Nicotine Replacement Therapy Perceptions Essay
Nicotine Replacement Therapy Perceptions Essay
Manuscript Title:
“Knowledge and Perceptions regarding Nicotine Replacement therapy among Dental Students in Karnataka”
Abstract:
1. Background:
Organized dentistry has recognized the role of oral health professionals in discouraging tobacco use. Unexplored level of knowledge regarding the benefits and prescription of NRT have aroused interest among us which initiated us to assess the knowledge and perception of Dental students towards Nicotine Replacement therapy (NRT) among various dental colleges in Karnataka , South India.
2. Material and Methods:
A questionnaire survey was done among 16 selected colleges in Karnataka. It was distributed for 3rd Year, Final year and Interns. The study group provided answers to 14 item close ended questionnaire. The first dimension obtained information on sex, age, course and year of study and other dimension on forms in which NRT’s are supplied, Effectiveness of NRT’s, Side effects of NRT’s, Rate of success of NRT’s, E-cigars and Recommendations of NRT’s. Statistical analysis was done using frequency distribution of responses.
3. Results:
A total of 1984 undergraduate students from Dental Colleges in Karnataka responded to the questionnaire. Most of the students were unaware about NRT term & its forms. Most of the students were aware about the effectiveness of NRT’s (54%) for the rescue of the smokers to quit and felt transdermal patch (42%) could be the most effective way for smokers to quit followed by chewing gums respectively.
More than half of the respondents (53.5%) were unaware of Electronic Cigars (E-cigar’s) and also felt that NRT’s and Counseling cumulatively can contribute for cessation of tobacco habit. Nicotine Replacement Therapy Perceptions Essay.
4. Conclusion: A large proportion of Dental students in this part of country were unaware about NRT.
Keywords: Dental students, Knowledge, Nicotine Replacement therapy
3. Text
Introduction
Tobacco smoking takes away not just your health but wealth. It is estimated that 5-15% of a smoker’s disposable income is spent on tobacco, which could be an enormous economic burden on you and your family.
Tobacco use causes an acknowledgeable amount of suffering for families and individuals associating with smokers. This suffering manifests itself in the form of diminished quality of life, death, and financial burden. Smoking affects social interaction and relationships negatively.
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Many smokers are afraid to quit because they have tried to quit in the past and were unsuccessful. They think it will be too hard because they don’t believe they can overcome withdrawal symptoms, they feel like they have no support, or just don’t think they are capable of success.1
Organized dentistry has recognized the role of oral health professionals in discouraging tobacco use. Patients expect and are comfortable with receiving dental advice to quit tobacco use. Interaction with dentist, a respected health care provider has a powerful influence and can be tailored to individual patient interests, conditions, and culture. Tobacco prevention and control are important because reducing tobacco use is essential in improving quality of life, preventing and treating many oral diseases.2
Dental clinic serves as ideal setting for tobacco cessation services as preventive treatment services, full mouth screening and patient education always have been a largest integral part of the dental practice. Repeated follow-ups and a longer duration of contact during each time with special preference individually can be easily provided in dental practice than in many medical care environments.
In conjunction to behavioral therapies, there are also pharmacological therapies available which can overcome nicotine withdrawal symptoms. The two major types of medication available that may be able to relieve withdrawal symptoms are: Nicotine replacement therapies (NRTs) and non-nicotine replacement therapies. NRTs include things such as nicotine gum and patch
Dental professionals are so placed that during consultation it can provide an opportunity to point out the detrimental effects of tobacco use on oral and general health. Nicotine Replacement Therapy Perceptions Essay. Previous studies on tobacco cessation in dental clinics indicated that there was strong correlation between oral lesions and directly relating them to the patient’s tobacco use which can be considered as a powerful motivating factor for the initiation of a cessation attempt.
Dentists are placed uniquely in such a position that they will deliver specific, authoritative information concerned with the adverse oral effects of tobacco use as they render frequent dental services to adult and adolescent smokers.
Previous studies have reported dentists weren’t certain in suggesting NRT. Their unexplored level of knowledge regarding the use and prescription of NRT have aroused interest among us which initiated us to ascertain level of knowledge regarding NRT’s among Dental Students in selected Dental Colleges among Karnataka, South India.
Materials & Methods
The Study was conducted in October-December 2014 in Dental Colleges in Karnataka, India.
