Nicotine replacement therapy

Nicotine Relacement Therapy

Perhaps better named nicotine reduction therapy, this can offer great support for those patients who want to give up smoking, but who have difficulty making it through the first three difficult months.

The principle of nicotine patches is to gradually wean the patient off nicotine, by receiving smaller doses of it through the skin over a period of 10- 12 weeks. Compared with smoking, the quantity of nicotine the patient receives is dramatically reduced, even with the largest and strongest patches. Although the patient receives none of the "high" that he would get from a cigarette, the patch takes the edge off the worst of the craving for nicotine.

Nicorette gum has been availabe for some time and is still useful for moments of stress, but the patches act as a constant low level background.There are now three patches on the market: Nicotinell (Geigy Pharmaceuticals), Nicorette (Kabi Pharmacia), and Nicabate (marion Merrell Dow). The prices are similar, and the cost per day roughly compares to the price of a packet of 20 cigarettes, at an average of a little over £2.00. The patches may be bought over the counter, or on a private prescription in a 28 day pack or, if the patient prefers, a seven day pack. Nicabate is also available in a 14 day pack.

The main difference between them is the time the patient wears them. There is a 24 hour patch, which the patient leaves on all the time, and a 16 hour or "daytime" patch.

Currently, Micabate is prescribable on the NHS, as it has yet to be blacklisted. This is a loophole which I currently exploit to prescribe the product for my patients, but which I am sure will be corrected in the next few months.

The first patch to be released was Nicotinell, from Geigy Pharmaceuticals, which appeared last June. This involves a 12 week course of treatment which comes in three strengths: Nicotinell TTS 30, which delivers 21 mg of nicotine through the skin over 24 hours, Nicotinell TTS 20, which delivers 14 mg, and Nicotinell TTS 10, which delivers 7mg. (The 30 20 and 10 refer to the size of the surface area of the patch in mm). Each strength of patch should be worn for four weeks and changed every day.

Nicabate, from Marion Merrell Dow, is also a 24 hour patch, but has a 10 week programme. In this case, the quantity of nicotine is reflected in the name of the patch: 21 mg for six weeks, 14 mg for two weeks and 7 mg for two weeks.

Nicorette patches (Kabi Pharmacia) work on a 16 hour cycle. Again, there are three pathces which the wearer keeps on during the hours when he is awake. There are three strengths: 15 mg of nicotine worn for a period of eight weeks, 10 mg for two weeks and 5 mg for two weeks.

Side Effects
Side effects have been reported with 24 hour patches in about 7% of users, particularly skin irritation, sleep disturbance, insomnia, vivid dreams and even nightmares. However, these effects are generally transient. It is worth noting that some of these effects may be experienced when a smoker quits, even without nicotine replacement, and, if the patient persists, they tend to disapper after about 10 days. Having had this explained, most patients accept the short term discomfort for the long term gain.

If side effects prove to be a problem, there are various solutions. Skin irritation can be reduced if the patch is moved to a different site each day. If sleep disturbance continues, the patient may well be advised to try a 16 hour patch. The Nicorette patch is sold on the benefit that the patient is not absorbing nicotine whilst asleep, when he would not normally take in nicotine anyway. This has been shown to reduce the risk of insomnia and sleep disturbance, and fewer skin allergies have also been noted. However, the break from nicotine overnight means that the patient may wake in the morning with a craving for a cigarette, and it will take between one and two hours for the fresh patch to take effect. However, overall, trials have shown that both types have much the same success rates (Fagerstrom et al, 1991). As I have had more experience with the first patch, Nicotinell, I tend to recommend starting on a 24 hour patch and, if patients experience side effects, transfer them to a 16 hour patch.

The patch should be placed on a dry, hairless part of the skin, for example the outer aspect of the arm, the chest or the hip. As the adhesive is pressure sensitive, the patient should hold the patch firmly in place and count to 10. It should then be possible for the wearer to swim, bath or shower with the patch in place. Nicotine will be absorbed continuously throughout the night and the next day, until the evening, when the patch should be removed and replaced with new one.

The principle of the patches is, in essence, very simple, and they can be tailored to fit the requirements of every kind of patient, although the manufacturers do not recommend this. It is therefore up to the individual practitioner to explain the pathces action to the patient and take responsibility for the decision to adjust the dose.

Pregnancy
Although the patches are contraindicated in pregnancy or when breastfeeding, I have taken the responsibility upon my own shoulders to prescribe them for women who wish to use them and who appreciate the situation. Scientifically, it is safer for them to wear a nicotine patch than to smoke, as the nicotine dose is much lower, and they do not receive tar or carbon monoxide associated with smoking. The same would also apply to patients with angina or advanced heart disease.

With experience, it's possible to juggle the patches according to the patient's requirements; indeed it is essential to discuss patients' smoking habits before they start. Someone on 10 cigarettes a day or less, should start on the 14mg second patch, as the 21 mg size is for heavier smokers. However, if they are very heavy smokers, it may be that they should wear two patches, one of 14mg and one of 21mg, or even two 21 mg patches, and gradually scale the dose down, although the manufacturers recommend the use of one patch only per day.

