Page 816 - Cardiac Nursing

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792 PA R T V / Health Promotion and Disease Prevention
DISPLAY 34-3 Nicotine Replacement Therapy
Nicotine Gum also be aware that 8% to 25% of nicotine gum users who
successfully quit smoking use the gum beyond the 6
Nicotine chewing gum has been available in the United months recommended for maximal use. Habitual use of
States since 1984, and has been available over the the gum to deal with negative emotional states is often
counter since 1997. It comes in 2- and 4-mg doses. It the cause of this prolonged use. 97 As noted previously,
is a resin-based gum that releases nicotine into the the prolonged use of the gum is preferred to smoking and
bloodstream through the buccal mucosa inside the has not been shown to be harmful. 61
mouth. The success of nicotine gum is highly dependent
on its proper use. It has been shown to be highly ineffec- Nicotine Patch
tive when dispensed without proper chewing instruction.
Moreover, when nicotine gum is prescribed without any The transdermal nicotine patch has been available in the
counseling or strong advice, it has been shown to United States by prescription since 1991 and over the
produce very low cessation rates. 94 counter since 1997. The nicotine patch produces a thera-
Patients should start using the gum immediately as soon as peutic effect by releasing a controlled amount of nicotine
they stop smoking. Although nicotine gum was originally through the skin that is absorbed through the capillary
prescribed to be taken on an as-needed basis, studies sug- bed.
gest that a regular schedule of taking the gum, normally The nicotine patch is designed to be worn for a period
one piece every 60 minutes during waking hours, ensures of 16 to 24 hours depending on the brand, with a
constant blood nicotine levels. 95 Side effects are also mini- recommended dose of 21 mg/24 h, or 15 mg/16 h. Lower
mal and transient if the gum is administered properly. doses (10–14 mg) are recommended for some cardiovas-
Most often, these side effects are limited to local mouth ir- cular patients, see above. Patches are designed to be
ritation, some gastrointestinal distress such as nausea and changed daily and are normally recommended to be used
heartburn, palpitations, and jaw ache from excessive for 8 weeks, with weaning beginning at 4 weeks. During
chewing. the weaning period, the dose is reduced in a stepwise
An acidic environment in the mouth blocks nicotine absorp- manner (i.e., 21, 14, and 7 mg) to 7 mg/24 h, or 5 mg/16 h,
tion. Because the use of beverages such as colas, coffee, and finally discontinued. 98 The nicotine patch is often
tea, and juices changes the oral pH to an acidic environ- considered the preferred choice for patients because of
ment, these agents should not be used within 15 minutes ease of use. It requires little effort to apply the patch and
of using the gum or during the first 15 minutes of chew- coverage can be ensured for up to 24 hours.
ing the gum. 96 Because nicotine gum is now available The most frequent side effect of the nicotine patch is local
over the counter, it is imperative that teaching be done skin redness, which occurs in approximately 35% to 54%
by the nurse or, alternatively, the patient should be of patients using the patch. 99–102 Severe skin reactions,
encouraged to discuss proper use with a pharmacist. which include rashes or eczema, have led to discontinua-
Nicotine chewing gum is normally used for a period of 3 tion of therapy in less than 7% of patients. 103,104 Other
to 6 months. A tapering schedule of at least 1 month is side effects reported, which occur much less frequently,
recommended. Weaning can be accomplished by decreas- include gastrointestinal problems of dyspepsia, abdomi-
ing the dosage, cutting gum pieces in half, and substitut- nal pain, and diarrhea; muscle and limb weakness; pares-
ing sugarless gum for some of the doses. Nurses should thesia; nervousness; and vivid or disturbing dreams. 105
smoking as an addiction. Cigarette smoking has clearly been trouble-shoot any problems associated with the use of pharma-
found to be an addiction because it fulfills the requirements for cologic therapies.
addiction of (1) highly controlled or compulsive use; (2) psy- Although a brief intervention is the minimum that all health
choactive effects; and (3) drug-reinforced behavior. 22 care providers should offer their patients, the guidelines 61,62
clearly point out that implementation of a more intensive inter-
Step 5: Arrange—Schedule vention is the goal because there is a strong dose–response relation
Follow-Up Contact between counseling intensity and success in smoking cessation.
The meta-analyses conducted for the current guideline strongly
The guideline 62 concluded that reinforcement by numerous indicate that there is a dose–response relationship between session
contacts and health care professionals leads to greater smoking length and abstinence rates, total amount of contact time and ab-
cessation rates. Ideally, follow-up contact should occur soon af- stinence rates, and the number of sessions and treatment efficacy.
ter the established quit date, preferably within the first week In terms of session length, it was found that abstinence rates in-
and then again within the first month. Follow-up can be per- crease from 10.9 with no contact to 22.1 with longer counseling
formed in person or by telephone. Important components of sessions (lasting 10 minutes). In terms of contact time, it was
follow-up include congratulations on success, support, rein- found that abstinence rates increase from 11.0 with no contact
forcement, and problem solving. If the patient slipped or re- time to 28.4 with 91 to 300 minutes. In terms of number of ses-
lapsed, follow-up provides the opportunity to review the cir- sions, abstinence rates double from 12.4 with no or one session to
cumstances that led to the slip or relapse, create a new plan to 24.7 with more than eight sessions. The guideline thus recom-
deal with a similar situation in the future, and establish a new mends four or more sessions lasting longer than 10 minutes for a
quit date. Follow-up also allows the clinician to review and total contact time of more than 30 minutes.