Nicotine


Article Author:
Amritpal Sandhu


Article Editor:
Abdolreza Saadabadi


Editors In Chief:
Alexandra Caley
Sameh Boktor


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
4/4/2019 3:18:25 PM

Indications

Nicotine replacement therapy (NRT) is for those who want to quit smoking, as quitting abruptly can cause withdrawals and cravings. Nicotine withdrawal occurs after smoking cigarettes is suddenly discontinued. Using NRT helps one to reduce the motivation of smoking cigarettes because the body still gets nicotine from another safer method. Evidence has shown that using NRT helps increase the chances of quitting by about 50% to 70%. Withdrawals include restlessness, more than usual hunger, feeling depressed or irritable, and craving another cigarette.[1][2][3][4]

  • Nicotine comes in a patch, lozenge, inhalers, spray, and gum forms and can provide the body the dose of nicotine that it used to get from cigarettes. Using these forms of NRT increases chances of success of quitting smoking and are FDA approved.
  • NRT contains less nicotine than the average cigarette and has a slower effect on the body. It does not contain the harmful chemicals of cigarettes, such as tar.
  • It is highly recommended to start using an NRT 1 to 2 weeks before quitting or right after quitting cigarettes.
  • Bupropion is also an antidepressant with smoking cessation effects and can be combined with the nicotine patch for a higher chance of success.

Mechanism of Action

Nicotine is an alkaloid, which is only produced in tobacco. It is a tertiary amine that has pyrrolidine and pyridine rings. It binds selectively to nicotinic-cholinergic receptors in multiple locations. The brain, neuromuscular junctions, adrenal medulla, and the ganglia all have these receptors. When nicotine is inhaled through smoking cigarettes, it diffuses through the lungs into the circulation, eventually going to the brain. It affects the reward center in the limbic system as well as having a stimulating effect in the cortex. Dopamine in the frontal cortex, mesolimbic area, and corpus striatum is released. Dopamine is linked to delivering the pleasurable experience. NRTs try to mimic the nicotine response from smoking. Higher doses of NRTs will have more of a rewarding feeling, whereas lower doses of nicotine have more of a stimulating effect.[5][6]

Administration

Forms of NRT do not need to be prescribed by a doctor; most are available over the counter. Directions should be followed for each form of NRT. Even though there are different brands and forms, evidence shows no greater effectiveness of one type of NRT compared to another.  Studies also show that there is no benefit for using NRTs longer than eight weeks. Heavier smokers should use increased strength/dose of nicotine therapy.

  • Nicotine patches come in different brands, where some patches are designed for a 24-hour period at 5-mg to 52.5-mg dosages, where the higher doses are for heavier smokers. Other patches are designed to be only worn 16 hours a day and come in 5-mg to 25-mg doses. Patches need to be applied to a non-hairy, dry, clean area of the arm or upper body. Press onto skin for 10 seconds. Apply to a different area each time. Treatment is for about 8 to 10 weeks.
  • Nicotine gum is available in different doses as well, at 2 mg and 4 mg. Gum is to be chewed slowly until it tingles, and chew until the tingle disappears. Chew when the urge to smoke strikes. Recommended is 8 to 12 pieces of gum.
  • Nicotine lozenges are available in 1-mg, 1.5-mg, 2-mg, and 4-mg doses. Allow 20 to 30 minutes to dissolve slowly. Do not chew or swallow. Recommended is 8 to 12 lozenges daily.
  • Nicotine sublingual tablet comes in a 2-mg dose.
  • Nicotine inhalation cartridge comes in 10 mg. The cartridge should be inserted into inhaler then popped into place. Inhale deeply or puff consecutively in short breaths.
  • Nicotine nasal spray comes in 0.5 mg per spray. Blow nose prior to use. Tilt head back and insert the tip of the bottle and spray once in each nostril.

Do not use 2 doses back to back. If a dose is missed, take it as soon as possible. If it is close to the time of the next dose, skip the missed dose.

Adverse Effects

Known adverse effects of nicotine include headaches, depression, back pain, and dizziness. Others include nervousness, drooling, shakiness, cold sweats, diarrhea, hypertension, increased heart rate, and vivid dreams.

  • With the oral/nasal mucosa absorbing NRT’s, nose and mouth ulcers and irritation has been reported. Some had dyspepsia and hiccups as well. Other side effects include swelling of the lips, throat, and tongue.
  • Transdermal patches have caused some people skin rash or irritation.

Inform a doctor immediately if any of the above side effects occur.

Contraindications

  • Hypersensitivity to nicotine. People allergic to soy should not use the Nicorette lozenge.
  • Nicotine also has drug interactions with adenosine, cimetidine, and varenicline. Adenosine may increase tachycardia effect of nicotine. Cimetidine may increase the serum concentration of nicotine. Varenicline can induce some of the nicotine side effects.
  • Pregnant women should also quit smoking during pregnancy. Nicotine is shown to cross the placenta as well as breast milk. NRT is not recommended for breastfeeding mothers as the side effects could harm the infant.

