Reinforcing Effects

Nicotine causes the brain to release chemicals such as dopamine, norepinephrine, acetylcholine, vasopressin, serotonin, and beta-endorphins. These chemicals produce effects in the brain that cause the user to experience pleasure, anxiety and tension reduction, a sense of well-being when one feels down, arousal (perks one up when tired), short-term memory improvement, and appetite suppression. These neurochemical rewards that nicotine provides a tobacco user are called reinforcing effects.⁵ These reinforcing effects reward tobacco users and increase their desire to continue using tobacco (Table 34-4).

TABLE 34-4 Effects of Chemicals Released by the Brain When Exposed to Nicotine

Tolerance

With chronic exposure to nicotine, brain cells adapt to compensate for the actions of nicotine. This process is called neuroadaptation. Tolerance results from neuroadaptation, so that over time a given level of nicotine eventually has less of an effect on the brain and a larger dose is needed to produce the rewarding effects that lower doses formerly produced. Thus the longer clients use tobacco, the more nicotine they need to achieve the desired reinforcing effects.⁵

Physical Dependence

Although the brain adapts to function normally in the presence of nicotine, it also becomes physically dependent on nicotine for that normal functioning. When nicotine is not available, the brain function becomes disturbed, resulting in withdrawal symptoms (Table 34-5). Symptoms peak within 12 to 24 hours and last 2 to 4 weeks if tobacco use is discontinued. Not all individuals experience withdrawal symptoms, and the degree of discomfort from withdrawal also varies. In general, however, the nicotine withdrawal symptoms produced by nicotine abstinence necessitates clients to continue to increase their tobacco use to prevent withdrawal symptoms. Therefore, although initially individuals use tobacco for the reinforcing effects of pleasure, enhanced short-term memory, and mood modulation, often tobacco use ends up dominating their lives. Because tobacco use produces tolerance and physical dependence, it results in addiction and loss of control over use. This loss of control is due to the individual’s intense need to use tobacco to self-medicate to prevent withdrawal symptoms.⁵ In general, the highly dependent tobacco user poses the greatest challenge to cessation efforts, usually requiring pharmacotherapy combined with intense behavioral counseling.

TABLE 34-5 Nicotine Withdrawal Symptoms and Suggested Behavioral Coping Strategies

Modified from Severson H: Enough snuff: a guide to quitting smokeless tobacco, Point Richmond, Calif, 1997, Applied Behavior Science.

Psychologic Aspects

Psychologic aspects of nicotine addiction relate to a tobacco-using client’s need to use tobacco to cope with stress and/or depression. Many tobacco users perceive their tobacco as “a friend” that is always with them, providing a sense of comfort and security. Tobacco use also initially may be used as passive entertainment to decrease boredom or as a diversion from a strife-filled existence.

Behavioral Aspects

Behavioral aspects of nicotine addiction relate to learned anticipatory responses that tobacco users develop from having experienced various forms of gratification from tobacco use in certain previous situations.⁵ When a tobacco user encounters these environmental cues, they serve as situational reminders of tobacco use (e.g., after a meal or when drinking alcohol) and its associated pleasure or other reinforcing effects. These cues or stimuli then generate a strong urge to use tobacco known as a learned anticipatory response. Such learned anticipatory responses can last 6 months or longer after physical dependence has been overcome and often are responsible for relapse that occurs beyond the first 2 to 4 weeks of cessation. For successful cessation, tobacco users have to learn to anticipate situational cues that will trigger the desire to use tobacco and to plan ahead to identify alternative rewards and ways to cope with these trigger situations so as to remain tobacco-free.

