ABC | Volume 112, Nº4, April 2019

FSCLP Statement Oliveira et al 2019: Recommendations for reducing tobacco consumption in Portuguese-Speaking countries Arq Bras Cardiol. 2019; 112(4):477-486 Table 10 – Determinants of initiation of drug therapy • Smokes 20 or more cigarettes per day, OR • Smokes the first cigarette of the day up to 30 minutes after waking up and smokes at least 10 cigarettes per day, OR • Previous attempt with cognitive-behavioral therapy alone was ineffective due to withdrawal symptoms. Table 11 – Nicotine replacement therapy (NRT) Rapid nicotine delivery: nicotine gum and lozenge • Used in the presence of craving (imperative need to smoke) or at intervals of 1-2 hours. • Promotes faster nicotine delivery. May be combined with nicotine patch or associated with bupropion and varenicline. • Nicotine is released in approximately 5 minutes with the tablets and 10 minutes with the gum. • The maximum tolerated dose is around 10 gums/lozenges per day. • The patient should chew the gum/tablet until it tastes spicy. At this point, he should stop chewing for 2 minutes (time to absorb the nicotine) until the taste disappears; then should chew again by repeating the cycle within 20 minutes for a second nicotine release. A glass of water should be drank before use to neutralize the oral pH, which changes with food consumption, and for removal of food residues, which may decrease absorption by the oral mucosa. • Side effects: hypersalivation, nausea, hiccups, gingival ulceration leading to teeth softening, and temporomandibular joint (TMJ) pain. • Contraindication: inability to chew, lesions of the oral mucosa, peptic ulcer, TMJ subluxation, and use of removable dental prostheses. Slow nicotine delivery: nicotine patch • The patches are available in packages with seven units each, with dosages ranging from 7 to 25 mg. • Recommended for maintaining a continuous level of circulating nicotine during 24 hours, in a process of gradual smoking cessation. • May be recommended as a pre-cessation therapy for 2 to 4 weeks in smokers who find it very difficult to reduce the number of cigarettes or set a date to stop. • The patches should be applied in the morning, in covered areas, in the upper part of the thorax, and anterior, posterior and superior arm areas, with site rotation and replacement daily at the same time. Avoid sun exposure on the site. • May be used in combination with bupropion or varenicline. • Therapeutic schedule: – Smokers of 20 cigarettes/day and/or with a Fagerström score of 8-10 points: Patches with 21 to 25 mg/day between the 1st and 4th week; 14 to 15 mg/day between the 5th to 8th weeks; 7 mg/day between the 9th and 10th weeks. Recommended application in the morning upon awakening. In cases of insomnia, should be removed after 16 hours of use. In special cases of increased dependence, up to two adhesives of 21 mg may be applied, if no contraindication. – Smoker 10-20 cigarettes/day and/or Fagerström score of 5-7 points: Patches with 14 to 15 mg/day for the initial 4 weeks and 7 mg/day from the 5th to the 8th week. • Side effects: pruritus, rash, erythema, headache, nausea, dyspepsia, myalgia, and tachycardia when the dose is excessive. • Contraindications: history of recent myocardial infarction (in the previous 15 days), severe cardiac arrhythmia, unstable angina pectoris, peripheral vascular disease, peptic ulcer, cutaneous diseases, pregnancy, and lactation. Table 9 – Symptoms of nicotine withdrawal syndrome Neurobehavioral symptoms Physical symptoms Anxiety Reduced blood pressure Headache Reduced heart rate Difficult concentration Sweating Difficult memorization Dizziness Restlessness Craving (urgency to smoke) Irritability Tremors Feel of frustration or anger Increased appetite Depressed mood Weight gain Insomnia Motor incoordination In the pharmacological approach with NNRTs, bupropion and varenicline are available as first-line medications (Table 12). 11-15 Clonidine and nortriptyline are second-line treatment options, due to their side effects. The NNTs for bupropion and varenicline are 18 and 10, respectively, for successful treatment, and 36 and 20, respectively, for avoiding premature death. 11 Table 13 presents a summary of the usual pharmacological treatment for smoking. 11-15 Legislation Since smoking is a population phenomenon that also imposes risks for nonsmokers, pregnant women, fetuses, and children, in addition to wasting a large amount of public (financial and organizational) resources and causing dependence (which is equivalent to making individuals vulnerable to addiction to other drugs), medical care and health education are not sufficient. Legislation must contemplate control of tobacco exploitation and use in any form, alongside the control of other addictive drugs. Economic interests involved in tobacco growing , production, industrialization, commercialization, and advertising are large and transnational, which makes the categorization of tobacco as an issue that is purely medical 483