Nicotine is a highly addictive chemical compound found in tobacco plants. It is commonly consumed through smoking cigarettes, cigars, or pipes, as well as through the use of smokeless tobacco products like chewing tobacco or snuff.

Nicotine acts as a stimulant in small doses, affecting the central nervous system and increasing alertness and concentration. It is also known to elevate mood and reduce appetite. However, nicotine is highly addictive, and long-term use can lead to dependency and a range of health issues, including cardiovascular disease, respiratory problems, and an increased risk of cancer.

Nosmok (Nicotine) lozenges, sprays, gums, and transdermal patches are used in smoking cessation programs to help individuals quit smoking. These nicotine formulations provide nicotine to minimize the withdrawal syndromes after smoking cessation. Other drugs used to aid smoking cessation include:

• Bupropion (Wellbutrin) and
• Varenicline (chantix).

Nicotine Uses:

• Smoking cessation:
  • It is used to reduce the withdrawal effects of nicotine after smoking cessation.

Nosmok (Nicotine) dosage in adults:

Smoking cessation: (patients should completely stop smoking upon starting therapy):

Nicotine Gum:

• When you feel like smoking, chew one piece of gum.
• If you still feel the urge to smoke, you can use another piece within an hour, but don't chew multiple pieces one after the other.
• If you smoke your first cigarette within 30 minutes of waking up, use the 4 mg gum; otherwise, use the 2 mg gum.
• Follow this schedule for 12 weeks:
  • Weeks 1 to 6: Chew one piece of gum every 1 to 2 hours (up to 24 pieces a day).
  • Weeks 7 to 9: Chew one piece of gum every 2 to 4 hours (up to 24 pieces a day).
  • Weeks 10 to 12: Chew one piece of gum every 4 to 8 hours (up to 24 pieces a day).

Nicotine Inhalation (using a special inhaler):

• Start with 6 to 16 cartridges a day for up to 12 weeks.
• Try to puff frequently for about 20 minutes for the best effect.
• Don't use it for more than 6 months.
• If you're still smoking by the fourth week, stop using it.

Nicotine Lozenge:

• Use one lozenge when you feel the urge to smoke.
• Don't use more than one lozenge at a time.
• If you smoke your first cigarette within 30 minutes of waking up, use the 4 mg lozenge; otherwise, use the 2 mg lozenge.
• Follow this schedule for 12 weeks:
  • Weeks 1 to 6: Use one lozenge every 1 to 2 hours (up to 20 lozenges a day).
  • Weeks 7 to 9: Use one lozenge every 2 to 4 hours (up to 20 lozenges a day).
  • Weeks 10 to 12: Use one lozenge every 4 to 8 hours (up to 20 lozenges a day).

Nicotine Nasal Spray:

• Use 1 to 2 doses per hour, but not more than 5 doses (10 sprays) per hour.
• Don't exceed 40 mg per day or use it for more than 3 months.
• Use it at least 8 times a day for the best results.
• If you're still smoking by the fourth week, stop using it.

Nicotine Transdermal Patch:

• If you smoke more than 10 cigarettes a day, start with step 1 (21 mg/day) for 6 weeks, then step down to step 2 (14 mg/day) for 2 weeks, and finally step 3 (7 mg/day) for 2 weeks.
• If you smoke 10 or fewer cigarettes a day, start with step 2 (14 mg/day) for 6 weeks, then step down to step 3 (7 mg/day) for 2 weeks.

Gradually reduce your nicotine use over 6 to 12 weeks after the initial treatment. Some people can stop abruptly without reducing gradually.

Use in Children:

Not indicated.

Nosmok (Nicotine) Pregnancy Category: D

When a pregnant woman smokes, the nicotine in cigarettes can harm both her and the baby. It's important to understand how this happens:

• Nicotine can pass through the placenta to the baby, which means the baby gets exposed to it.
• Different things affect how harmful nicotine is, like how much is taken in, how it's taken (like smoking or using smokeless tobacco), and how long the exposure lasts.
• When a pregnant woman smokes, it raises the risks of problems like orofacial clefts, ectopic pregnancy, delivering the baby too early, or even stillbirth.
• Smoking during pregnancy can also lead to issues like smaller-than-normal babies, sudden infant death syndrome (SIDS), problems with the placenta, and trouble with the baby's brain and lungs.
• Using smokeless tobacco or being around secondhand smoke also increases the risks for pregnancy problems.
• Pregnant women should be encouraged to quit smoking as soon as possible. Stopping at any time during pregnancy can help both the mom and the baby, but it's best if it's done before 15 weeks of pregnancy.
• While nicotine replacement products can help people quit smoking, studies show that they're only effective during pregnancy when used along with counseling or other support.
• It's important for pregnant women to talk to their doctors before using nicotine replacement products because there's not a lot of clear information about how safe they are during pregnancy. Doctors can help weigh the risks and benefits and provide close supervision if these products are used.

