(2003; 211 pages)
2. Clinical guidelines and therapies available for tobacco smoking cessation
Effective smoking-cessation therapy can involve a variety of methods, such as a combination of behavioural treatment and pharmacotherapy (4). A number of strategies have been developed to help smokers to quit. These include self-help manuals, individual or group counselling, aversive conditioning, hypnosis, clonidine, nicotine replacement therapy (7) and the use of antidepressant medications.
The most widely reported treatment is nicotine replacement therapy (NRT), which is available in the form of nicotine gum, nicotine patches and, more recently, as an oral inhaler. Nicotine replacement therapy is an established pharmacological aid to quitting smoking and it has consistently been shown to almost double the rate of quitting, irrespective of additional interventions (8).Many studies have confirmed these findings (1,7,9 - 18). A brief description of each of the NRTs is given below.
Nicotine gum delivers nicotine through transbuccal absorption. The gum should be discarded, not swallowed, after 30 minutes. The patient can chew another piece when there is an urge to smoke (19). The total recommended dose is 10 to 12 pieces of gum daily for 1 - 3 months. After 3 months, a gradual withdrawal from gum use is recommended, with completion of treatment within 6 months (20).
Transdermal administration of nicotine is available in three active forms (21, 14 and 7 mg), each steadily delivering an average of 0.7 mg nicotine per cm2 per 24 h (21). The strength of the patch is reduced gradually (by reducing the size of the patch) over the course of therapy, 8 - 12 weeks per 24 h treatment or 14 - 20 weeks per 16 h treatment (with patches that are worn only during the day) (19). To reduce the likelihood of local skin irritation, the manufacturers recommend that the patch site be changed daily and that the same site is used not more than once every 7 - 10 days (19,22,23).
The 1996 Smoking Cessation Clinical Guideline, which compared the use of NRT patches to nicotine gum, considered the patch easier to use and also more likely to enhance adherence (24).
Oral nicotine inhalers consist of a disposable cartridge containing 10 mg nicotine and 1 mg menthol inserted in a plastic mouthpiece. Nicotine is delivered at a rate of 13 mg of nicotine/puff (80 puffs = 1 mg).The recommended dose is 6 - 12 cartridges over 24 h (10). In one study, participants were encouraged to decrease use of the inhaler after 4 months, but were permitted to continue treatment for 18 of the 24 months (10).
Behavioural therapies have been used in combination with NRTs, to enhance adherence to treatment and to help patients stop smoking. The therapies employed have included individual counselling, group therapy sessions and telephone hotline support, all of which provide encouragement, guidance, and strategies to combat urges and cravings to smoke. The intensity of the behavioural sessions varied between studies (e.g. weekly or daily, lasting between 15 minutes and 1 hour, and provided by a nurse, a physician or an MS/PhD therapist (5,7,8,11,12,15,17 - 20,24 - 26). Pharmacists have also been proposed as potential providers of information and guidance concerning NRTs and tobacco in general (27).