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From The Medical Letter on Drugs and Therapeutics
September 4, 2018

Drugs for Tobacco Dependence

JAMA. 2018;320(9):926-927. doi:10.1001/jama.2018.12463

Tobacco dependence remains the primary preventable cause of death in the United States. It is a chronic disorder that often requires pharmacologic therapy, but counseling may be equally effective and can add to the effectiveness of any treatment for this indication.1,2 Abrupt cessation of smoking appears to be as effective as gradual reduction.3

All FDA-approved nicotine replacement therapies (NRTs) deliver nicotine to nicotinic receptors in the central nervous system (CNS) in a lower dose and at a substantially slower rate than tobacco cigarettes. They increase smoking cessation rates by 50-70% and, in the short term, may decrease weight gain associated with smoking cessation.4,5 Nicotine undergoes first-pass metabolism, which limits its effectiveness in oral pill formulations. Nicotine gum, lozenges, and patches are available without a prescription in the US for persons ≥18 years old; these products appear to be as effective as those that require a prescription (nicotine oral inhaler and nasal spray). Used as monotherapy, a rapid-onset NRT such as a gum, lozenge, nasal spray, or oral inhaler should be taken on a regular schedule to prevent nicotine withdrawal symptoms. Combining the nicotine patch with a rapid-onset formulation (combination NRT) is more effective than monotherapy.