Nicotine use during breastfeeding:

• Nicotine from smoking can get into breast milk and show up in a baby's blood.
• The amount of nicotine in breast milk can vary, depending on whether the mother is using nicotine replacement products.
• In one study, the levels of nicotine in breast milk were similar when a mom used nicotine patches or smoked a certain number of cigarettes each day.
• Nicotine stays in a newborn's body for longer right after birth.
• It's generally considered okay to use nicotine replacement products while breastfeeding if the amount of nicotine is lower than what's found in cigarettes.
• Using products like nicotine gum or lozenges is better.
• But it's important to be cautious, and it's a good idea to talk to a doctor before using these products while breastfeeding.

Dose in Kidney Disease:

• The instructions from the manufacturer don't include any specific changes in dosage.
• This means there aren't clear guidelines for adjusting the dose based on different factors like kidney function.
• However, severe kidney problems might affect how the body clears nicotine and its byproducts.
• It's essential for people with severe kidney issues to be cautious when using nicotine products.

Dose in Liver disease:

• The manufacturer's instructions don't include any specific dosage adjustments for people with liver problems.
• This means there aren't clear guidelines for changing the dose based on liver impairment.
• Since the effects of nicotine products on individuals with liver issues haven't been studied, it's important for those with such conditions to be cautious.

Nasal spray/inhaler:

Common Side Effects of Nosmok (Nicotine):

• Central nervous system:
  • Headache
• Gastrointestinal:
  • Inhaler:
    • Mouth irritation
    • Dyspepsia
• Respiratory:
  • Inhaler:
    • Throat irritation
    • Cough
    • Rhinitis

Rare Side Effects of Nosmok (Nicotine):

• Central Nervous System:
  • Withdrawal Syndrome
• Dermatologic:
  • Acne Vulgaris
  • Burning Sensation Of The Nose (Nasal Spray)
• Gastrointestinal:
  • Flatulence
  • Gingival Disease
  • Diarrhea
  • Dysgeusia
  • Hiccups
  • Nausea
  • Tooth Enamel Damage (Abrasions)
• Genitourinary:
  • Dysmenorrhea
• Neuromuscular & Skeletal:
  • Back Pain
  • Arthralgia
  • Jaw Pain
  • Neck Pain
• Respiratory:
  • Sinusitis

Uncommon side effects of Nosmok (Nicotine) Frequency not defined:

• Central Nervous System:
  • Depression
  • Dizziness
  • Headache
  • Insomnia
  • Lack Of Concentration
  • Nervousness
  • Pain
  • Paresthesia
• Dermatologic:
  • Diaphoresis
• Gastrointestinal:
  • Aphthous Stomatitis
  • Constipation
  • Diarrhea
  • Dysgeusia
  • Dyspepsia
  • Flatulence
  • Gingival Hemorrhage
  • Glossitis
  • Hiccups
  • Nausea
  • Sialorrhea
  • Stomatitis
  • Tooth Enamel Damage (Abrasions)
  • Xerostomia
• Dermatologic:
  • Skin Rash
• Hypersensitivity:
  • Hypersensitivity Reaction
• Local:
  • Application Site Reaction
  • Localized Edema
  • Localized Erythema
• Neuromuscular & Skeletal:
  • Arthralgia
  • Jaw Pain
  • Myalgia
• Respiratory:
  • Cough
  • Sinusitis

Contraindications to Nosmok (Nicotine):

• If someone is allergic to nicotine or any ingredient in nicotine products, they shouldn't use them.
• For example, Nicorette lozenges contain soya, so individuals with a soy allergy should avoid them.
• It's essential to read the labels carefully and avoid using these products if there's a known hypersensitivity to any of the ingredients.

Warnings and precautions

Cardiovascular disease

• Nicotine can affect the heart and blood vessels, leading to increased heart rate and blood pressure.
• In people with cardiovascular or peripheral vascular diseases, including those with a history of heart attack, angina, serious heart rhythm problems, or certain vascular conditions like Buerger disease or Raynaud phenomenon, the risks and benefits of using nicotine products should be carefully considered.
• It's important to be cautious in patients with conditions like angina, high blood pressure, or recent heart attacks.
• If irregular heartbeats or palpitations occur, the use of nicotine products should be stopped.
• Nicotine should generally be avoided during the immediate period after a heart attack, in people with serious heart rhythm problems, or those with severe or worsening angina.
• Additionally, caution should be exercised in individuals with accelerated hypertension due to the risk of malignant hypertension.

