The nicotine in tobacco is largely responsible for the addiction to smoking, as nicotine is a stimulant that primarily affects the functioning of the sympathetic nervous system.
The nicotine in gum or patches can help people who are dealing with smoking addiction. The main side effects of nicotine are a feeling of bitterness in the mouth while chewing gum, local irritation of the skin while using the patches, and headaches

Category

Chemical class: Pyridine alkaloid
Therapeutic class: Smoking cessation adjunct

Pregnancy category: C

(nicotine polacrilex), D (other forms of nicotine)

Indications

To relieve nicotine withdrawal symptoms, including craving CHEWING GUM
Adults. Initial: 2 or 4 mg p.r.n. or every 1 to 2 hr, adjusted to complete withdrawal by 4 to 6 mo. Maximum: 30 pieces of 2-mg gum daily or 20 pieces of 4-mg gum daily. NASAL SOLUTION
Adults. 1 to 2 sprays (1 to 2 mg) in each nostril/hr. Maximum: 5 mg/hr or 40 mg daily for up to 3 mo. ORAL INHALATION Adults and adolescents. 6 to 16 cartridges (24 to 64 mg) daily for up to 12 wk; then dosage gradually reduced over 12 wk or less. Maximum: 16 cartridges (64 mg) daily for 6 mo. TRANSDERMAL SYSTEM
Adults. Initial: 14 to 22 mg daily, adjusted to lower-dose systems over 2 to 5 mo.
DOSAGE ADJUSTMENT For adolescents and for adults weighing less than 45 kg (100 lb) and who smoke less than 10 cigarettes daily or have heart disease, initial dosage reduced to 11 to 14 mg daily and adjusted to lowerdose systems over 2 to 5 mo.

Mechanism of Action

Binds selectively to nicotinic-cholinergic receptors at autonomic ganglia, in the adrenal medulla, at neuromuscular junctions, and in the brain. By providing a lower dose of nicotine than cigarettes, this drug reduces nicotine craving and withdrawal symptoms.

Contraindications

Hypersensitivity to nicotine, its components, or components of transdermal system; life-threatening arrhythmias; nonsmokers; recovery from acute MI; severe angina pectoris; skin disorders (transdermal); temporomandibular joint disease (chewing gum)

Interactions

acetaminophen, beta blockers, imipramine, insulin, oxazepam, pentazocine,
theophylline: Possibly increased therapeutic effects of these (chewing gum,
NASAL SPRAY, transdermal system) alpha blockers, bronchodilators: Possibly increased therapeutic effects of these (chewing gum, transdermal system)
bupropion: Potentiated therapeutic effects of nicotine, possibly increased risk of hypertension sympathomimetics: Possibly decreased therapeutic effects of these (chewing gum, transdermal system) theophylline, tricyclic antidepressants: Possibly altered pharmacologic actions of these (oral inhalation) acidic beverages (citrus juices, coffee, soft drinks, tea, wine): Decreased nicotine absorption from gum if beverages consumed within 15 minutes before or while chewing gum caffeine: Increased effects of caffeine (chewing gum,
NASAL SPRAY, transdermal system)

Side Efect

CNS: Dizziness, dream disturbances, drowsiness, headache, irritability, lightheadedness, nervousness (chewing gum, transdermal system); amnesia, confusion, difficulty speaking, headache, migraine headache, paresthesia (
NASAL SPRAY); chills, fever, headache, paresthesia (oral inhalation)
CV: Arrhythmias (all forms); hypertension (chewing gum, transdermal system); peripheral edema (
NASAL SPRAY)
EENT: Increased salivation, injury to teeth or dental work, mouth injury, pharyngitis, stomatitis (chewing gum); altered taste, dry mouth (chewing gum, transdermal system); altered smell and taste, burning eyes, dry mouth, earache, epistaxis, gum disorders, hoarseness, lacrimation, mouth and tongue swelling, nasal blisters, nasal irritation or ulceration, pharyngitis, rhinitis, sinus problems, sneezing, vision changes (
NASAL SPRAY); altered taste, lacrimation, pharyngitis, rhinitis, sinusitis, stomatitis (oral inhalation)
GI: Eructation (chewing gum); abdominal pain, constipation, diarrhea, flatulence, increased appetite, indigestion, nausea, vomiting (chewing gum, transdermal system); abdominal pain, constipation, diarrhea, flatulence, hiccups, indigestion, nausea (
NASAL SPRAY); diarrhea, flatulence, hiccups, indigestion, nausea, vomiting (oral inhalation)
GU: Dysmenorrhea (chewing gum, transdermal system); menstrual irregularities (
NASAL SPRAY)
MS: Jaw and neck pain (chewing gum); arthralgia, myalgia (chewing gum, transdermal system); arthralgia, back pain, myalgia (
NASAL SPRAY); back pain (oral inhalation)
RESP: Cough (chewing gum, transdermal system); bronchitis, bronchospasm, chest tightness, cough, dyspnea, increased sputum production (
NASAL SPRAY); chest tightness, cough, dyspnea, wheezing (oral inhalation)
SKIN: Diaphoresis, erythema, pruritus, rash, urticaria (chewing gum, transdermal system); acne, flushing of face, pruritus, purpura, rash (
NASAL SPRAY); pruritus, rash, urticaria (oral inhalation)
Other: Allergic reaction (chewing gum, transdermal system); physical dependence (
NASAL SPRAY); flulike symptoms, generalized pain, withdrawal symptoms (oral inhalation)

