What is the proper protocol for prescribing nicotine (Nicotinamide) lozenges for smoking cessation?

From the Guidelines

Nicotine lozenges should be prescribed based on the patient's smoking habits, with 4mg strength for those who smoke their first cigarette within 30 minutes of waking and 2mg strength for those who smoke later, as supported by studies such as 1 and 1. The typical regimen is one lozenge every 1-2 hours for the first 6 weeks, then one lozenge every 2-4 hours for weeks 7-9, and finally one lozenge every 4-8 hours for weeks 10-12. Some key points to consider when prescribing nicotine lozenges include:

• Patients should use at least 9 lozenges daily during the initial phase but not exceed 20 lozenges per day (4mg) or 24 lozenges per day (2mg) as indicated in 1.
• Instruct patients to place the lozenge in their mouth and allow it to dissolve slowly over 20-30 minutes without chewing or swallowing it.
• They should avoid eating or drinking for 15 minutes before and during lozenge use. This treatment works by delivering controlled amounts of nicotine to reduce withdrawal symptoms while the patient breaks the smoking habit, with the gradual reduction in dosing helping to wean them off nicotine dependence over the 12-week period, as discussed in 1. Combining nicotine lozenges with other forms of nicotine replacement therapy (NRT) or pharmacotherapy, such as bupropion or varenicline, may also be effective in increasing cessation rates, as suggested by studies such as 1 and 1. However, it's essential to consider the potential side effects and interactions of these medications, as well as the patient's medical history and current health status, before making a prescription decision, as noted in 1.

From the Research

Prescribing Nicotine Lozenge

To prescribe nicotine lozenge, consider the following:

• The patient's level of nicotine dependence, as assessed by the time to the first cigarette of the day 2
• The patient's preference for acute oral forms, as some smokers may reject chewing gum 2
• The dosage of the nicotine lozenge, with 2-mg and 4-mg options available 2
• The potential for adverse events, such as nausea, insomnia, anxiety, irritability, fatigue, and abnormal dreams, although these are usually mild to moderate 3

Dosage and Administration

• Low-dependence smokers may be prescribed the 2-mg nicotine lozenge, while high-dependence smokers may be prescribed the 4-mg lozenge 2
• The lozenge should be used as needed, with the patient instructed to suck on the lozenge until it dissolves, usually within 20-30 minutes
• The patient should be advised not to chew or swallow the lozenge whole

Efficacy and Safety

• Nicotine lozenge has been shown to be a safe and effective treatment for smoking cessation in low- and high-dependence smokers 2
• Treatment with the nicotine lozenge resulted in significantly greater 28-day abstinence at 6 weeks, compared with placebo 2
• The use of the active lozenge also resulted in reduced craving and withdrawal symptoms 2

Comparison with Other Treatments

• Varenicline and bupropion are non-nicotinic pharmacotherapies that have been used in addition to nicotine replacement therapy for smoking cessation 3
• Varenicline has been shown to be more effective in maintaining abstinence and reducing craving than bupropion and NRT 3
• Nicotine replacement therapy, including lozenges, may be used in combination with prescription medications, such as varenicline, to improve quit rates 4, 5