Monitoring

Patients with cardiovascular or peripheral vascular disease should have the risks versus benefits weighed before deciding to start an NRT due to hypertension and increased heart rate side effects. Use caution when starting patients who have had angina or recent myocardial infarction. Discontinue if palpitations or irregular heartbeats occur.[7][8][9][10]

Toxicity

The liver metabolizes nicotine. Therefore, swallowing pills through the gastrointestinal (GI) system will get first pass metabolism by the liver, and bioavailability would only be about 20%. This will reduce the bioavailability of nicotine in the system and possibly cause side effects of the GI. Hence, the only available methods for nicotine are in a non-pill form such as a lozenge, sublingual tablets, transdermal patches, gum, inhaler, and sprays. This lets the nicotine enter through the oral or nasal mucosa, or skin and bypass the GI system for longer bioavailability. The route of absorption is pH dependent. Acidic foods and drinks can lower the absorption of nicotine. The skin patch releases nicotine at a slower rate. This makes toxicity from nicotine much less likely and prevents any GI side effects from happening. Symptoms in the rare event that nicotine is overdosed, include nausea, vomiting, diarrhea, dizziness, difficulty breathing, tachycardia, weakness, or rash.

Enhancing Healthcare Team Outcomes

All healthcare workers have a responsibility for educating patients on the harms of smoking. The patient should be told about the nicotine replacement therapies currently available.  Evidence has shown that using NRT helps increase the chances of quitting by about 50% to 70%. Withdrawals include restlessness, more than usual hunger, feeling depressed or irritable, and craving another cigarette. Bupropion is also an antidepressant with smoking cessation effects and can be combined with the nicotine patch for a higher chance of success. These patients need continual support and positive reinforcement. Unfortunately, with all therapies, relapse rates are very high. (Level V)


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Nicotine - Questions

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Which acetylcholine agent is a central nervous system stimulant?



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When using the nicotine gum for cessation of smoking, what are the appropriate instructions?



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Which of the following is not a dose form of nicotine as a smoking deterrent?



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Using nicotine replacement treatments can induce which one of these side effects?



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A pregnant patient comes into the office for a 6-month checkup. She reports she does not drink alcohol anymore but she is still currently smoking at 24 weeks pregnant. What should the patient be told about the effects of nicotine from her smoking?



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Nicotine overdose from different forms of nicotine replacement treatments can be easily missed. Which of the following are signs and symptoms of toxicity?



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A 25-year-old smoker is going to have an elective surgery for a breast enhancement. The patient is going to be in the hospital for 2 days total. The patient is asking you how she can continue smoking. What is the best response?



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Nicotine - References

References

Bellenguez Y,Chevalier F,Duhaut P,Colpart E,Dernoncourt A, [Smoking cessation in secondary prevention of acute coronary syndrome: The role of the electronic cigarette]. Annales de cardiologie et d'angeiologie. 2019 Jan 22;     [PubMed]
Lee LJ,Li Q,Bruno M,Emir B,Murphy B,Shah S,Reynolds M,Marchant N,Park PW, Healthcare Costs of Smokers Using Varenicline Versus Nicotine-Replacement Therapy Patch in the United States: Evidence from Real-World Practice. Advances in therapy. 2019 Feb;     [PubMed]
Kalkhoran S,Benowitz NL,Rigotti NA, Reprint of: Prevention and Treatment of Tobacco Use: JACC Health Promotion Series. Journal of the American College of Cardiology. 2018 Dec 11;     [PubMed]
Liberman K,Van Schuerbeek P,Herremans S,Meysman M,De Mey J,Buls N, The effect of nicotine patches on craving in the brain: A functional MRI study on heavy smokers. Medicine. 2018 Sep;     [PubMed]
Zhu J,Nelson K,Toth J,Muscat JE, Nicotine dependence as an independent risk factor for atherosclerosis in the National Lung Screening Trial. BMC public health. 2019 Jan 22;     [PubMed]
Loukas A,Marti CN,Perry CL, Trajectories of Tobacco and Nicotine Use Across Young Adulthood, Texas, 2014-2017. American journal of public health. 2019 Jan 24;     [PubMed]
Nethan ST,Sinha DN,Chandan K,Mehrotra R, Smokeless tobacco cessation interventions: A systematic review. The Indian journal of medical research. 2018 Oct;     [PubMed]
Livingstone-Banks J,Ordóñez-Mena JM,Hartmann-Boyce J, Print-based self-help interventions for smoking cessation. The Cochrane database of systematic reviews. 2019 Jan 9;     [PubMed]
Jackson SE,McGowan JA,Ubhi HK,Proudfoot H,Shahab L,Brown J,West R, Modelling continuous abstinence rates over time from clinical trials of pharmacological interventions for smoking cessation. Addiction (Abingdon, England). 2019 Jan 7;     [PubMed]
Frank Wolf M,Bar-Zeev Y,Solt I, [INTERVENTIONS FOR SUPPORTING WOMEN TO STOP SMOKING IN PREGNANCY]. Harefuah. 2018 Dec;     [PubMed]

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