Diabetes:

• In individuals with insulin-dependent diabetes (Type 1 diabetes), caution should be exercised when using nicotine products.
• Nicotine can affect blood sugar levels and insulin sensitivity, potentially complicating diabetes management.

Gastrointestinal Disease:

• For individuals with active peptic ulcer disease, caution should be taken when using nicotine products.
• Nicotine can potentially delay the healing process of peptic ulcers, worsening the condition.

Hepatic impairment

• In individuals with severe hepatic impairment (serious liver problems), caution is advised when using nicotine products.
• The effects of nicotine metabolism in people with severe liver issues are not well understood.

Hyperthyroidism:

• In individuals with hyperthyroidism (an overactive thyroid gland), caution should be exercised when using nicotine products.
• Nicotine can potentially exacerbate symptoms associated with hyperthyroidism, such as increased heart rate and metabolism.

Pheochromocytoma:

• In individuals with pheochromocytoma, a rare tumor of the adrenal gland that can cause high blood pressure and other symptoms due to excess catecholamine production, caution should be exercised when using nicotine products.
• Nicotine can further stimulate the release of catecholamines, potentially exacerbating symptoms of pheochromocytoma such as high blood pressure, palpitations, and sweating.

Renal impairment

• In individuals with severe renal impairment (serious kidney problems), caution is advised when using nicotine products.
• The effects of nicotine elimination in people with severe kidney issues are not well understood.

Nicotine: Drug Interaction

Note: Drug Interaction Categories:

• Risk Factor C: Monitor When Using Combination
• Risk Factor D: Consider Treatment Modification
• Risk Factor X: Avoid Concomitant Use

Risk Factor C (Monitor therapy)
Adenosine	Nicotine may enhance the AV-blocking effect of Adenosine. Nicotine may enhance the tachycardic effect of Adenosine.
Cimetidine	May increase the serum concentration of Nicotine.
Varenicline	May enhance the adverse/toxic effect of Nicotine.

Monitoring parameters:

Signs and Symptoms of Nicotine Toxicity

• Headache: Severe headaches can occur.
• Dizziness: Feeling dizzy or lightheaded.
• Mental Confusion: Having trouble thinking clearly or understanding things.
• Disturbed Hearing and Vision: Changes in hearing or vision, such as ringing in the ears or blurry vision.
• Abdominal Pain: Pain or discomfort in the stomach area.
• Rapid, Weak, and Irregular Pulse: Heartbeat may become fast, weak, or irregular.
• Salivation: Excessive saliva production.
• Nausea and Vomiting: Feeling sick to the stomach and vomiting.
• Diarrhea: Frequent, loose bowel movements.
• Cold Sweat: Sweating even when not feeling hot.
• Weakness: Feeling physically weak or tired.

How to administer Nosmok (Nicotine)?

Nicotine Gum:

• Chew slowly until you feel a tingling sensation.
• Once tingling starts, place the gum between your cheek and gum until the tingling stops.
• Repeat this process until most of the tingling is gone, which usually takes about 30 minutes.
• Avoid eating or drinking anything 15 minutes before or while the gum is in your mouth.

Nicotine Lozenge:

• Do not chew or swallow the lozenge; allow it to dissolve slowly in your mouth, which usually takes about 20 to 30 minutes.
• Try to minimize swallowing, and occasionally move the lozenge from one side of your mouth to the other until it's completely dissolved.
• Avoid eating or drinking anything 15 minutes before or while the lozenge is in your mouth.

Nicotine Nasal Spray:

• Prime the pump before the first use or if it hasn't been used for 24 hours by pumping it until a fine spray appears (6 to 8 times initially, then 1 to 2 times for subsequent uses).
• Blow your nose before using the spray.
• Tilt your head back slightly and insert the tip of the bottle into one nostril.
• Spray once in each nostril while breathing through your mouth; do not sniff, swallow, or inhale through your nose during administration.
• Wait 2 to 3 minutes before blowing your nose.
• Avoid contact with skin, eyes, and mouth to prevent nicotine overdose.

Nicotine Oral Inhalation:

• Insert the cartridge into the inhaler and push hard until it pops into place.
• Replace the mouthpiece and twist the top and bottom so that the markings do not line up.
• Inhale deeply into the back of the throat or puff in short breaths.
• The nicotine in the cartridge is used up after about 20 minutes of active puffing.
• Clean the mouthpiece regularly with soap and water.