Sensory Aspects

Puffing on a cigarette or having a dip of a specific size and texture in one’s mouth provides oral gratification, which relates to the sensory aspect of nicotine addiction. Because of the sense of well-being this oral gratification provides, the use of nontobacco oral substitutes (e.g., chewing gum, sunflower seeds) is important to the quitting process.⁵ In addition, because nicotine is an appetite suppressant, individuals often increase their food intake when they reduce their nicotine exposures. Individuals who successfully stop their tobacco use on average gain 10 pounds. Drinking a lot of water, getting exercise, and eating a balanced low-fat diet can help avoid this weight gain.⁶

Sociocultural Aspects

Sociocultural aspects of nicotine addiction that pose challenges to cessation include peer pressure, the influence of family members and significant others who use tobacco, and a social network that supports and accepts tobacco use. Tobacco users trying to stop their tobacco use often need to avoid situations where they will be tempted to use until they are secure that they can refrain from using tobacco in these situations.

Ask

It is important to identify all tobacco users systematically at every visit. This identification occurs by using an in-office system such as including an item on the health history form that asks about tobacco use and having all tobacco users complete a separate Tobacco Use Assessment Form, such as the one presented in Figure 34-5, for inclusion in the client-care record. In addition, the dental hygienist verbally asks each client about tobacco use (see Table 34-6 for suggested language). Cues or prompts, such as chart stickers or codes on the client schedule, are recommended to remind the hygienist to ask each client.

Figure 34-5 Tobacco use assessment form.

(Adapted from U.S. Department of Health and Human Services: Tobacco effects in the mouth, NIH Publication No. 94-3330, Bethesda, Md, 1992, U.S. Government Printing Office.)

Advise

The dental hygienist advises all tobacco users to stop their tobacco use to protect their current and future health. Such advice should be clear, unequivocal, nonjudgmental, and related to something immediately relevant to the client (see Table 34-6 for suggested language). For example, if clients have oral mucosal tissue changes as a result of tobacco use (see Figure 34-4), the dental hygienist points out the tissue changes to them in their own mouths and incorporates this information to personalize advice to stop using tobacco. Personalizing cessation advice with findings visible to the client provides a “teachable moment” that can motivate the client to decide to make a quit attempt.² During the advice component of the Five A’s approach, it is very appropriate to discuss actual and potential adverse health effects associated with tobacco use. After the advice component, however, the dental hygienist replaces discussion of negative health effects with discussions about the benefits of quitting to enhance motivation to stop tobacco use (Box 34-3).

Assess

For all clients who report tobacco use, the dental hygienist determines which tobacco users are willing to make a quit attempt by assessing their readiness to quit. To assess readiness to quit, the dental hygienist simply asks clients if they would like to stop their tobacco use in the next month. The concept of readiness to quit relates to the stages of change theory.⁸ According to this theory, tobacco cessation (or any other behavior change) involves movement through a series of five stages. These stages are precontemplation, contemplation, preparation, action, and maintenance. Precontemplation is the stage of change where the client has no thought of stopping tobacco use. Using tobacco is not viewed by the client as a problem. Contemplation is the stage where clients think they should stop tobacco use some day, but not in the next month. Preparation is the stage of change where clients are willing to set a quit date and to begin changing their behavior and thinking related to tobacco use in preparation for quitting in the next month. Action is the stage where clients have stopped their tobacco use for less than 6 months. Maintenance is the stage of change where clients have stopped tobacco use for more than 6 months. Precontemplators and contemplators will respond in the negative when the dental hygienist asks if they would like to try to quit their tobacco use in the next month. It is important for the dental hygienist not to take this rejection personally but to recognize and understand that the client simply is not yet ready to quit. Even sound advice coupled with demonstrating the damaging effects of tobacco use may not move the client who is in precontemplation or contemplation to take action to quit tobacco use (preparation). Only when clients perceive that the personal benefits of stopping tobacco use outweigh the benefits of continued use will they make a decision to quit. Nevertheless, personalized advice to quit delivered in a caring nonjudgmental manner often moves a client in the precontemplation stage to the contemplation stage of change. This shift in stage of change constitutes success because such movement is in the direction of making a decision to quit some day. Clients’ readiness to quit determines the appropriate strategy for assisting them with the quitting process.