The ethical approval for the study was obtained from the Institutional Ethical Board.
Sixteen Colleges were selected out of total 46 Dental Colleges in Karnataka by Computer generated random sampling. The questionnaire was completed by third year, final year undergraduates and Internees who were present on that day.
The total number of Dental undergraduates was 2240 out of which 1984 were present on the day of survey. The study group provided answers to 14 item close ended questionnaire that was grouped into 2 parts. The first dimension obtained information on sex, age, course and year of study. The second dimension obtained information on forms in which NRT’s are supplied, Effectiveness of NRT’s, Side effects of NRT’s, Rate of success of NRT’s, E-cigars and Recommendations of NRT’s. The internal reliability (Cronbachs’ alpha) of the questionnaire was tested in a pilot study done before the final study and it was found to be acceptable (0.62).Statistical analysis was done using frequency distribution of responses. [SPSS ver 11.5]
Results
In total, this study analyzed data for 1984 undergraduate students from Dental Colleges in Karnataka State. About 95% more of all Dental students were younger than 30 years old. The proportion of female dental students was almost 76% compared with males (Table 1).
Almost 63% of the students were aware about NRT term. Most of the students (46%) were aware about the NRT forms (Patch gums, Lozenges, Nasal spray, Tablets). Approximately 54% of the students were aware about the effectiveness of NRT’s for the rescue of the smokers to quit. Most of the respondents (42%) felt transdermal patch could be the most effective way for smokers to quit followed by chewing gums respectively (Table 2).
Almost 54% of the respondents felt that usage of NRT’s can lead to side effects and about 40% of the respondents felt the need of tapering the dosage of NRT’s.
Regarding the rate of success most of the respondents (52.5%) felt that NRT’s and Counseling cumulatively can contribute for cessation of tobacco habit. More than half of the respondents (53.5%) were unaware of Electronic Cigars (E-cigar’s) and among them who knew most of them were unaware that E-cigar can help the individual with strong dependence who failed to quit smoking with the aid of Nicotine replacement therapy. Most of the respondents (56%) were uncertain about prescribing NRT’s for pregnant mothers and also felt that NRT’s are not recommended for occasional smokers. On the end more than 3/4th of the respondents (84%) felt that NRT’s should be included in the present academic curriculum (Table 2).
Discussion
Health professionals have a pivotal role in the cessation of tobacco. Clinicians can induce a major difference even with a minimal intervention and also there would be an association which exists between the intensity of intervention and outcome of tobacco cessation. Even when patients’ exhibits negative attitude towards a quit attempt, doctor-administered brief interventions compliment motivation and enhance the likelihood of impending quit venture.
Tobacco users are being centered to consider quitting by a wide range of societal and environmental factors. Nicotine replacement therapy is found to be an effective remedy to decrease cravings related with smoking cessation. As observed with cigarettes the methods used in this therapy will not produce the same peak levels of nicotine in the blood, hence do not cause the same subjective effects. However, they curb nicotine withdrawal symptoms. Smokers can now change their addictedness to a substitute nicotine delivery system which can be gently dropped out. Tobacco smoking takes away not just your health but wealth. It is estimated that 5-15% of a smoker’s disposable income is spent on tobacco, which could be an enormous economic burden on you and your family.1 Because of the better accessibility than other health care professionals to healthy tobacco users seeking routine dental care, dentists are positioned uniquely and advantageously to offer cessation counseling and also the have direct professional interest in tobacco due to its harmful effects on the oral cavity.3
In our present study we found almost 3/4th of the participants were unaware of NRT term. The reason might be non-inclusion of NRT in their curriculum. Most of the students in our study reported they had heard about NRT term but when more questions were asked in detail most of them failed to answer especially regarding forms of NRT’s where almost 1/4th of the students were unaware. Nicotine Replacement Therapy Perceptions Essay. Their insufficient knowledge regarding the prescription of Nicotine replacement therapy could be succeeded by having pharmacists at the Dental colleges and train students about tobacco cessation medications, and provide instructions regarding these medications. If the students are taught about the NRT medications, they will feel more confident in prescribing these medications to their patients willing to quit.3
Significant gender differences were noticed with respect to only questions related to E-cigars, forms of NRT in which males response rate was better than females. Although, respondents weren’t ascertained with habit of smoking, the reason probably might be smoking male students might have come across E-cigars when they might wanted to quit.
