Pharmacotherapy Options

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• Can be purchased over the counter (no prescription needed).
• Provides a rate-controlled delivery of nicotine that is absorbed through the skin.
• Treatment generally lasts 8-12 weeks or longer if necessary.
• Has a slow onset and contains lower levels of nicotine than cigarettes and higher levels than gum.

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• Can be purchased over the counter (no prescription needed).
• Substitutes a piece of gum for the craving for a cigarette, providing gratification for oral needs and nicotine cravings.
• Is not chewed continuously, rather, chewed 2-3 times, then parked between the cheek and the gum. "Bite, bite and park", wait a minute then repeat over 30 mins or less.
• Treatment generally lasts several weeks to several months, or longer if necessary.

There is evidence that combining the nicotine patch with nicotine gum increases long-term abstinence rates over those produced by a single form of NRT.

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• Can be purchased over the counter (no prescription needed).
• Is a mouthpiece with a nicotine cartridge insert.
• One puff delivers less nicotine than one puff from a cigarette.
• Addresses both the physical and behavioural dependency of smoking as it mimics the hand to mouth ritual of smoking.
• 'Puff (into mouth) and hold'. Nicotine is absorbed by blood vessels in the buccal cavity. The number of puffs taken depends on the amount of nicotine required to meet individual's cravings and dependence.
• 6-12 cartridges a day for 3 months is recommended by manufacturer, but many need significantly less.

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Options such as nicotine nasal spray, sublingual tablets and lozenges are not currently available in Canada.

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Bupropion hydrochloride is also marketed as the anti-depressant medication Wellbutrin®. It is a non-nicotine medication and requires a prescription. The exact mechanism by which bupropion works is unknown, but it is presumed to alleviate cravings associated nicotine withdrawal affecting noradrenaline and dopamine, two chemicals in the brain that may be components of the nicotine addiction pathway.

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Varenicline tartate will be available in Canada in 2007, and was approved by the US Food and Drug Administration in May 2006. Studies have shown Varenicline to increase the odds of quitting by four times compared to placebo, and double compared to Zyban® at 12 weeks and at 1 year. Varenicline targets nicotinic acetylcholine receptors to decrease craving, withdrawal, and the reinforcement associated with smoking cigarettes.

Clonidine and Nortriptyline are second-line prescription medications used in smoking cessation. These are pharmacotherapies for which there is evidence of efficacy for treating tobacco dependence, but which have a more limited role than first-line medications.

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