Smoking Cessation: What to Tell Patients about Over-the-Counter Treatments

Mr. T, age 56, has major depressive disorder that is well controlled with fluoxetine, 40 mg/d. He has smoked [greater than or equal to] 1 packs of cigarettes per day for the last 25 years. On a recent visit, he indicates that he has begun using a 21-mg nicotine patch as advised by his pharmacist and that things are going OK, although he has had some "slip ups." He is on week 7 of his quitting regimen and now is stepping down the patch dosage. Upon further questioning he says that he has been cutting the 21-mg patches in half to save money. Mr. T also explains that occasionally he has given in to a strong urge to smoke because it was "too much to handle." He states that he does not think this is a big deal because he uses electronic cigarettes and has heard that these products don't contain "the bad cancer stuff." At the end of Mr. T's visit, he asks for something to help him sleep because has been unable to sleep consistently and has been having vivid dreams since starting the patch. He also wants to know how to reduce itching from the patch. Approximately 46 million Americans smoke and cigarette smoking accounts for 1 of every 5 deaths in the United States each year. (1) Since the advent of "Stop Smoking" campaigns, bans on smoking in public buildings, over-the-counter (OTC) nicotine replacement products, and Surgeon General recommendations, discussing smoking cessation with patients has become standard practice. Research suggests that treatment to quit smoking should include a combination of pharmacotherapy and counseling, such as cognitive-behavioral strategies, support groups, and quitting hotlines. (2) Pharmacotherapy consists of OTC nicotine replacement therapy (NRT) products and prescription medications. This article briefly highlights how to counsel patients about using OTC NRT products (Table, page 44). (2-5) Visit this article at CurrentPsychiatry.com for a table that highlights prescription smoking cessation agents. [ILLUSTRATION OMITTED] Patches Nicotine replacement patches are best used for maintenance treatment of nicotine cravings. They deliver a fixed amount of nicotine over 24 hours. (3) Patches have a specially formulated transdermal matrix system and should not be cut. Doing so damages the drug delivery system and could lead to drug evaporation from the cut edges. (4) Mr. T's psychiatrist advises him not to cut patches but instead purchase the 14-mg patch because he is at this step of the smoking cessation regimen. Skin irritation caused by adhesive is a common adverse event from nicotine patches. Rotating the location of each patch to a different hairless body area is the best way to prevent or combat skin irritation. If rotating the location of the patch does not relieve irritation, patients can apply a thin layer of an OTC hydrocortisone 1% cream to the affected site 2 to 4 times a day after gently washing the area. (5) Instruct patients to avoid using occlusive dressings over the topical application. Nicotine replacement patches also have been reported to cause vivid dreams and insomnia. (3) These side effects may be caused by nighttime nicotine absorption which might be avoided by switching to a different NRT product or removing the 24-hour patch when going to bed. (4) Combining treatments Many patients experience nicotine cravings while using the nicotine replacement patch. Stressful situations and events can trigger a patient's desire for nicotine and withdrawal symptoms that a patch that delivers a continuous amount of nicotine over 24 hours cannot alleviate. Combining different forms of treatment could combat these symptoms. (2), (3), (5) Combination therapy might consist of using sustained-release bupropion or a nicotine patch with rapid-acting NRT products such as a lozenge, gum, nasal spray, or inhaler. In Mr. T's case, clinicians recommend that he use nicotine polacrilex gum in addition to the patch to quell his cravings. …