As individuals attempt to stop tobacco use, relapse (reverting to regular tobacco use) followed by recycling through the stages of change occurs frequently. When relapse occurs the client will return to the contemplation or precontemplation stage before attempting to quit again. The dental hygienist encourages clients to view relapse as a learning opportunity because what is learned from relapse can be applied to the next quit attempt. See Table 34-7 for a summary and suggested dental hygiene interventions.

TABLE 34-7 Stages of Readiness to Change⁸

Adapted from Prochaska JO, DiClemente CC: Stages of change in the modification of problem behaviors, Prog Behav Modif 28:184, 1992.

Assist

The manner in which the dental hygienist assists clients in quitting tobacco depends on their readiness to quit (see Figure 34-6 for a tobacco intervention flow chart and the detailed discussion that follows). Whether or not clients are ready to quit, it is critical that the dental hygienist engage them by applying patient-centered communication.^9,10

Figure 34-6 Tobacco intervention flow chart.

Characteristics of patient-centered communication are as follows7,9:

Collaborating, not persuading: The dental hygienist–client relationship involves a partnership that honors the client’s experience and perspectives. The dental hygienist seeks to create a positive interpersonal atmosphere that is conducive to change, but not coercive.

Eliciting information, not imparting information: The dental hygienist’s tone is not one of imparting information, but rather of drawing out motivation for change from the person. Clients do most of the talking, and dental hygienists listen carefully.

Emphasizing the client’s autonomy, not the authority of the expert: Responsibility for change is left with the client.

Arrange

Scheduling a follow-up contact is the fifth A, and it is comparable to the evaluation phase of the dental hygiene process of care. In follow-up contacts, the dental hygienist checks in on where clients are in their thinking about quitting, or on their progress in coping with the quitting process. For those clients who have made an unsuccessful quit attempt, modifications (e.g., new quit date, other pharmacologic adjuncts, different coping mechanisms, as described in later sections) may be introduced. New goals may be set.^2,10

The Brief Intervention

The brief intervention takes less than 3 minutes to perform. The goal is to communicate acceptance of the client’s stage of change and to provide information on the benefits of stopping tobacco use.¹⁰ When a client refuses an offer of help to stop tobacco use in the brief intervention, the dental hygienist does the following¹⁰:

States, “I understand that you are not ready to stop smoking now, but if you don’t mind I would like to give you some information on the benefits of stopping for you to consider” (see Box 34-3). This statement communicates to the client that he or she has been heard and that the dental hygienist understands that the client is not ready to stop now. In addition, the dental hygienist offers information on the benefits of quitting to help move the client to the next stage of change and in the direction of making a decision to quit some day.

Reassures client by stating, “When you decide to try to stop, if you wish, we can help you.”

Asks permission to check in again at the next visit to see where the client is in the decision-making process by stating, “Would it be all right if I check in with you at your next dental hygiene care appointment regarding your thinking about all this?”

Makes a note in the chart to check in again at the next continued-care visit.

The Motivational Interview

In addition to applying the brief intervention as noted previously, the dental hygienist may judge that the client would be open to a motivational interview.⁹ The motivational interview is a form of patient-centered communication to help clients get “unstuck” from the ambivalence that traps them in their tobacco use so they can start the change process.⁹ Ambivalence is a common human experience and is a normal stage in the process of change (i.e., contemplation). Once ambivalence is resolved, little else may be required for the client to decide to stop tobacco use. It is interesting to note, however, that attempts to force resolution of ambivalence by direct persuasion to stop tobacco use can lead to strengthening the very behavior that the clinician intended to diminish. For example, nagging may increase rather than decrease smoking. The theory of psychologic reactance⁹ predicts an increase in the rate and attractiveness of “problem” behavior if a person perceives that his or her personal freedom is being infringed or challenged. Therefore discovering and understanding a client’s motivations for tobacco use are important first steps toward promoting change.