Although Nicotine patches and Gums available in Indian Market, almost 1/4th of respondents were unaware.
Dentists do not often recommend NRT for people less than 18, largely since they are tested only on adults.4
Since all NRTs found to equally effective, many smokers choose a regimen according to ease of use keeping into consideration about what possible side effects it may cause. It is also found that each and every form of NRT’s has adverse effects, but the types of adverse consequences differ across various NRTs. In the present study, almost half of respondents are well known about the adverse effects of nicotine replacement therapy.
Nicotine patches can be stopped abruptly or gradually can taper the dose of nicotine According to literature there was no evidence that tapered therapy was better than abrupt withdrawal, but most of our respondents were unaware of the same.
Regarding safety of NRT’s during gestation, before the NRT’s are suggested, most doctors will suggest that you try alternate ways to stop. In our study more than half of the respondents were unsure about the same.5
Undoubtedly we can infer that the transition from student to junior doctor is immense hop with regard to responsibility. The procedures and Skills which are learnt in counterfeit environments are being succeeded for actual, and more often under pressure of time and with huge workloads.6
It is important to reinforce peer educators complete tobacco training, before big events like Collegiate Smoke out. It is also vital to link with nurses from the health center or campus counselors to ascertain about nearby resources, and also hold a competition between residence hall groups to find out who can perform the most complete assessment of cessation options.
Conclusion
A large proportion of Dental students in this part of country were unaware about NRT. Professional training programs for Graduates and Under-graduates are required to increase knowledge, understanding and practices that foster prescriptions of various agents of NRT’s. Universities and Dental Colleges charged with the responsibilities of preparing personnel must include Tobacco cessation counseling and NRT as a component of the curriculum. Contemporary & Comprehensive efforts are needed to train dental students on tobacco cessation techniques.
References
- Available from: www.who.int/iris/bitstream/10665/112834/1/9789241506922_eng.pdf . [Last accessed on 2015 Feb 02].
- A Ehizele, C Azodo, A Umoh, B Akinboboye.Attitude of Dental Students to Tobacco Cessation Services. The Internet Journal of Dental Science. 2008 Volume 7 Number 1.
- Murugaboopathy V,Ankola AV,Hebbal M,Sharma R. Indian dental students’ attitudes and practices regarding tobacco cessation counseling. J Dent Educ.2013 Apr;77(4):510-7.
- Stead LF, Perera R, Bullen C, Mant D, Hartmann-Boyce J, Cahill K, Lancaster T. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev. 2012 Nov 14;11:CD000146. Nicotine Replacement Therapy Perceptions Essay.
- Silagy C, Mant D, Fowler G, Lancaster T. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev. 2000;(3):CD000146.
- Charlotte Rothwell, Bryan Burford, Jill Morrison, Gill Morrow, Maggie Allen, Carol Davies, Beate Baldauf, John Spencer, Neil Johnson, Ed Peile.Jan Illing. Junior doctors prescribing: enhancing their learning in practice. Br J Clin Pharmacol. 2012 Feb; 73(2): 194–202.
Table 1. Frequency Distribution of respondents according to Gender, Age, and Year of Studying.
 Gender
Males Females |
N (%)
477 (24) 1507(76) |
| Age
< 30Years > 30Years |
1885 (95)
99 (5) |
| Year of Studying
3rd Year 4th Year Internship |
418(21)
674(34) 892(45) |
Table 2. Responses of the respondents to the questions related to NRT.
| Questions | N (%) |
| Q1.Have you heard about the term nicotine replacement therapy (NRT)?
Yes No |
1243(62.7)
741(37.3) |
| Q2.Currently what all forms of NRT’s are available?
a. Patch gums, Lozenges b. Inhalator, Nasal Spray, Tablets c. Both a and b d. Don’t know |
341(17.2)
141(7.1) 902(45.5) 601(30.3)) |
| Q3.Do you think NRT’s are effective enough to help smokers quit?
a)Yes b)No c)Don’t know |
1041(53.5)
381(19.2) 562(28.3) |
| Q4.Do you know what all forms NRT’s are supplied?
a)Yes b)No c)Don’t know |
702(35.4)
481(25.2) 801(40.2) |
| Q5.Which among these do you think is most effective way for smokers to quit?
