Patient Care Physicians can now prescribe nicotine-containing chewing gum [Nicorette] to help cigarette smokers quit. Just how does the gum work?
Farquhar Much as oral methadone HCl [Dolophine] works to curb heroin withdrawal symptoms. I don’t think the analogy farfetched: In many ways, the cigarette smoker’s addiction to nicotine is as tenacious as the drug abuser’s addiction to heroin. Both substitutes prevent withdrawal symptoms without producing the “pleasures” of the addicting drugs.
Specifically, nicotine gum works by providing blood levels of nicotine — via absorption through the buccal mucosa — comparable to the nicotine levels produced by smoking. The patient regulates the nicotine blood level by the rate of gum chewing, just as a smoker regulates the nicotine blood level by the number of cigarettes smoked, the frequency of puffs taken, and the depth of inhalation.
PC Who are ideal candidates for gum use?
Farquhar First-line candidates are patients with chronic obstructive pulmonary disease or cardiovascular disease and individuals at high risk for developing smoking-related illness.
The primary care physician can use the Fagerstrom inventory — the short questionnaire designed to assess degree of nicotine dependency–as a guide to determine a smoker’s need for nicotine gum. Questions include:
* How many cigarettes do you smoke per day? (The more cigarettes a patient smokes per day, the higher his or her degree of nicotine dependency.)
* Do you smoke more in the morning than at other times during the day? (Smoking more in the morning, when nicotine levels in the body are very low, points to greater nicotine dependency.)
* Do you find it difficult to refrain from smoking in places where it is forbidden, such as in church? (Little external and relatively more internal stimulus control, manifested by frequent urges to smoke in places where its is forbidden, point to greater nicotine dependency.)
The higher an individual’s score on the Fagerstrom inventory, the more likely the gum will be of benefit.
Patients who are well-motivated to stop smoking are apt to have the most success with nicotine gum. It can provide the necessary boost to any smoker who has tried to stop before and failed but who retains a strong commitment to quit. It’s not fruitful to prescribe the product to smokers who seem to have a casual or cavalier attitude about quitting.
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PC Under what other circumstances should the gum be avoided?
Farquhar Nicotine gum is contraindicated in patients recovering from a recent myocardial infarction, patients with life-threatening arrhythmia, and those with severe or worsening angina pectoris, intermittent claudication, and forms of Takayasu’s disease. The product should also be avoided in patients with active temporomandibular joint disease and in women who are, or may become, pregnant or who are nursing.
When a patient has systemic hypertension or a history of peptic ulcer disease, it’s wise to weigh the risks of using nicotine gum against those of cigarette smoking, since smoking is thought to perpetuate both hypertension and peptic ulcer disease. Of course, the gum should never be used by patients who are nonsmokers.
Patient Care What’s the optimal way for the physician to use nicotine-containing gum [Nicorette] to help patients stop smoking?
Farquhar As an adjunct to a formal behaviour-modification smoking cessation program or clinic. The gum helps relieve the symptoms of nicotine withdrawal–headache, irritability, restlessness, concentration impairment, and muscle aches and pains, for examples–while the program helps with the psychological and social aspects of quiting. When the physician prescribes the gum, it’s important to emphasize to the patient that it’s an aid, not a panacea; the gum won’t work unless the smoker is committed to stopping smoking.
PC What kind of smoking cessation program do you recommend?
Farquhar Personal counseling by the physician can have a strong impact in helping smokers quit. If a doctor doesn’t have the time or inclination to supervise the patient, referrel to one of the many group clinics or programs available is probably the next best option. For example, the American Cancer Society, the American Lung Association, and the Seventh-Day Adventist Church all sponsor group clinics at low cost, as do many local hospitals. More expensive commercial programs are available through Smoke Enders and Schick Laboratories [see “‘Quit smoking’ resources,” page 200].
PC What instructions should the physician give the patient about using the gum?
Farquhar If the patient is a heavy smoker–smokes two or more packs of cigarettes a day–he or she should taper to 12-15 cigarettes a day before starting to use the gum, to accustom the body to lower levels of nocotine. Most smokers find they can cut to this level without undue discomfort; withdrawal symptoms may begin when they try to taper below this level.
The person should then set a target date to stop smoking. It’s helpful to try chewing the gum–one or two pieces each day–two or three days before the quit date to get used to its slightly bitter, peppery taste.
From the quit date until the craving for cigarettes subsides, the patient should slowly chew one piece of gum whenever he feels the urge to smoke–or even better, 15-20 minutes before he anticipates a craving will occur. (The gum usually takes about 15-20 minutes to be effective.) For example, if a person can predict he’ll have a craving for a cigarette after his coffee break, he should start chewing the gum before he has his coffee to forestall the urge.
A useful tip for gum users is to chew the gum enough times to taste its nicotine flavor, then hold the gum in the mouth, chewing only enough to maintain the taste. The gum should be chewed for about 30 minutes to release most of the nicotine.
PC How is the ex-smoker weaned from the gum?
Farquhar It happens automatically. As the urge to smoke gradually subsides, the individual naturally reduces the number of pieces of gum he chews each day. But premature termination of gum use is a potential cause of failure: Caution patients not to stop using the gum until the craving for nicotine is satisfied with just 1-2 pieces per day. Most people can discontinue the gum after about-two months; the manufacturer recommends that it not be used for more than six months.
Patient Care What are the most common side effects of nicotine-containing gum [Nicorette]?
Farquhar If a person chews the gum too fast, side effects mimic those that would occur if he or she smoked a cigarette too rapidly. Light-headedness, throat and mouth irritation, hiccups, and stomach upset–including belching, gas, nausea, and vomiting–are among the most common complaints. Less common side effects mentioned in the package insert that may occur during the first few days of gum use include mouth ulcers, jaw muscle ache, headache, heart palpitations, and excess saliva in the mouth.
In our research, we found that while most gum users report some side effects, they are easily controlled and disappear after the first week.
PC What’s the cost of the gum?
Farquhar About $20 for a box of 96 pieces. At the rate of 10 pieces fo gum per day, the cost is not quite as much as what a heavy smoker might spend on a daily basis for cigarettes–a point worth mentioning to prospective ex-smokers.
PC Are data available yet on the success rate of nicotine gum in helping smokers to quit?
Farquhar Yes–and results look promising. In our own work, 50 percent of smokers given nicotine gum and smoking cessation counseling maintained nonsmoking status 11 months after quitting.
In a 1982 British study, 47 percent of smokers given nicotine gum were not smoking one year after quitting, compared with 21 percent given placebo gum. The investigators concluded that the nicotine gum is quite useful in helping smokers quit; they emphasized that success requires attention to patients’ expectations about the gum and provision of clear instructions on proper usage.