Patches may also be cut up if, for example, the patient's requirements falls between two sizes of patch. Similarly, a 24 hour patch may be taken off at night and used for a second day. In this way, patients can remain in control of their own therapy and, in consultation with their health professional, can titrate the dose he needs

Nicotine Gum
Nicorette gum is available in two strenghts over the counter and can be a great help to patients at times of great stress and extra craving. Again, despite the manufacturer's recommendations, the gum can be used safely in conjunction with the patches. As the patches keep a continuous low plateau of nicotine present in the blood, the smoker may feel the need for the instant high from a cigarette at a moment of anxiety or stress, and, although it does not work as quickly as a cigarette, the gum can boost nicotine levels in the short term. This is covered by a paper by Fagerstrom and colleagues which is to be published shortly on the effects of combining nicotine patches and gum. ("Nicotine replacement in smoking withdrawal: effectiveness of individual versus combined treatments", Psychopharmacology).

Weight gain is far less than with any other form of smoking cessation, as the continuous low dose of nicotine suppresses appetite and increases the metabolic rate. A three month trial showed that wearers of an active pathch gained 0.2 lb in weight (3.5 oz) compared with a weight gain of 9.7 lb using a placebo patch. A relapse study, using Nicotinell, showed that the success rate after a year was twice that of using a placebo patch, and this was maintained after two years. A 12 month abstinence is achieved by about 35 per cent for people on active pathces, and only half that for those using a placebo. Nicotine gum has a similar long term effect, but the patient requires far more follow up and encouragement than when using patches.

There have been no reports of addiction to nicotine patches. The addictive nature of cigarettes is due to the speed with which nicotine reaches the brain within seven seconds (an IV injection takes 14 seconds), and the instant high that this gives. As the highs are eliminated along with the lows, patches have not been shown to cause addiction, and I have also used them successfully to wean certain patients off their addiction to nicotine gum.

All the patch programmes come with full and thorough information packs and help for the smoker trying to quit. Nicorette offers a "Fresh Start" pack which includes guides for practice nurses, posters, leaflets, a relaxation audio cassettes, smoking diary stickers and a recorded telephone advice line.

The Nicabate Quit Smoking programme is designed to be used either by the patient alone, or as a supplement to the practice programme. Each new user receives an enrolment card, a freephone number, and a support pack including a cassette, wallchart and booklets is sent by post in 24 hours.

Nicotinell comes with a support pack including a booklet of tips, and emergency card for dealing with "moments of temptation", a 12 week calendar, and details of a telephone help line, manned by trained counsellors.

Although patches are available over the counter, patients trying to give up smoking are more likely to succeed if they are given help and encouragement by health professionals. There is an important role for the practice nurse in explaining the action of patches, counselling and advising patients, and following them up.

Practice nurses are seen by patients generally as much more amenable and approachable than GPs, and they have a very powerful and important role to play in helping patients to stop smoking. Given proper training in smoking cessation, they tend to be better at it than GPs.

Break the Habit
Success at helping patients give up smoking depends on a three point plan:
* Choose your patients correctly: if they are not motivated, forget it.
* Use nicotine reduction therapy: it doubles the success rate.
* Follow uo patients properly.
When you have found a motivated patient, get him to commit himself to a day when he will give up. This should be entered into the notes as Quit Day or Q Day. This committment, in writing, is very important to the patient's resolve. Then, on the evening before Q Day, having smoked and enjoyed his last cigarette, the patient should apply the nicotine reduction patch and start the NRT therapy.

Follow Up
Follow up is essential. The patient should be given general instructions on starting the therapy, but advice may well be required to fine tune it to his needs at a further visit. Ask the patient to return after one week, two weeks, four weeks, eight weeks and 12 weeks. There should be minimal intervention, and a series of five minute appointments, totalling 25 minutes in all, should be enough to tide the patient through the first three months. Patients should be asked how they are getting on; have they had any problems; have they smoked. If not, give them lots of praise and encouragement; if they have, how many? Help them look on the positive side: if they normally smoke 20 cigarettes a day, and they have only had two, they have therefore cut down by 18, and so on. Stricktly of course, they should not smoke at all during their treatment programme. By the end of the programme, they should have weaned themselves off their addiction.

Potential Hazards
There are, however, potential hazards associated with nicotine patches, mostly related to their availability over the counter. There is a heavy responsibility on the pharmacist to question the patient appropriately about his smoking habits, and ensure that he receives the correct smoking patch. There have been instances where a pharmacist has given a patient too strong a dose, with ensuing serious and avoidable side effects, such as nausea, palpitations and dizziness. It is essential that pharmacists are properly prepared to advise patients on nicotine replacement. At the same time, I believe it is incumbent on patients to read the instructions for themselves, and make sure that they understand them.

Helping smokers stop could be very straightforward: ban tobacco advertising and sponsorship, give smokers nicotine replacement therapy on the NHS, and double the price of cigarettes overnight. At the moment nicotine addiction is the only addicition that a doctor cannot treat on the NHS. Blacklisting of nicotine replacement therapy discriminates against smokers, despite the government's apparent show of concern for the problem in documents such as The Health of the Nation.

It is unlikely the government will support prescribing of nicotine replacement on FP10, as cigarette sales tax represents such an enormous part of government revenue, currently raising 17.2 million per day. In the meantime, however, nicotine patches offer the safest and most flexible available hope for smokers trying to break themselves of the habit.

IMPORTANT NOTICE : This content is from the Dr Chris Steele personal archive and is provided for convenience only. Information contained here may no longer agree with the most up to date medical advice. Please check with a medical professional before taking any action.

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