a)Chewing gums b)Transdermal patch c)Nasal spray d)Don’t know |
582(29.3)
842(42.4) 140(7.1) 420(21.2) |
| Q6. Do you think NRT’s like chewing gums and transdermal patch lead to side effects?
a)Yes b)No c)Don’t know |
1062(53.5)
321(16.2) 601(30.3) |
| Q7. Do you think tapering of NRT’s is needed?
a)Yes b)No c)Don’t know |
801(40.4)
321(16.2) 862(43.4) |
| Q8.Adhesive transdermal patches can be applied to:
a)Trunk b)upper arm c)Both d)Don’t know |
140(7.1)
361(18.2) 800(40.4) 674(34.3) |
| Q9.Which among the following do you think has higher rate to success?
a)NRT’S b)Counselling c)Both d)Don’t know |
341(17.2)
441(22.2) 1041(52.5) 161(8.1) |
| Q10. Have you heard about E-cigar’s?
a)Yes b)N0 |
932(46.5)
1052(53.5) |
| Q11. Do you think E-cigar might help individual with strong dependence who failed to quit smoking with the aid of NRT’s?
a)Yes b)No c)Don’t know |
912(45.5)
220(11.1) 862(43.4) |
| Q12. Are NRT’s recommended for occasional smokers?
a)Yes b)No c)Don’t know |
321(16,2)
1052(53.5) 611(30.3) |
| Q13. Do you think study of NRT’s should be included in the present academic curriculum?
a)Yes b) No |
1662(83.8)
322(16.2) |
| Q14. Pregnant smokers can be given NRT’s:
a)Yes b) No c) Don’t know |
Today tobacco use is the single greatest preventable cause of death in the world. Tobacco use is often incorrectly perceived to be solely a personal choice. This is contradicted by the fact that when fully aware of the health impact, most tobacco users want to quit but find it difficult to stop due to the addictiveness of nicotine. Henceforth, Nicotine replacement therapy (NRT) came into existence which temporarily replaces much of the nicotine from tobacco to reduce motivation to consume tobacco and nicotine withdrawal symptoms, thus easing the transition from cigarette smoking to complete abstinence.Nicotine Replacement Therapy Perceptions Essay. Various alternative nicotine sources (gum, transdermal patch, nasal spray, inhaler and sublingual tablets/lozenges) have been incorporated into tobacco cessation programs. Recent research is more focusing on rapid delivery of nicotine (Nicotine preloading, true pulmonary inhaler) and immunological approaches (nicotine vaccine) to tackle nicotine dependence. These NRTs are in general well tolerated and have minimal adverse effects. The review aims to summarize literature on various modes of nicotine replacement therapy methods currently used to treat nicotine dependence, and to give an overview about future possible approaches to treat tobacco use disorder.
Nicotine is the main active ingredient in tobacco products that reinforces individual to tobacco addiction behavior, (1, 2, 3) it is tobacco’s other components which cause widespread mortality and morbidity.(4, 5, 6, 7) Although almost all of the toxicity of smoking is attributed to other components in cigarettes, it is the pharmacological effects of nicotine that lead to tobacco addiction. Therefore, pharmacological interventions for tobacco cessation continue to evolve with our growing knowledge of the neurochemical basis of nicotine addiction. Nicotine is the main alkaloid of tobacco smoke and the principal modulator of the psychopharmacological effects associated with addiction.(8)Nicotine replacement therapy (NRT) aims to reduce motivation to consume tobacco and the physiological and psychomotor withdrawal symptoms through delivery of nicotine. (9) The evidence that NRT helps to stop smoking is now well accepted, and many clinical guidelines recommend NRT as a first line treatment for people seeking pharmacological help to stop smoking. (10) This review aims to summarize literature on various modes of nicotine replacement therapy methods currently used to treat nicotine dependence, and to give an overview about future possible approaches to treat tobacco use disorder.
Materials and Methods
A thorough literature search was performed to understand and identify the updates in the field of NRT. Electronic database PubMed was searched from January 1990 up to May 2015 for the relevant literature using key phrase of “nicotine replacement therapy”. Citation pearl growing technique employed and reference articles of the selected article were referred. We included systematic reviews, narrative reviews, clinical trials, comparative studies and reports/guidelines of international health agencies. Only articles reported in English were considered for review. Nicotine Replacement Therapy Perceptions Essay.