Principles

Four general principles that underlie motivational interviewing are as follows⁹:

Express empathy: The attitude is one of acceptance. The dental hygienist respectfully listens to the client with a desire to understand his or her perspectives without judging, criticizing, or blaming. The client’s perspectives are responded to as understandable and valid. Paradoxically, acceptance of people “as they are” seems to free them to change, whereas insistent nonacceptance tends to immobilize the change process.

Develop discrepancy: Change is motivated by a perceived discrepancy between smoking and important personal goals or values (e.g., “So you enjoy smoking, but you worry about the negative effect your smoking may have on your teenage son”).

Roll with resistance: Resistance is not directly opposed but is acknowledged as being natural and understandable. The dental hygienist avoids arguing for change.

Support self-efficacy (self-confidence): The dental hygienist enhances clients’ confidence in their capability to cope with obstacles and to succeed in change. The hygienist’s own expectations about a client’s likelihood of stopping tobacco use can have a powerful effect on outcome.

Tools

The goal of motivational interviewing is to have the client voice the arguments for change, known as change talk. Change talk includes reasons for concern and the advantages of change (i.e., the good things to be gained.) Tools for eliciting change talk include four strategies referred to by the acronym OARS.^9,10 These tools are as follows:

Open-ended questions: Open-ended questions are questions that cannot be answered by a simple “yes” or “no” response. Open-ended questions begin with asking “What,” “How,” or “Why” and require the client to explain the response. During the motivational interview the dental hygienist allows the client to express himself or herself and explores both sides of the client’s ambivalence about tobacco use by asking open-ended questions (e.g., “What do you like about tobacco use?” “What is the downside?” “So what kind of roadblocks come to mind when you think about stopping smoking?”)

Affirming change talk: This strategy reinforces and focuses on client comments that support stopping tobacco use (e.g., “That’s a good point. Do you have any other concerns?”)

Reflective responding: This technique acknowledges to the client “Here is what I heard you say” (e.g., “So one of the most important considerations for you is how your smoking may affect your daughter.”)

Summarizing results of the dialogue: This strategy brings closure to the session (e.g., “So if I understand you so far, you enjoy smoking because it relaxes you, but you have some real concern that it is beginning to affect your health and that you may be a negative role model for your daughter. These are all important and valid considerations. With what you have shared with me today, it is clear that you have overcome a number of challenges in your life. I have confidence that you’ll be able to resolve this issue of smoking once you make up your mind. If it is all right with you, I’d like to check in with you at your next dental hygiene appointment to see where you are in your thinking about all of this. Just know that if you decide to try to stop smoking, we can help.”)

The Elicit-Provide-Elicit Model

A recommended model for tobacco cessation assistance with referral is the Elicit-Provide-Elicit model promoted by the Mayo Clinic.⁷ Using this model, the dental hygienist does the following:

Elicits information to enhance motivation to quit

○ Asks about the client’s reasons for quitting and reinforces them (e.g., “That’s a great reason!”)

○ Asks about past quit attempts and reassures

States that most individuals have to try multiple times to quit before they are successful, but that each time they try to quit, they learn something new about the quitting process that better prepares them to quit the next time they try

Concludes that as long as individuals are trying to quit they are not failing

Provides:

○ Education about the concept of a quit date, a date clients select 2 to 4 weeks from the time they decide to quit on which they will be tobacco-free

○ Education about nicotine addiction and withdrawal (Box 34-4)

○ Education about the types of pharmacotherapy

○ A self-help booklet on stopping tobacco use and printed materials on benefits of quitting (see Box 34-3)

○ Encouragement to seek social support from family and friends

○ Referral to an external or internal tobacco cessation treatment program

Elicits client’s decision about cessation treatment (e.g., “What would you like to do?”)