Cautions

When administering nicotine by oral inhalation, expect optimal effect to result from continuous puffing for 20 minutes.

To avoid possible burns, remove patch before patient has an MRI.

PATIENT SAFTY

Instruct patient to read and follow package instructions to obtain best results with nicotine product.

Advise patient to notify prescriber about other she takes.

Stress that patient must stop smoking as soon as nicotine treatment starts to avoid toxicity.

For chewing gum therapy, instruct patient to wait at least 15 minutes after drinking coffee, juice, soft drink, tea, or wine. Advise her to chew gum until she detects a tingling sensation or peppery taste and then to place gum between her cheek and gum until tingling or peppery taste subsides. Then direct her to move gum to a different site until tingling or taste subsides, repeating until she no longer feels the sensation—usually about 30 minutes. Caution against swallowing the gum.

For
NASAL SPRAY, tell patient to tilt her head back and spray into a nostril. Caution against sniffing, swallowing, or inhaling spray because nicotine is absorbed through nasal mucosa.

Warn patient that prolonged use of nasal form may cause dependence.

For oral inhalation, tell patient to use 6 to 16 cartridges daily to prevent or relieve withdrawal symptoms and craving. Starting with 1 or 2 cartridges daily yields poor success. Direct patient to inhale through device like a cigarette, puffing often for 20 minutes.

For transdermal system, tell patient not to open package until just before use because nicotine is lost in the air. Advise her to apply system to clean, hairless, dry site on upper outer arm or upper body. Instruct her to change systems and rotate sites every 24 hours and not to use the same site for 7 days. To avoid possible burns, advise patient to remove patch before undergoing any MRI procedure.
WARNING Urge patient to keep all unused nicotine forms safely away from children and pets and to discard used forms carefully. (Enough nicotine may remain in used systems to poison children and pets.) Instruct her to contact a poison control center immediately if she suspects that a child has ingested nicotine.

Explain to patient with asthma or COPD that nicotine may cause bronchospasm.

Inform patient that it may take several attempts to stop smoking. Urge her to join a smoking cessation program.

Trade Name & Company Name

Trade name	Company name
NIQUITIN 2MG MINT LOZENGE	GLAXOSMITHKLINE (GSK)
NIQUITIN 4MG MINT LOZENGE	GLAXOSMITHKLINE (GSK)
NICOTINELL TTS-10	LTS LOHMANN Therapie-Systeme
NICOTINELL TTS-20	LTS LOHMANN Therapie-Systeme
NICOTINELL TTS-30	LTS LOHMANN Therapie-Systeme
NICOTINELL 1MG LOZENGES	SANICO

effect of Nicotine in Pregnancy, Fetal Health and Breast feeding

Pregnancy

. Cigarette smoking is directly linked to an array of health care problems whose costs to society are staggering. Active and passive maternal smoking has damaging effects in each trimester. Cigarette smoke contains numerous toxins that exert a direct effect on placental and fetal cell proliferation and differentiation. It is the single largest modifiable risk for pregnancy-related morbidity and death in the US. Cigarette smoking increases the rate of subfertility and failed IVF. Addiction to nicotine is a primary contributor to tobacco use. Nicotine replacement facilitates cessation by relieving the physiologic symptoms of withdrawal. Nicotine delivery systems include gum, patch, nasal spray, and vapor inhaler. Because nicotine medications do not deliver the toxins and carcinogens delivered by cigarettes, they are considered safer than smoking if used as directed. Women should be advised to stop smoking completely during pregnancy, and that 781 a simple reduction in the number of cigarettes smoked, or switching to so-called low-tar or low-nicotine concentration cigarettes will not significantly reduce the perinatal risks. Nicotine patch therapy may help some pregnant smokers, but the success rate during

Pregnancy

is low. Despite the failure of large numbers of treated women to quit, the average birth weight is increased by therapy. The success rate may be enhanced by the addition of an SSRI and formal counseling. Preliminary study suggests women who cannot quit smoking after the 1st trimester metabolize nicotine more rapidly than those who can. Thus, the optimal response may be to raise the support level during pregnancy, not lower it. Social support systems can enhance the likelihood of long-term success in women who do quit smoking during pregnancy. The initial dose of nicotine during replacement therapy should approximate the dose of nicotine being consumed. Intermittent-use formulations of NRT (gum, spray, inhaler) are preferred as the total dose of nicotine delivered to the fetus is less than with continuous-use formulations (transdermal patch).

