           |
|        |           |         | \$        |           |           |
|        |           |         | 25.69/110 |           |           |
|        |           |         | pieces    |           |           |
|        |           |         |           |           |           |
|        |           |         | \         |           |           |
|        |           |         | $0.23-\$0 |           |           |
|        |           |         | .27/piece |           |           |
|        |           |         |           |           |           |
|        |           |         | avg       |           |           |
|        |           |         | \$2-\     |           |           |
|        |           |         | $6.50/day |           |           |
+--------+-----------+---------+-----------+-----------+-----------+
| **Co   | ***Con    | ***R    |           |           | **        |
| ntrain | traindica | elative |           |           | *Relative |
| dicati | tions:*** | Contrai |           |           | Con       |
| ons/Re |           | ndicati |           |           | traindica |
| lative | -history  | ons:*** |           |           | tions:*** |
| C      | of        |         |           |           |           |
| ontrai | seizures  | -Hy     |           |           | \-        |
| ndicat |           | persens |           |           | patients  |
| ions** | -predi    | itivity |           |           | with      |
|        | sposition |         |           |           | serious   |
|        | to        | -Pre    |           |           | neurops   |
|        | seizures  | gnancy: |           |           | ychiatric |
|        | (i.e.     | C       |           |           | disorders |
|        | severe    | ategory |           |           | (         |
|        | head      | D       |           |           | including |
|        | trauma,   |         |           |           | suicidal  |
|        | CNS       | -Use    |           |           | and       |
|        | tumor,    | within  |           |           | homicidal |
|        | hepatic   | 14 days |           |           | ideation) |
|        | c         | post    |           |           |           |
|        | irrhosis) | MI, or  |           |           | \-        |
|        |           | serious |           |           | patients  |
|        | -abrupt   | or      |           |           | with a    |
|        | w         | wo      |           |           | history   |
|        | ithdrawal | rsening |           |           | of        |
|        | from      | angina  |           |           | suicidal, |
|        | heavy,    |         |           |           | h         |
|        | daily     | -P      |           |           | omicidal, |
|        | alcohol   | atients |           |           | or        |
|        | or other  | should  |           |           | a         |
|        | sedative  | be      |           |           | ssaultive |
|        |           | advised |           |           | behavior  |
|        | -MAO      | not to  |           |           | in the    |
|        | inhibitor | smoke   |           |           | past 12   |
|        | within 14 | while   |           |           | weeks     |
|        | days      | on      |           |           |           |
|        |           | n       |           |           | -patients |
|        | -bulimia, | icotine |           |           | with an   |
|        | anorexia  | repl    |           |           | untreated |
|        | nervosa   | acement |           |           | or        |
|        |           | therapy |           |           | unstable  |
|        | **        |         |           |           | mental    |
|        | *Relative |         |           |           | disorder  |
|        | Con       |         |           |           | such as   |
|        | traindica |         |           |           | psychotic |
|        | tions:*** |         |           |           | disorder, |
|        |           |         |           |           | bipolar   |
|        | -hypers   |         |           |           | disorder, |
|        | ensitvity |         |           |           | major     |
|        |           |         |           |           | d         |
|        | -p        |         |           |           | epressive |
|        | regnancy: |         |           |           | disorder, |
|        | category  |         |           |           | and PTSD  |
|        | B         |         |           |           |           |
|        |           |         |           |           | \- severe |
|        |           |         |           |           | renal     |
|        |           |         |           |           | i         |
|        |           |         |           |           | mpairment |
|        |           |         |           |           |           |
|        |           |         |           |           | \-        |
|        |           |         |           |           | Pregnancy |
|        |           |         |           |           | category  |
|        |           |         |           |           | C         |
+--------+-----------+---------+-----------+-----------+-----------+

\*remove Nicotrol patch at bedtime

†In general, greater than 20 cigarettes per day or use of first
cigarette within 30 minutes of awakening is considered high dependence

‡all NRTs have been shown to double 6-12month abstinence rates compared
to placebo

║ cost based on FSS or BIG4 pricing as listed on PBM website
(<http://www.pbm.va.gov/PBM/prices.htm>)

**Note:** Two additional prescription products, a nicotine inhaler and
nicotine nasal spray, are also FDA approved for nicotine replacement
therapy however these products are not available on the VA National
Formulary. For more information on these products, visit the American
Lung Association Smoking Cessation Support website at:
<http://www.lungusa.org/site/pp.asp?c=dvLUK9O0E&b=33566>