The American Dental Hygienists’ Association Ask, Advise, Refer Model

The American Dental Hygienists’ Association (ADHA), in partnership with the Smoking Cessation Leadership Center at the University of California, promotes a public health action plan for dental hygienists that simplifies tobacco cessation to a three-step process. The three-step process promotes asking about tobacco use at every visit, advising those who use tobacco to quit, and referring tobacco users to a state or national tobacco quitline by distributing a card with a national number: 1-800-QUITNOW. This model addresses time constraints expressed by dental hygienists related to tobacco cessation counseling. To enhance understanding of the Ask, Advise, Refer (AAR) tobacco cessation model, the ADHA has developed a website (www.askadviserefer.org) with resources to download to use for chairside communications.

Statewide Tobacco Use Quit Lines

Excellent external resources for referral for tobacco cessation assistance are tobacco use telephone quitlines in 42 states in the United States. They offer easy access at no cost to the client and address ethnic and geographic disparities. Many tobacco users prefer quitlines to face-to-face programs because telephone counseling is more convenient and provides anonymity. Key factors that increase quitline effectiveness include the use of trained counselors, a proactive format in which staff initiates contact and follow-up, and the combination of the quitline with client self-help materials and approved pharmacotherapy.⁵

Assessment

Initially, the tobacco cessation counselor assesses clients’ motivation to quit, reasons for quitting, previous quit attempts, nicotine dependence level, tobacco use patterns in a typical day (i.e., the number of dips, chews, or cigarettes used per day and associated cravings and mood states), mood disorder history, and pharmacotherapy contraindications. These assessment data are used to tailor client quit plans based on individual needs. The following information relates to this assessment process.

Motivation to Quit

Motivation is fundamental to changing behavior. A client’s level of motivation to stop tobacco use is often a good predictor of outcome.⁹ To enhance clients’ motivation and to measure motivation to quit, the counselor reads the following question and asks clients to circle an answer⁷:

The number circled then serves to measure clients’ initial motivation and to monitor motivation to stop tobacco use at subsequent appointments.⁷ The number circled also serves as the basis of a discussion to increase clients’ motivation to quit. For example, if a client circles the number 5, the counselor might say, “Great! But why did you circle a 5 rather than a 3?” This open-ended question requires clients to talk positively about their motivation to quit, which serves to enhance their motivation. In general, asking clients why they circled a higher number rather than a lower number on the importance of quitting scale triggers clients to respond positively about their motivation to quit. On the other hand, asking clients why they circled a lower number rather than a higher number requires clients to talk negatively about their motivation to quit, which can become discouraging for them and decrease their motivation to make a quit attempt.

Nicotine Dependence

There are many ways to assess nicotine dependence. Recommended evidence-based questions to ask clients are as follows:

“Do you smoke every day?”

“Do you use tobacco within 30 minutes of waking?”

“Do you use most of the day?”

“Do you crave tobacco when you have not used for 2 hours?”

Clients who respond “yes” to any of these questions, especially with regard to using tobacco within 30 minutes of waking, are determined to be nicotine-dependent.6

Nicotine dependence also can be assessed by asking the question, “When you smoke, how many cigarettes per day do you usually have?” Clients who report they smoke one to 15 cigarettes per day are considered to be nicotine-dependent lighter smokers, compared with those who report they smoke more than 15 cigarettes per day. To minimize discomfort from nicotine withdrawal, it is important for nicotine-dependent tobacco users to wean themselves off of nicotine before the quit date rather than to stop abruptly (i.e., “cold turkey”). Strategies that combine behavioral and FDA-approved adjunctive pharmacologic support achieve the best outcomes for nicotine-dependent clients.^2,5

Patterns of Tobacco Use

To assess patterns of use in a typical day, clients are asked to recall each cigarette, chew, or dip they have in a typical day.6 Focusing on a typical day, the counselor helps the client fill out the form shown in Figure 34-7. Beginning with the first dip, chew, or cigarette of the day, the time of day tobacco usually is used and the situation in which the use occurs are recorded.⁶ Clients are then asked to do the following:

Rate their desire or craving for each recorded tobacco use on a scale of 1 to 10, where a score of 1 represents “do not crave it at all” (the lowest craving) and a score of 10 indicates “have to have it” (the strongest craving). The tobacco uses with lower craving scores are the easiest to eliminate, and it is recommended that clients give them up first in the weaning process.