Mechanism of action of nicotine
Nicotine acts by stimulation of neural nicotinic acetylcholine receptors (NAChRs) in the ventral tegmental area of the brain. This causes release of dopamine in the nucleus accumbens. Which lead to reduction in nicotine withdrawal symptoms in regular smokers who abstain from smoking. (11) NRT may also provide a coping mechanism, making tobacco products less rewarding. It does not completely eliminate the symptoms of withdrawal because none of the available nicotine delivery systems reproduce the rapid and high levels of arterial nicotine achieved when cigarette smoke is inhaled. (12)All the available medicinal nicotine products rely on systemic venous absorption and do not therefore achieve such rapid systemic arterial delivery. (13) It takes a few seconds for high doses of nicotine from a cigarette to reach the brain; medicinal products achieve lower levels over a period of minutes (for nasal spray or oral products such as gum, inhalator, sublingual tablet, or lozenge) and hours (for transdermal patches). (13)
Forms of Nicotine Replacement Therapy
The most widely studied and used pharmacotherapy for managing nicotine dependence and withdrawal is therapeutic use of nicotine containing medications. (14) NRT products take a number of forms: gum, transdermal patch, nasal spray, oral inhaler, and tablet. Transdermal Patch is a slow sustained release form of nicotine delivery. Other products like gum, nasal spray, oral inhaler, and tablet are acute dosing forms of nicotine.Nicotine Replacement Therapy Perceptions Essay. They provide general craving relief and breakthrough craving relief with immediate release of nicotine. (15,16) All of these products have different levels of efficacy and variable rates of nicotine absorption, and they are most effective when the consumer also receives parallel cessation-counseling, but nevertheless are effective even without accessory behavioral therapy. (13)
Transdermal patch
Nicotine patches are applied to the skin and deliver nicotine through the skin at a relatively steady rate. (14) Patches are available in a range of dosages, which permits higher dependent smokers to use the strongest patches and lower-dependent smokers to use a lower. The range of dosages allows users to gradually decrease their nicotine intake over a period of several weeks or longer to enable a gradual adjustment of their bodies to lower nicotine levels and ultimately to a nicotine-free state. (13) Current evidence supports the safety of long-term use of nicotine patch treatment for tobacco abstinence. (17) The main advantage of nicotine patches over acute NRT formulations is that compliance is simple; the patient simply places the patch on the body in the morning, rather than actively using a product throughout the day. (12) It delivers nicotine more slowly than acute NRT formulations, although nicotine plasma concentrations can get higher during the day with patch use than with acute NRT use. (18) They are available in different doses, and deliver between 5mg and 22mg of nicotine over a 24-hour period, resulting in plasma levels similar to the trough levels seen in heavy smokers. (11) The most frequently reported side effects are local skin reactions. (11)Moving the site of patch application daily as instructed can reduce the incidence of skin reactions to the patch. Sleep disturbances have also been commonly reported with 24-hour patches. (13)
Acute Dosing Nicotine Products
Acute-dosing products have the benefit that both the amount and timing of doses can be titrated by the user.Nicotine Replacement Therapy Perceptions Essay. Thus, smokers with more nicotine tolerance or greater need can get a higher nicotine dose, and smokers who are experiencing acute adverse effects can scale back their intake. Control over the timing of self-dosing enables smokers to use NRT medications as “rescue medication” when they encounter particularly strong cravings or threats to abstinence. (18) These acute craving episodes are particularly problematic for some cigarette smokers and are associated with very high risk of relapse. (19) Acute dosing nicotine products include gum, lozenge, sublingual tablet, oral inhaler, and nasal spray.