Nicotine Transdermal Patch:

• Apply a new patch to clean, dry, non-hairy skin on the upper body or upper outer arm.
• Each patch should be applied to a different site.
• Press the patch onto the skin for about 10 seconds immediately after removing the backing.
• The patch can be worn for either 16 or 24 hours.
• If you experience cigarette cravings upon awakening, wear the patch for 24 hours; if you experience vivid dreams or sleep disturbances, remove the patch at bedtime and apply a new one in the morning.
• Do not cut the patch as it may cause rapid evaporation, rendering it ineffective.
• Do not wear more than one patch at a time, and do not leave the patch on for more than 24 hours to avoid skin irritation.
• Wash your hands after applying or removing the patch, and dispose of used patches properly in the trash.

Mechanism of action of Nosmok (Nicotine):

• Nicotine, which is a natural compound found in tobacco, attaches to specific receptors in the body called nicotinic-cholinergic receptors.
• These receptors are found in various places, including autonomic ganglia, the adrenal medulla, neuromuscular junctions, and the brain.
• Nicotine has two main effects on the central nervous system (CNS) that contribute to its addictive properties: a stimulating effect and a rewarding effect.
• The stimulating effect primarily affects the cortex through the locus ceruleus, leading to increased alertness and activity.
• The rewarding effect, on the other hand, occurs in the limbic system, which is associated with pleasure and motivation.
• At lower doses, the stimulating effects of nicotine are more prominent, while at higher doses, the rewarding effects become stronger.
• This combination of effects makes nicotine addictive, as it provides both immediate stimulation and a sense of pleasure or reward, reinforcing its use.

Onset of Action:

• Intranasal: Begins to work more quickly and closely resembles the time course of nicotine levels in the blood after smoking cigarettes compared to other forms.

Absorption:

• Buccal Mucosa, Transdermal: Absorption is slow.
• Intranasal: About 53% of the administered dose is absorbed.
• Inhaler: Less than 5% of the nicotine reaches the lower respiratory tract.

Distribution:

• Nicotine distributes throughout the body at a rate of 2 to 3 liters per kilogram.

Protein Binding:

• Between 5% to 20% of nicotine binds to proteins in the body.

Metabolism:

• Nicotine is primarily metabolized in the liver, kidney, and lung.
• It produces more than 20 metabolites, with cotinine and trans-3-hydroxycotinine being the primary ones.

Half-life Elimination:

• Transdermal: Approximately 4 hours.
• Intranasal: 1 to 2 hours.
• Oral Inhalation: 1 to 2 hours.

Time to Peak, Serum:

• Transdermal: Peaks in the blood around 2 to 8 hours after application.
• Intranasal: Peaks in the blood between 4 to 15 minutes after administration.
• Oral Inhalation: Peaks in the blood within 15 minutes of use.
• Gum: Peaks in the blood around 30 minutes after chewing.

Excretion:

• Approximately 10% of nicotine is excreted unchanged in the urine.

International Brand Names of Nicotine:

• GoodSense Nicotine
• Nicoderm CQ
• Nicorelief
• Nicorette Mini
• Nicorette Starter Kit
• Nicorette
• Nicotine Mini
• Nicotine Step 1
• Nicotine Step 2
• Nicotine Step 3
• Nicotrol
• Nicotrol NS
• Thrive
• EKMO
• Habitrol Gum
• Nicabate
• Nicabate Clear
• Nicabate CQ
• Nicabate Lozenges
• Nicabate Soft Gum
• Nicolan TTS
• Nicoman
• Nicomild
• Nicopass sans sucre menthe fraicheur
• Nicopass sans sucre reghsse menthe
• Nicopatch
• Nicorest
• Nicorette
• Nicorette Coolmint
• Nicorette Fruit
• Nicorette Inhaler
• Nicorette Menthe
• Nicorette Menthe Fraiche
• Nicorette Orange
• Nicorette Orange sans sucre
• Nicostop
• Nicotab
• Nicotinell
• Nicotinell Chewing Gum
• Nicotinell Fruit sans sucre
• Nicotinell Menthe sans sucre
• Nicotinell Mint Lozenge
• Nicotinell TTS
• Nicotrans
• Nicotrol Gum
• Nikofrenon
• Niquitin
• NiQuitin
• Niquitin Clear
• Niquitin CQ
• Niquitin Mint
• Niquitin sans sucre
• Nobacco
• Nosmok
• Pelzont
• QuitX

Nicotine Brand Names in Pakistan:

No Brands Available in Pakistan.