Describe their mood at each recorded tobacco use by indicating a number between 1 and 10, where 1 = relaxed; 2 = bored; 3 = angry; 4 = happy; 5 = stressed; 6 = excited; 7 = tired; 8 = sad; 9 = hungry; and 10 = irritable.

Figure 34-7 Diary monitoring patterns of tobacco use.

(From Jensen J, Hatsukami D: Tough enough to quit using snuff: a self-help manual for quitting spit tobacco, Minneapolis, 1994, University of Minnesota Tobacco Research Laboratory.)

Understanding the level of craving and the client’s mood when tobacco is used helps to establish a quit plan and to identify coping strategies to prevent relapse once the client quits. After working with the client to monitor tobacco use in a typical day, the counselor may say something like,

“To help you to prepare for quitting, I would like you to continue to monitor your tobacco use over the next week. To accomplish this, I will give you a diary to assess the number of cigarettes you have each day during the next week, the time of day you smoke, the intensity of cravings you have for each cigarette, the place where you are when you use your tobacco, the activity you are doing at the time, and your associated mood state. I would like you to complete the diary I am going to give you and bring it to your next appointment so we can review it together. The craving scores will help us understand which cigarettes might be the easiest to give up first. The mood scores will help us to understand why you use, and that knowledge will help identify ways to help you cope with not using (e.g., if you smoke to relieve stress, then we need to find other ways for you to manage your stress so you won’t need to use tobacco for that purpose).”¹⁰

Contraindications to Pharmacotherapy

Clinical practice guidelines for treating tobacco use and dependence state, “All patients attempting to quit should be encouraged to use effective pharmacotherapies for cessation except in the presence of special circumstances.” To identify special circumstances that would contraindicate certain types of pharmacologic agents approved for smoking cessation, the cessation counselor assesses the presence of any contraindications to FDA-approved medications. Tables 34-8 and 34-9 list contraindications for specific pharmacologic agents.

TABLE 34-8 Over-the-Counter Pharmacotherapies for Tobacco Cessation^∗

TABLE 34-9 Prescription Pharmacotherapies for Tobacco Cessation^∗

Setting a Quit Date

Counselors encourage clients to set a quit date 2 to 4 weeks from the time they decide to quit.⁵ Then between the time clients decide to quit and their quit date, they can get ready to quit. There is no “ideal” time to quit, but some times are better than others. Low-stress times are best, such as a day when there are no work deadlines. Some clients will select a date of particular significance to them, such as a birthday, anniversary, or new car purchase. On the quit date, total abstinence is essential. The goal is “Not even a single puff or dip after the quit date.”

Choosing a Method

Once a quit date is set, the counselor helps clients establish a method to get ready to quit and to cope with the quitting process. The two basic methods of quitting tobacco use are cold turkey and gradual nicotine reduction. Cold turkey is the approach of quitting tobacco use abruptly on one’s quit date (Box 34-6).⁵ Gradual nicotine reduction is the approach that slowly and systematically reduces the amount of nicotine clients use so that they will have fewer symptoms of withdrawal on their quit date. Nicotine reduction can be accomplished either by brand switching or by gradually tapering down use of the original brand.⁶

Brand switching involves changing to another brand of tobacco with a lower level of available nicotine to gradually reduce exposure to nicotine. For example, Table 34-1 lists some brands of spit tobacco according to level of bioavailable nicotine. The counselor emphasizes to clients that if they switch to a brand of tobacco with a lower nicotine content, they must be careful not to increase the amount of tobacco they use in an effort to maintain the same level of nicotine.⁶