Nicotine Gum
The first NRT that was made available to consumers was transmucosally delivered nicotine polacrilex (nicotine gum). (20) It is not chewed like ordinary confectionary gum, but is intermittently chewed and held in the mouth over about 30 minutes, as needed, to release its nicotine. It is available in both 2 mg and 4 mg dosage forms.18 Smokers that are more dependent have been shown to improve their chances of achieving abstinence with the 4-mg than the 2-mg gum. After a few weeks or months, the number of doses per day is reduced gradually until it is no longer required. (13) Acidic beverages have been shown to interfere with buccal absorption of nicotine; therefore, patients should avoid acidic beverages (eg, soda, coffee, beer) for 15 minutes before and during chewing gum. (14)
Nicotine Lozenge
The lozenge is available in 2mg and 4mg formulations. Instructions for use and dosing are similar to nicotine gum, but the lozenge is not chewed; it dissolves in the mouth over approximately 30 minutes with some variation across individuals. Nicotine Replacement Therapy Perceptions Essay. As with nicotine gum, nicotine from the lozenge is absorbed slowly through the buccal mucosa and delivered into systemic circulation. (13) The lozenge provides an alternative to the gum for persons who need intermittent and controllable nicotine dosing, but who do not find gum chewing acceptable. The amount of nicotine absorbed per lozenge appears to be somewhat higher than that delivered by gum. (21)
Nicotine Sublingual tablet
This product is designed to be held under the tongue where the nicotine in the tablet is absorbed sublingually. Like the lozenge, the tablet has the advantage of not requiring chewing. The levels of nicotine obtained by use of the 2mg lozenge and 2mg sublingual tablet are similar. (22) It is recommended that smokers use the product for at least 12 weeks. After 12 weeks, the number of tablets used should be gradually tapered. (14)
Nicotine Oral inhaler
It consists of a mouthpiece and a plastic cartridge containing nicotine. The vapour inhaler was designed to satisfy behavioral aspects of smoking, namely, the hand-to-mouth ritual, while delivering nicotine to reduce physiological withdrawal symptoms produced by tobacco withdrawal. It is important to note that although termed an “inhaler” the majority of nicotine is delivered into the oral cavity (36%) and in the oesophagus and stomach (36%). (22, 23) Very little nicotine is delivered to the lung (4%). Because absorption is primarily through the oral mucosa, the rate of absorption is similar to that of nicotine gum. Nicotine Replacement Therapy Perceptions Essay. Each inhaler cartridge contains 10mg nicotine, of which up to 4 mg can be delivered and 2 mg can be absorbed following frequent “puffing”. (24)
Nicotine Nasal spray
It was designed to deliver doses of nicotine more rapidly. The device available to consumers is a multi-dose bottle with a pump mechanism fitted to a nozzle that delivers 0.5 mg of nicotine per 50-uL squirt. Each dose consists of two squirts, one to each nostril. (11, 24) Nicotine nasal spray is absorbed into the blood rapidly relative to all other NRT forms.(25) Patients should be started with one or two doses per hour, which may be increased up to the maximum of 40 doses per day. One dose of nasal spray per hour (1mg nicotine) for 10 hours produces average plasma concentrations of 8ng/ml. (14)
Improving Delivery
Electronic nicotine delivery systems (ENDS) or Electronic cigarettes
ENDS are devices whose function is to vaporize and deliver chemical mixture typically composed of nicotine to the lungs of the user. Each device contains an electronic vaporization system, rechargeable batteries, electronic controls and cartridges of the liquid that is vaporized. (31) The liquid usually contains glycerol, propylene glycol, water, nicotine and a variety of flavors that the user can choose. By using this device, nicotine is delivered to the upper and lower respiratory tract without any combustion involved. (32) Nicotine content varies widely among products, typically ranging between 0 and 34 mg/mL, but recent studies have found discrepancies between labelled and measured nicotine content. (33) E-cigarettes are becoming a preferred alternative for nicotine delivery among many smokers because of their realistic look, feel, and taste compared to traditional cigarettes. Nicotine Replacement Therapy Perceptions Essay. (34) The FDA has reported that e-cigarette cartridges and solutions contain potentially harmful components and they recommend that the sale of e-cigarettes should be prohibited or regulated as dangerous nicotine delivery systems. (34) Moreover, for young people who have never smoked, these devices could potentially serve as a gateway drug. (35) The current evidence suggests that ENDS are an effective smoking cessation tool, but more research is needed to confirm its long-term effectiveness and safety. (36, 37)
High-dose nicotine patches
The conventional patches of 22-mg patch can only replace approximately half of the baseline serum nicotine and cotinine levels in smokers. (38) Therefore higher transdermal nicotine doses of ≥42 mg were evaluated. In terms of efficacy, a numerically higher abstinence rate was achieved with high-dose transdermal NRT. (9,40,41) However, a recent systematic review concluded that the safety and efficacy of high-dose transdermal NRT for tobacco cessation have not been established in the medical literature. (28)
