Treating Tobacco Use During Pregnancy and Beyond

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Treating Tobacco Use During Pregnancy and Beyond

• Pharmacological Aids to Assist Pregnant Women
  With Smoking Cessation
• Dr. Monica Scheibmeir
• Associate Professor School of Nursing
• University of Kansas Medical Center

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Pharmacologic Intervention

• Behavioral interventions are first-line treatment
  in pregnant women (the 5 As)
• Pharmacotherapy has not been sufficiently tested
  for efficacy or safety in pregnant smokers

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Smoking and nicotine

• Other toxins in tobacco smoke, not nicotine, are
  responsible for majority of adverse health
  effects
• gt 4000 different chemicals
• tar, carbon monoxide, irritant and oxidant gases
• gt 40 carcinogens (9 group 1 carcinogens)

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Smoking and nicotine

• The main adverse effect of nicotine from tobacco
  is addiction, which sustains tobacco use
• Nicotine dependence leads to continued exposure
  to toxins in tobacco smoke

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Nicotine Replacement Therapy

• Delivers a small, steady dose of nicotine into
  the body, which helps to relieve the withdrawal
  symptoms
• Increases the long-term quit rates
• Should be used in combination with counseling,
  such as health care provider, Quitline, etc.

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Nicotine replacement therapy

• Nicotine replacement therapy (NRT) can be used
  instead of tobacco to aid quitting
• NRT delivers nicotine without the toxins from
  tobacco
• NRT helps combat the symptoms of withdrawal
• Nicotine dose from NRT is lower and administered
  more gradually than with smoking and this reduces
  the addictive potential

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Safety of NRT

• Risk of cancer from NRT is negligible compared to
  the risk from continued smoking
• Nicotine per se is not a known cause of cancer
• Other tobacco smoke constituents are believed to
  be responsible for cancers

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NRT and pregnancy

• Maternal smoking is associated with poor
  pregnancy and childhood outcomes
• Many toxins in tobacco smoke could be responsible
• Nicotine is a potential fetal teratogen
• Nicotine may contribute to obstetrical
  complications in pregnant women and to sudden
  infant death syndrome

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NRT and pregnancy

• Benefits of NRT outweigh the risks of smoking
  during pregnancy
• reduce or eliminate the exposure of fetus to
  other toxins in tobacco smoke
• reduce overall dose and duration of exposure to
  nicotine

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Pharmacologic Intervention

• Behavioral interventions are first-line treatment
  in pregnant women (the 5 As)
• Pharmacotherapy has not been sufficiently tested
  for efficacy or safety in pregnant smokers
• It may be necessary for heavy smokers (1 or more
  packs per day)

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High Measure of Dependence

• 10-20 or more cigarettes per day
• Smokes within 30 minutes of waking
• Comorbid psychiatric disorders
• No previous quit attempt or repeated failed quit
  attempts

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Suggestions for Use of NRT

• Clinical Recommendations
• Use NRT in combination with behavioral therapy
• Select dose based on evidence of what is
  effective to achieve quit
• Individualize delivery system given patients
  symptoms
• Use non-continuous delivery mechanisms
• Start NRT as early as possible in pregnancy

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Choosing a Pharmacological Agent

• Patient preference
• Patients previous experience with medications
• Compliance/costs
• Clinician familiarity with medication

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NRT Products

• Polacrilex Gum Nasal
  Spray Nicorette (OTC)
  Nicotrol NS (Rx)
• Generic nicotine gum (OTC)
• Lozenge
  Inhaler
• Commit (OTC)
  Nicotrol (Rx)
• Transdermal Patches
• Nicoderm CQ (OTC)
• Nicotrol (OTC)
• Generic nicotine patches (OTC, Rx)

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The Nicotine Patch

• Published studies with pregnant women
• Rx in 1991 OTC in 1996
• Supplies a steady amount of nicotine to the body
  through the skin
• usually lower plasma nicotine levels than seen
  with smoking
• Low potential for dependence

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Transdermal Nicotine PatchComparisons
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Transdermal Nicotine Patch Dosing
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Issues/Side Effects of the Nicotine Patch

• Use upper body area when applying the patch
• Same site should not be used for at least 1 week
• Skin irritation Patient must rotate patch site
  each time a new patch is applied
• Often disturbs sleep at night (vivid dreams)