Tapering down use is a method of systematically reducing the number of tobacco uses by a set amount, such as one to two every few days; tapering may also be accomplished with nontobacco oral substitutes. When clients get to the point where they are using half of their original amount of tobacco, they can try to quit cold turkey. For clients who choose to taper down their tobacco use, the counselor refers to their pattern of use in a “typical day” diary collected during the assessment phase of counseling. Based on the diary information, the counselor suggests that clients start cutting back on those cigarettes or dips with the lowest craving scores.⁶ Table 34-6 lists some helpful suggestions for behavioral strategies to cope with nicotine withdrawal and the temptation to use tobacco. Specific coping strategies clients decide to use and the rewards they plan for themselves on their quit day and for the first week are recorded in the client record.

Coping Skills Training

Coping skills training involves assisting clients to identify action responses (things they can do) and thinking responses (things they can say to themselves) to avoid tobacco use⁶ when tempted (Box 34-7).

Support from Others

Clients are encouraged to tell family, friends, and co-workers about trying to quit tobacco use and to request their understanding and support.^5,6 Stopping tobacco use requires a great deal of effort and energy. Having the support of others is very important. If clients trying to quit are feeling irritable, spouses or partners, family, and friends will be more understanding if they are informed. They can help by not offering tobacco, by giving a pat on the back to reinforce when clients are refraining from tobacco use, and by giving encouragement if things are not going well.

Relapse Prevention

Although nicotine withdrawal lasts only 2 to 4 weeks, the temptation to use can last for years. In order to prevent relapse, it is critical for clients to identify at least three tough situations where they know they will be tempted most to use tobacco, and then to plan ahead to what they will do instead to remain tobacco-free. Planning for these high-risk situations helps clients to out-think their tobacco habit and avoid relapse.⁶ In addition, because drinking alcohol is highly associated with relapse, counselors often encourage clients to review their alcohol use and consider limiting their alcohol consumption or abstaining from alcohol during the quit process.

Transdermal Nicotine Replacement Therapy (Patch)

Transdermal nicotine patches are marketed for 24-hour usage. An advantage of the patch is that it delivers a constant dose of nicotine across the skin throughout its use. A small percentage of clients using the 24-hour patch have reported sleep interrupted by nightmares, an indication of nicotine toxicity. If this occurs, the dose of nicotine should be reduced either by removing the patch during sleeping hours or by using a lower-dose patch. Clients also may experience dermatitis as a side effect of using the patch (see Table 34-8). Directions for use require the client to place a new patch each day on a nonhairy site of the upper trunk. No one site should be used again in less than a week. Used patches should be disposed of carefully, because residual nicotine could harm small children and animals. Patches work on a dosing-down principle, and the aim is to gradually discontinue use over 12 weeks (e.g., 21 mg for weeks 1 to 8; 14 mg for weeks 8 to 10; and 7 mg for weeks 10 to 12). The client eventually is weaned off nicotine. Each patch dose is generally of a 2- to 4-week duration, depending on client response. Small-framed or obese clients may require dose modification. Triage with the client’s physician is advised, particularly if the client has systemic disease. In general, client compliance is easier to achieve with the patch than with other forms of nicotine replacement that require more behavior modification. Once the patch is placed, a client needs to do no more until the next day.¹⁰

Nicotine Polacrilex (Gum)