Fetal Health

Cigarette smoke contains thousands of chemicals, many of which are well-documented reproductive toxins (e.g., nicotine, carbon monoxide, lead). Nicotine rapidly crosses the placenta, and the fetuses of mothers who smoke are exposed to higher concentrations than their mothers. Smoking during

Pregnancy

is a major risk factor for spontaneous abortion, preterm placental abruption, IUGR, late fetal death, neonatal polycythemia, and SIDS. The increased miscarriage rate among mothers who smoke may be related to direct adverse effects of nicotine, cadmium, or the polyaromatic hydrocarbons on trophoblast invasion and proliferation. The mean reduction in birth weight in infants of smokers is 200g. Recent study indicates a greater prevalence of facial clefts in the offspring of smokers. Longitudinal studies in humans suggest that prenatal exposure to nicotine increases the risks for cognitive deficits, ADHD, conduct disorder, criminality in adulthood, and a predisposition of the offspring to abuse tobacco and alcohol. Sheep and human studies reveal that prenatal nicotine blunts elements of the fetal cardiorespiratory defense for hypoxia (HR, ventilatory and arousal responses), and has long-term effects on the postnatal breathing pattern. The newborn unable to maximize cardiac output during times of stress is at increased risk for morbidity and possible death. Acute exposure to nicotine significantly decreases fetal heart reactivity. Median epinephrine and NE concentrations in the umbilical cord are significantly lower in smokers compared with nonsmokers. The significance of this finding is unclear, but could reflect depletion. The finding of increased connective tissue expression in pulmonary vessels of fetal monkeys whose mothers were treated with nicotine suggests nicotine is transported across the placenta and directly interacts with nicotinic ACH receptors in pulmonary vessels to alter connective tissue expression and produce vascular structural alterations. Rodent studies show that nicotine exposure compromises neuronal maturation, leading to long-lasting structural alterations in key brain regions involved with cognition, learning, and memory. Human neonatal nicotine withdrawal does occur.

Breastfeeding

Nicotine is excreted in human milk at low concentrations. Milk cotinine (a by-product of nicotine) levels do not correlate with 782 the number of cigarettes smoked. Newborns breastfed by smoking women are exposed not only to environmental (??passive??) smoke, but also by ingesting nicotine metabolites and toxic by- products present in the milk. Maternal smoking cessation with the nicotine patch is a safer option than continued smoking. In one study of 15 women, the milk nicotine and cotinine concentrations were no different between smoking (mean of 17 cigarettes/d) and the 21mg/d patch, but concentrations were lower when patients were using the 14mg/d and 7mg/d patches. There was also a downward trend in absolute infant dose (nicotine equivalents) from smoking or the 21mg patch through

the follwing drugs will increse Nicotine by inhepiting cyp450

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the follwing drugs will decrease Nicotine by inhancing cyp450

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Smoking cessation agents

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Gen name	Trade name	Catagory name
nicotine	Commit	Smoking cessation agents
nicotine	Habitrol	Smoking cessation agents
nicotine	Leader Nicotine Polacrilex	Smoking cessation agents
nicotine	Nicoderm CQ	Smoking cessation agents
nicotine	Nicorelief	Smoking cessation agents
nicotine	Nicorette	Smoking cessation agents
nicotine	Nicotrol Inhaler	Smoking cessation agents
nicotine	Nicotrol NS	Smoking cessation agents
Nicotine	NICOTINELL 1MG LOZENGES
Nicotine	NICOTINELL TTS-10
Nicotine	NICOTINELL TTS-20
Nicotine	NICOTINELL TTS-30
Nicotine	NIQUITIN 2MG MINT LOZENGE
Nicotine	NIQUITIN 4MG MINT LOZENGE

Gen name	trade name	catogry
varenicline	Chantix	Smoking cessation agents
bupropion	Zyban	Smoking cessation agents
nicotine	Nicoderm CQ	Smoking cessation agents
nicotine	Nicotrol Inhaler	Smoking cessation agents
nicotine	Nicorette	Smoking cessation agents
nicotine	Commit	Smoking cessation agents
nicotine	Habitrol	Smoking cessation agents
nicotine	Nicotrol NS	Smoking cessation agents
bupropion	Buproban	Smoking cessation agents
nicotine	Leader Nicotine Polacrilex	Smoking cessation agents
nicotine	Nicorelief	Smoking cessation agents