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Nicotine Gum

• Published report with pregnant smokers
• Rx in 1984, OTC in 1996
• Chewing gum releases nicotine into the
  bloodstream through the lining of the mouth
• Sugar free base
• Available in 2mg and 4mg doses regular, mint,
  orange

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Nicotine Gum Directions for Use

• Must park and chew
• Have patient stop chewing when minty, peppery, or
  tingling sensation occurs
• When sensation fades, start chewing gum slowly
  again
• Initially chew gum for 30 minutes
• Frequent use initially (15-20 per day)
• Great for triggers

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Nicotine Gum Dosing

• Recommended Schedule for Gum

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Issues/Side Effects of Nicotine Gum

• Not appropriate for patients with TMJ
• Not appropriate for patients with dental work
• Absorption is slow peaks around 15 minutes

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Issues/Side Effects of Nicotine Gum

• Requires alkaline pH no soda, coffee, juice at
  least 15 minutes before or during use of the gum
• Not to use more than 24 pieces/day
• If swallowed, causes heartburn
• Mouth sores can occur

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Nicotine Lozenge

• No published studies in pregnancy
• Available in 2002 OTC
• Delivers about 25 more nicotine than gum
  equivalent
• Available in 2mg and 4mg strengths

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Nicotine Lozenge

• Dosage based upon time to first cigarette not
  number of cigarettes/day
• If patient smokes within 30 minutes of awakening,
  suggest 4mg lozenge
• If patient smokes her first cigarette more than
  30 minutes from awakening, suggest 2 mg lozenge
• Dosing schedule is identical to gum

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Nicotine Lozenge

• Instruct patient to allow lozenge to dissolve
• Do not chew or swallow the lozenge
• The lozenge will dissolve 20-30 minutes
• Do not have the patient eat or drink 15 minutes
  before or during use of the lozenge
• Should use 9 lozenges/day to improve changes of
  quitting

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Issues/Side Effects of Nicotine Lozenge

• Common side effects include nausea, hiccups,
  heartburn, cough, headache, and flatulence
• An advantage is easy to conceal
• May help with oral cravings

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Nicotine Nasal Spray

• No published studies in pregnant women
• Rx in 1996
• Quicker than patch or gum reduce cravings in
  minutes of use
• Each metered dose delivers 0.5 mg nicotine

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Nicotine Nasal Spray

• One 0.5mg dose in each nostril (up to 40 per
  day)
• Start with 1-2 doses per hour
• Increase prn to maximum of 5 doses per hour
• Patients should use at least 8 doses/day for the
  first 6-8 weeks
• Need to taper over 4-6 weeks

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Issues/Side Effects of Nicotine Nasal Spray

• Not recommended for patients with nasal or sinus
  conditions
• Watering eyes and nose
• Burning sensation in nose
• Irritated throat
• Sneezing and coughing

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The Nicotine Inhaler

• No published studies with pregnant women
• Rx in 1997
• Delivers 4m nicotine vapor
• May satisfy strong oral or hand-mouth urges
  (feels like smoking)

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The Nicotine Inhaler

• Initially, use 6 cartridges/day up to the max of
  16 cartridges/day
• Not to use gt 12 weeks duration
• Tapering may take an additional 6-12 weeks
• Instruct patient to inhale deeply or puff using
  quick breaths
• Cartridge doesnt have to be used all at once
• Is less effective in very cold/hot temperatures

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Issues/Side Effects of the Nicotine Inhaler

• Slower onset, like gum
• Throat and mouth irritation
• Coughing
• Not for patients with bronchial problems, such as
  asthma

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Tobacco Cessation Aids that Do Not Contain
Nicotine

• Bupropion (Zyban-sustained release formula)
• Available only by prescription
• Category B drug in pregnancy
• GlaxoSmithKline Pregnancy Registry
• (1-800-336-2176)
• Dose is 150mg (one dose per day, 2 doses after 3
  or 5 days). Should start using 1 week before quit
  date.

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Issues/Side Effects of Bupropion

• Greatest risk is seizures
• Dry mouth
• Insomnia
• Dizziness
• Not for patients with eating disorders

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Pharmacotherapies for smoking cessation during
pregnancy