Nicotine gum is available OTC in 2- or 4-mg doses. Dose is based on smoking pattern. For clients who smoke less than 25 cigarettes per day, 2-mg gum is recommended. For those smoking more than 25 cigarettes per day, 4-mg gum is recommended. The aim is to discontinue gum use gradually over 10 to 12 weeks. The recommended schedule is one piece of gum every 1 to 2 hours per day for weeks 1 to 6; one piece of gum every 2 to 4 hours for weeks 7 to 9; and one piece of gum every 4 to 8 hours for weeks 10 to 12. Proper gum use requires clients to chew the gum very slowly because the nicotine is absorbed through the oral mucosa (in an alkaline environment) and not the gut (an acidic environment). The client should stop chewing at the first sign of a peppery, minty, or citrus taste or tingle and then “park” the gum between the cheek and the gingiva. Overchewing can result in nicotine toxicity, in which the client may experience stomach upset, nausea, and/or vomiting. Success with nicotine gum is greater when the client has a fixed dosage schedule throughout the day to prevent craving. Often if clients wait until a craving arises before using a piece of gum, they will relapse to tobacco use, because a cigarette or dip provides more rapid absorption of nicotine into the blood compared with the gum. To avoid withdrawal and relapse, nicotine gum is sometimes used in the morning in combination with the patch when the patch is first placed. This action enables the client to receive a quick boost of nicotine with the addition of the gum to prevent breakthrough craving (see combination therapy below). The nicotine patch provides nicotine to the bloodstream at a constant rate and dosage. (See Table 34-8 for contraindications and side effects.)

Nicotine Lozenge

The nicotine lozenge is available OTC in 2- or 4-mg doses. The lozenge provides 25% more nicotine than the equivalent nicotine gum dose because the lozenge dissolves in the mouth completely in 20 to 30 minutes. Like the gum, it is used on a regular schedule (every 1 to 2 hours) throughout the day to prevent cravings. The initial dose is based on the time of first cigarette use after waking. Those who have a history of having their first cigarette within 30 minutes of waking begin with the 4-mg lozenge. The aim is to discontinue use gradually over 12 weeks on a schedule similar to that used for the gum. The lozenge is meant to be parked next to the oral mucosa. The client should not chew or swallow the lozenge for maximum effectiveness and to avoid adverse side effects similar to those reported for improper use of the gum. (See Table 34-8 for contraindications and side effects.)⁵

Nicotine Spray

The nicotine nasal spray is available by prescription only owing to the rapid absorption of its nicotine through the nasal membranes into the blood and therefore its potential for abuse. Of all of the nicotine replacement products the nicotine spray provides the fastest nicotine delivery system (i.e., nicotine is absorbed into the blood the fastest). Each dose spray is metered to deliver 0.5 mg of nicotine in each nostril. It is used on a daily fixed schedule beginning with one or two doses per hour. For best results, at least eight doses are recommended daily for the first 6 to 8 weeks. Dosage should never exceed five doses in 1 hour or 40 doses in 24 hours. The aim is to gradually discontinue use over an additional 4 to 6 weeks. (See Table 34-9 for contraindications and side effects.)

Nicotine Oral Inhaler

The nicotine oral inhaler is available by prescription only (see Figure 34-9). It consists of a mouthpiece and plastic cartridge delivering 4 mg of nicotine vapor. The client inhales into the back of the throat by puffing in short breaths. The nicotine is absorbed across the oropharyngeal mucosa. In general, the use of 6 to 16 cartridges per day for 3 to 12 weeks is recommended, however, use depends on clients’ individual smoking history. The inhaler is most effective if puffed frequently for 20 minutes at a time. The aim is to discontinue use gradually over an additional 6 to 12 weeks. (See Table 34-9 for contraindications and side effects.)

Combination Nicotine Replacement Therapy

The nicotine patch is a long-acting formulation that produces relatively constant levels of nicotine. Short-acting, rapidly absorbed formulations such as the nicotine gum, lozenge, inhaler, and spray are often used to augment the patch to prevent or control breakthrough cravings or withdrawal symptoms. These short-acting formulations (gum, lozenge, inhaler, nasal spray) allow for acute dose titration as needed in severely nicotine-dependent tobacco users trying to stop their tobacco use.^5,10