Nicotine Gum

Nicotine gum is a is a form of nicotine replacement therapy for smoking cessation that delivers nicotine through the linings of the mouth and tongue.

It is usually available in various flavours including fruit, liquorice and mint and each piece typically contains 2 or 4 mg of nicotine, roughly comparable to the content of 1 or 2 cigarettes. The 4mg strength is the recommended strength for those smoking more than 20 cigarettes a day.

Users are directed to chew the gum until it softens and produces a tingling sensation or "peppery" taste. The gum is then "parked," or tucked, in between the cheek and gums.

When the tingling ends the gum is chewed again until it returns, and is then re-parked in a new location. These steps are repeated until the gum is depleted of nicotine (about 30 minutes) or until the craving dissipates.


Clinical use of nicotine gum (FDA approved)
Patient selection
  • Appropriate as a first-line medication for treating tobacco use.
Precautions, warnings, contraindications, and side effects (see FDA package insert for complete list)
  • Pregnancy – Pregnant smokers should be encouraged to quit without medication. Nicotine gum has not been shown to be effective for treating tobacco dependence in pregnant smokers. (Nicotine gum is an FDA pregnancy Class D agent.) Nicotine gum has not been evaluated in breastfeeding patients.

  • Cardiovascular diseases – NRT is not an independent risk factor for acute myocardial events. NRT should be used with caution among particular cardiovascular patient groups: those in the immediate (within 2 weeks) postmyocardial infarction period, those with serious arrhythmias, and those with unstable angina pectoris.

  • Side effects – Common side effects of nicotine gum include mouth soreness, hiccups, dyspepsia, and jaw ache. These effects are generally mild and transient and often can be alleviated by correcting the patient’s chewing technique (see prescribing instructions, below).
Dosage
  • Nicotine gum (both regular and flavored) is available in 2-mg and 4-mg (per piece) doses. The 2-mg gum is recommended for patients smoking less than 25 cigarettes per day; the 4-mg gum is recommended for patients smoking 25 or more cigarettes per day. Smokers should use at least one piece every 1 to 2 hours for the first 6 weeks; the gum should be used for up to 12 weeks with no more than 24 pieces to be used per day.
Availability
  • OTC only.
Prescribing instructions
  • Chewing technique – Gum should be chewed slowly until a “peppery” or “flavored” taste emerges, then “parked” between cheek and gum to facilitate nicotine absorption through the oral mucosa. Gum should be slowly and intermittently “chewed and parked” for about 30 minutes or until the taste dissipates.

  • Absorption – Acidic beverages (e.g., coffee, juices, soft drinks) interfere with the buccal absorption of nicotine, so eating and drinking anything except water should be avoided for 15 minutes before or during chewing.

  • Dosing information – Patients often do not use enough prn NRT medicines to obtain optimal clinical effects. Instructions to chew the gum on a fixed schedule (at least one piece every 1–2 hours) for at least 1–3 months may be more beneficial than ad libitum use.
Costa
  • 2 mg (packaged in different amounts), boxes of 100–170 pieces = $48 (quantity used determines how long supply lasts)
  • 4 mg (packaged in different amounts), boxes of 100–110 pieces = $63 (quantity used determines how long supply lasts)
Source: Treating Tobacco Use and Dependence: 2008 Update. (Fiore et al, 2008)

aCost data were established by averaging the retail price of the medication at national chain pharmacies in Atlanta, GA, Los Angeles, CA, Milwaukee, WI , Sunnyside, NY, and listed online during January 2008 and may not reflect discounts available to health plans and others.

References

Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008.

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