Rapid release gum
A rapid-release gum has been formulated to provide biphasic nicotine delivery, starting with accelerated delivery to promote rapid craving relief and then leveling off to avoid overdosing. (42) A study compared this rapid-release gum to the current gum formulation for rapid craving relief following a provocative stimulus. The rapid-release gum achieved faster and more complete craving relief, differentiating itself from current nicotine gum. (43)
Combined Patch Plus Acute Forms
A strategy for further improving the efficacy of NRT is to combine one medication that allows for passive nicotine delivery (e.g. transdermal patch) with another medication that permits ad libitum nicotine delivery (e.g. gum, nasal spray, inhaler). The rationale for combining NRT medications is that smokers may need both a slow delivery system to achieve a constant concentration of nicotine to relieve cravings and tobacco-withdrawal symptoms, as well as a faster acting preparation that can be administered on demand for immediate relief of break through cravings and withdrawal symptoms. (32)The patch provides nicotine in a steady-state and passive form while gum can be manipulated to accommodate the users’ needs. Clinical trials suggest incremental efficacy of patch plus gum compared to either product alone. (44, 45, 46) Combining the nicotine patch with an oral form of NRT has been shown to increase quit rates by 34–54% compared to using the patch alone. (47) Adverse effects and adherence are similar to monotherapy, but there is a greater financial cost to the patient. (47)
The Future
Nicotine preloading
The use of nicotine replacement therapy before quitting smoking is called nicotine preloading. (36) This approach involves using NRT for a several weeks prior to quitting; it is also known as precessation or pre-quitting NRT. The most plausible mechanisms include habituation with use of NRT in the lead-up to quitting, attenuation of desire to smoke due to nicotine receptor saturation (48) and it reduces satisfaction from smoking by which it undermines the learned association between smoking and reward. (49) A review suggests that initiating patch use for a short period before making a quit attempt is moderately more effective than patch use initiated on the quit date itself. There is no evidence that suggests use of other forms of NRT precessation is more effective than starting use on the quit day.Nicotine Replacement Therapy Perceptions Essay. (50) A meta-analysis on precessation patch treatment found that it will produce a robust increase in quit rates compared to current regimens starting patch at quit day. However, large pragmatic randomized trial concluded that using NRT two weeks before the target quit day was safe and well tolerated but offered no benefit over usual care. (51)
True pulmonary inhaler
A true pulmonary inhaler, unlike the currently available nicotine inhaler, would delivery nicotine to the lung in a manner more comparable to cigarette smoking. (14) This would be predicted to deliver a dose of nicotine sufficient to reduce background cravings and withdrawal symptoms, and would allow for rapid relief of acute cravings and morning craving. Because the delivery of nicotine directly to the lung would effectively mimic the effects of cigarette smoking on a physiologic level, the smoker could eliminate the need for tobacco, and subsequently taper the nicotine level over time to alleviate dependence upon nicotine altogether. Although there are substantial technological challenges to producing an effective and acceptable lung inhaler, the greatest barrier to development may be the potential for abuse and the regulatory implications. (14) But the challenge is that nicotine molecules need to be appropriately condensed onto particles of approximately 1-micron median diameter to enable inhalation into the pulmonary alveoli, and the nicotine particles must be designed so as to prevent the production of unacceptably harsh sensory effects. (14)
Nicotine Vaccines
Nicotine vaccines represent a new approach to the treatment of nicotine dependence and are currently under investigation. Because nicotine is a small molecule and an incomplete antigen, it is linked to a carrier protein order to stimulate the necessary immune response. Nicotine-based vaccines can prime the immune system to recognize nicotine as foreign and to mount an immune response against the drug. In doing so, vaccines may reduce the amounts of nicotine penetrating into the brain. (52) A number of organizations have developed vaccines for smoking cessation, with NicVAX developed by Nabi Biopharmaceuticals being perhaps the best known. (53) A potential drawback of vaccines to treat tobacco dependence is the fact that smokers will often compensate for decreases in the actions of nicotine, as would be expected when a vaccine decreases concentrations of nicotine penetrating into brain tissues, by increasing their tobacco consumption to overcome this effect. (53) Other potential issues related to the successful use of vaccines include difficulties achieving sufficiently high antibody titers, the fact that vaccines are generally short lived, and significant inter-individual variation in response to the vaccine typically observed. (54) A recent systematic review reported that there is no current evidence that nicotine vaccine enhance long term smoking cessation and emphasized the need for further trials. (55)
Nicotine Replacement Therapy Perceptions Essay
